Prevalence of Multimorbidity Among Adults Seen in Family Practice

It is not surprising for anyone involved in family practice to read Fortin et al’s account, indicating that patients in the community commonly have more than one chronic condition, and that the number of ailments a patients has, increases with age. Fortin et al attempt to quantify this in a unique way, providing a numerical figure to bolster our innate sense of what must be ‘true’ anyway. The idea that 50% of 45 to 65 year olds have 5 or more chronic conditions seems very high –this must be due to the characteristics of the area. It would be very interesting to repeat this in a variety of different areas.

It may be possible to use such information to inform payment strategies for family doctors. For example, primary care reform in Ontario is moving away from fee for service work (to try to encourage models more in line with preventive medicine). Instead, models of care relying on capitation are being developed and encouraged. A patient with multimorbidity is more complex than a patient with one condition - perhaps the cumulative illness rating scale (CIRS) can be used to assess a clinicians’ load, or the severity of illness burden and then compensation be offered accordingly (on top of the capitation type of payment system). In the UK, the ‘chronic disease register’ is a way of trying to address this, but it only requires that the practitioner keep an index of all patients with a particular chronic disease (for example, diabetes). The CIRS used by Fortin et al takes into account the cumulative nature and the severity of the illnesses.

Current UK primary care renumeration policy tries to account for varying physicians’ workloads by using the Townsend deprivation index 1 and Jarman Under privileged area score 2 and other deprivation indices. These were developed to assess socio-economic status and poverty in areas of the UK, according to the local postal code. The idea was that a more deprived area would impact on a doctors’ workload and the compensation was altered accordingly. The CIRS could be used similarly and is actually more reflective of the actual burden.

Dr Gina Agarwal, MBBS MRCGP CCFP Assistant Professor, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada agarg@mcmaster.ca

References 1. Townsend P. Deprivation. J Soc Policy 1987;16(2):125-46.

2. Jarman B. Underprivileged areas: validation and distribution of scores. Br Med J (Clin Res Ed). 1984 Dec 8;289(6458):1587-92..

Competing interests:   None declared