Multimorbidity and hospitalisation

Clinicians, researchers and policy makers alike are increasingly interested in the subject of multimorbidity. The presence of more than one long-term clinical condition is the norm, and will undoubtedly become increasingly common given our aging population. Just under a quarter of the entire population are multimorbid, with this rising to almost two-thirds in patients aged over 65 years. These patients experience poorer physical and psychosocial quality of life, and the problems are compounded in those with co-existing mental health problems. The situation is also aggravated in the setting of socioeconomic deprivation:  such patients generally develop multimorbidity at an earlier age, suffer poorer health and have greater healthcare needs, whilst also experiencing poorer service provision.

Multimorbidity results in increased health service use, which may be entirely appropriate. However, unplanned hospital admissions may be undesirable. Previous work has examined the association between multimorbidity and hospitalisation. We have recently published work in the Canadian Medical Association Journal which explores this in more detail, studying the additional impact of mental health problems and socioeconomic deprivation on the association between unplanned hospitalisation and physical multimorbidity. The study, in 180,815 adult patients registered in general practices in Scotland, shows that the most multimorbid individuals are considerably more likely to experience unplanned hospital admissions – 6 times the odds for any admission type, and 14 times the odds for potentially preventable unplanned hospitalisation. Importantly, the odds of admission are doubled again in those experiencing mental health conditions, and in the most deprived compared with the least deprived patients. Indeed, the most physically multimorbid patients with concurrent mental health problems, living in the most deprived areas, experience 18 times the odds of an unplanned admission and 51 times the odds of an potentially preventable unplanned admission, compared with the healthiest people living in the most affluent areas.

Why should the presence of mental health problems be associated with admission for primarily physical problems? Why do deprived patients end up in hospital? Part of this may reflect these patients being more likely to experience greater disease severity, not captured in simple measures of physical morbidity. Part of it is probably due to such patients having fewer personal and social resources to help them cope with ill health. This includes problems with the provision of primary care, where GPs struggle to meet the complex needs of such individuals, compounded by shorter consulting times, poorer access and worse continuity of care. We observed a particularly high risk of admission for those experiencing problems deemed potentially preventable through better ambulatory care. And it is primary care which is almost certainly best situated to tackle these issues. Hospital and specialist care is still organised around single diseases. There also remains a huge gulf between physical and mental health services. And secondary care clinicians are arguably less familiar with the social problems facing many patients, particularly in deprived areas. General practices are the ideal place to integrate care across diseases, managing physical, emotional and social aspects of health in a holistic manner – we now need to find out if doing so will ultimately improve quality of life and reduce hospital use.

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