BJDVD

Managing complex long-term conditions (LTC) and multi-morbidity

The increasing challenge of complex LTC and multi-morbidity will change the way we practise medicine. Archana Dhere reports from this important meeting held jointly by ABCD and the Royal College of Physicians (RCP) on Feb 18th at the RCP, London.

Introduction

Complex long-term conditions (LTC) and multi-morbidity are on the rise. Healthcare systems, medical education and research worldwide are designed to deliver care for individual diseases. These systems are proving to be inefficient in caring for people with multi-morbidity and a wider approach is necessary (Figure 1).1 The Royal College of Physicians (RCP) in conjunction with the Association of British Clinical Diabetologists (ABCD) organised a conference with the aim to improve understanding about LTC. Common LTC like chronic obstructive pulmonary disease (COPD), heart failure, dementia, chronic kidney disease (CKD), diabetes, chronic steroid use, serious mental illness and physical disease and Parkinson’s disease were discussed. The interactive sessions focused on views and experiences of various medical experts in the UK on care pathways, care networks and care models that can help to manage LTC.

16_2_85_87-dhere-figure1

Growing impact and need for change

Dr Bob Goddard and Professor Nigel Mathers

LTC stretches all aspects of health services, as resources struggle to keep up with demand. A cross-sectional study in 2007 across 314 medical practices in Scotland revealed that 42% of all primary care patients had one or more morbidities and 23% were multi-morbid.1 “Hospitals on the edge?”, a report by RCP in 2012, identified a significant increase in clinical demands on acute services with a 37% cumulative rise in hospital attendances in the last decade.2 About two-thirds of patients admitted to hospital are over 65 years of age. A Future Hospital Commission report to the RCP in 2013 highlighted challenges such as increasing clinical demands with reduced facilities for acute medicine, changing needs of patients over 65 years of age, poor continuity of care on admission to hospital, inadequate arrangement for out-of-hours care in hospitals and a looming workforce crisis amongst trainees and consultants that needed to be addressed.3 In 2014, only 60% of higher specialist trainees accredited in acute and general internal medicine, and most of these trainees reported unmanageable workload and poor job satisfaction. Almost 40% of consultant posts advertised in acute and general internal medicine remained unfilled. The shape of training review presented to the RCP in 2013 identified a need to reshape postgraduate training in the UK. The recommendations included efforts to enhance the value of general internal medicine, increase training numbers in acute and general internal medicine, improve job satisfaction by allowing flexibility in training and rewards for wider leadership roles.4 A new model of care envisaged by the Commission aimed at delivering safe high-quality continuous coordinated care for patients across 7 days and will be possible only if the traditional reactive medical crisis management model is replaced with a holistic psychosocial model that encompasses early proactive support planning to prevent a crisis. This requires minimising structural divisions between primary, secondary, specialised and social care with improved commissioning, contracting and funding opportunities at various levels of the health and social care system.

The House of Care framework (Figure 2) is one such initiative that makes the patient central to the care. The roof of the house comprises best clinical and organisational evidence, the first wall supports professional collaboration between specialists and generalists, the second wall supports patients and their carers to encourage self-care and the foundations of the house comprise the commissioning groups.

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COPD

Professor Mike Morgan

Hospitalisation for a severe exacerbation of COPD is is linked with poor prognosis. The introduction of structured self-management and transitional care plans in the community aims to reduce re-hospitalisation in the first three months after discharge.5 In addition to specific treatment strategies such as steroids for eosinophilic inflammation, prophylactic macrolides for recurrent exacerbations and volume reduction surgery for emphysema, the National COPD Audit and Cochrane Review in 2015 showed significant benefits to exercise capacity and quality of life from pulmonary rehabilitation.6 Half of COPD patients have one or more co-morbidities,7 and pulmonary rehabilitation was beneficial to those with obesity and congestive heart failure.8,9 A Cochrane review in 2014 showed that collaboration between healthcare providers like nurses, general practitioners, physiotherapist and chest physician to facilitate an integrated disease management programme including different components like self-management, exercise and nutrition improves outcomes like dyspnoea, 6 min walking distance and hospital admissions.9,10

