Multi-morbidity and the Emperor’s New Clothes: a challenge for primary care researchers

Are single disease guidelines and indicators are going out of fashion? Well they are with people interested in multi-morbidity. The argument is straightforward. Single disease guidelines are usually based on trials which exclude people with multiple complex problems. So how does the physician know how a cholesterol guideline developed from trials on 65 year old CHD patients relates to the 85 year old in front of him with seven other comorbid conditions? The risks of polypharmacy are increased as the number of prescribed meds goes up, so what is the physician to do? Does he follow eight disease guidelines for the old lady in front of him? Or is there another way?

Well, Victor Montori thinks there needs to be. He gave the opening keynote at this year’s NAPCRG conference. Despite being an endocrinologist, he sees clear problems in attempting to apply multiple single disease guidelines to our increasingly multi-morbid patients. His answers were about meaningful engagement with patients and their priorities, and shared decision making which takes into account a clear explanation of risks, benefits and alternative treatment approaches. That’s good, but it’s not good enough. We’ve opened up an intellectual space by criticising the single disease approach in multi-morbid older populations, but we haven’t yet filled it adequately.

A number of major problems remain. Here are two.

First is the assumption that more is worse. This may be true, and certainly polypharmacy is both hazardous and responsible for substantial morbidity. However, although many trials exclude people with multi-morbidity, the absolute risks faced by the very elderly may be greater than for patients included in trials. So the benefits may be greater too. We often just don’t know. But we certainly shouldn’t assume we shouldn’t be treating people just because they’re old and frail. Surprisingly, polypharmacy doesn’t seem to be a risk factor for unscheduled hospital admission in highly multi-morbid patients.

Second, a primary care physician may be uneasy about the patient in front of him on 15 medications, but it’s hard to know which one to stop. Which diabetic patient doesn’t need tight glucose control? Which stroke patient doesn’t need close blood pressure monitoring? So it’s not only hard for the physician to know if he or she is providing the best care for people, it’s hard for other people to know too. Part of the reason that quality indicators for single diseases have gained such prominence (e.g. in P4P schemes) is that physicians increasingly have to demonstrate that they are providing high quality care. And that won’t go away just because our patients are becoming older and more complex.

So here’s a real challenge to the academic primary care community. We’ve exposed many of the weaknesses of single disease guidelines and quality indicators. But we haven’t put anything adequate in their place. We’ve opened up an intellectual space, but we haven’t filled it. No-one else is going to lead the way on this. It’s up to us, or the single disease paradigm will continue to dominate.

This blog was first posted on the CMAJ website as part of a series on global primary care research to coincide with NAPCRG’s  2014 Annual Meeting, and is reproduced here with permission.

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