Steroids in non-endocrine practice

Dr Miguel DeBono

Glucocorticoid-induced side effects are reported by 90% of patients and the impact on patient health and quality of life is dose-dependent.11 The lowest effective dose of glucocorticoids should be used for the shortest period to avoid the risk of osteoporosis, hyperglycaemia and HPA axis suppression. Bone density measurements if glucocorticoids are administered for more than 3 months, early screening and treatment initiation for steroid-induced hyper-glycaemia and vigilance for hypothalamic pituitary axis suppression are recommended.

Dementia and end-of-life care in patients with diabetes

Professor Alan Sinclair

Diabetes Frail is an emerging concept that explores frailty and its association with diabetes. Frailty is a clinically recognised state of increased vulnerability resulting from ageing associated with a decline in the body’s physical and psychological reserves.12 Frailty increases the level of disability in diabetes. Cognitive impairment and dementia is more common in diabetes and is associated with an increased risk of hypoglycaemia, poor treatment adherence, and dependency.13 A multidisciplinary assessment of psychosocial and functional capabilities, with medical needs to anticipate risks and devise management strategies is recommended. The aim is to maintain functional independence, improve the quality of life, reduce symptom and medicine burden.14 Relaxing glucose control, stopping unnecessary medications, withdrawing statins and pain management at end of life are important.

Chronic kidney disease (CKD) and diabetes

Dr Peter Winocour and

Dr Andrew Frankel

Diabetic renal disease is the most common cause of renal failure in the UK. About 20–40% people with diabetes develop CKD. There is an increased risk of cardiovascular disease (CVD) in the presence of diabetes and CKD. A multifaceted care programme coordinated through a diabetologist, nephrologist, dietician and primary care physician in preventing and treating diabetic nephropathy is effective.15 The eight pillars of care to focus on are optimal glycaemic control; avoiding extremes of glycaemia; monitoring eGFR and proteinuria; interventions to reduce cardiovascular risk like smoking cessation, weight reduction, low salt diet, blood pressure control, cholesterol reduction with statin and aspirin prophylaxis; foot screening; retinopathy screening; treatment of anaemia; treatment of bone disease.16 Management of diabetes in end-stage renal disease remains a challenge due to the rapid changes in the glucose homeostasis and altered pharmacokinetics of glucose-lowering medications. Insulin requirement may vary between dialysis and non-dialysis days.

Heart failure

Dr Hugh McIntyre

Heart failure prevalence rises as age advances and has a high five-year mortality of 45%.17 The all-cause mortality rises in the presence of co-morbidities like CKD, anaemia, diabetes and COPD.18 Treatment strategies for patients should take into account whether ejection fraction in heart failure is preserved or reduced, B-type natriuretic peptide (BNP) level, frailty score, and nutritional status.

Mental illness and physical disease

Professor Richard Holt

Physical co-morbidities like diabetes mellitus, obesity, COPD, and CVD are more common in patients with schizophrenia, and are more likely to be missed.19 Associated reduced life expectancy by 11–20 years is seen20 Factors like reduced motivation; side effects from psychotropic medications; unhealthy lifestyle including smoking, poor diet, excess alcohol may contribute. Intrauterine environment and childhood adversity play a role. Increased collaboration between mental and physical health services is likely to be helpful.

Parkinson’s disease

Professor David Burn, Newcastle

Parkinson’s disease is a common neurodegenerative condition affecting 127,000 people in the UK. About 80% of people with Parkinson’s develop dementia. The national Parkinson’s audit in 2012–2013 identified shortcomings like lack of implementation of best practice, limited access to PD nurse, inadequate patient information in the clinics, lack of integration between occupational therapist and speech and language therapist, lack of training and education. The UK Parkinson’s Excellence Network was established in 2015 in an attempt to improvise care for people with Parkinson’s disease.21 The 18 network groups support patients and professionals to build awareness and drive changes in their local area in improving education, research and service development.

Progress so far

As part of the NHS Five Year Forward view published in 2014, new innovative care models, extra funding arrangements and commissioning approaches have been explored as pilots. The Vanguards programme at 29 sites backed by a £200 million transformation fund for developing new models of care for seamless service across hospitals, primary care, mental health, community nursing, pharmacy and social care was initiated in March 2015. Integrated Personal Commissioning has combined the health and social care budgets from April 2015 and is expected to empower patients. In April 2016 Greater Manchester got devolved control of a £6 billion budget for restructuring and integrating health and social care services based on local needs. The success of these innovations will help determine if these can be used as blueprints for redesigning the entire health care system.

References

1.     Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross- sectional study. Lancet 2012;380:37-43. http://dx.doi.org/10.1016/S0140-6736(12) 60240-2

2.     Royal College of Physicians (RCP). Hospitals on the edge? The time for action. London: RCP, 2012.

3.     Future Hospital Commission. Future hospital: caring for medical patients. A report from the Future Hospital Commission to the Royal College of Physicians. London: RCP, 2013.

4.     Shape of training: Securing the future of excellent patient care, Final report to Royal College of Physicians. London: RCP, 2013.

5.     Suissa S, Dell'Aniello S, Ernst P. Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality. Thorax 2012;67:957-63. http://dx.doi.org/10.1136/thoraxjnl-2011-201518

6.     McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2015; (2):CD003793. http://dx.doi.org/10.1002/14651858.CD003793.pub3.

7.     van Manen J, Bindels P, IJzermans C, van der Zee JS, Bottema BJ, Schadé E. Prevalence of comorbidity in patients with a chronic airway obstruction and controls over the age of 40. J Clin Epidemiol 2001;54:287-93.

8.     Greening N, Evans R, Williams J, Green RH, Singh SJ, Steiner MC. Does body mass index influence the outcomes of a Waking-based pulmonary rehabilitation programme in COPD? Chronic Respir Dis 2012;9:99-106. http://dx.doi.org/10.1177/1479972312439317

9.     Evans R, Singh S, Collier R, Loke I, Steiner MC, Morgan MD. Generic, symptom based, exercise rehabilitation; integrating patients with COPD and heart failure. Respir Med 2010;104:1473-81. http:dx.doi.org/10.1016/j.rmed.2010.04.024

10.  Kruis A, Smidt N, Assendelft W, et al. Cochrane corner: is integrated disease management for patients with COPD effective? Thorax 2014;69:1053-5. http://dx/dor.org/10.1136/thoraxjnl-2013-204974

11.  Curtis J, Westfall A, Allison J, et al. Population-based assessment of adverse events associated with long-term glucocorticoid use. Arthritis Rheum 2006;55:420-6.

12.  The British Geriatrics Society in association with the Royal College of General Practitioners and Age UK. Consensus Best Practice Guidance for the care of older people living with frailty in community and outpatient settings. London, 2014.

13.  Sinclair A, Hillson R, Bayer A. Diabetes and dementia in older people: a Best Clinical Practice Statement by a multidisciplinary National Expert Working Group. Diabet Med 2014;31: 1024-31. http://dx.dor/org/0.1111/dme. 12467

14.  Sinclair A, Dunning T, Rodriguez-Mañas L. Diabetes in older people: new insights and remaining challenges. Lancet Diabetes Endocrinol 2015;3:275-85. http://dx.dor.org/10.1016/S2213-8587(14)70176-7

15.  Hahr A, Molitch M. Management of diabetes mellitus in patients with chronic kidney disease. Clin Diabetes Endocrinol 2015;1. http://dx.dor.org/10.1186/s40842-015-0001-9

16.  Kidney Disease Improving Global Outcomes (KDIGO). Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013;3:1-163.

17.  National Heart Failure Audit report 2013-2014. www.ucl.ac.uk/nicor/audits/heartfailure/documents/annualreports/hfannual13-14-updated.pdf/(last accessed 3 May 2016).

18.  van Deursen V, Urso R, Laroche C, et al. Co-morbidities in patients with heart failure: an analysis of the European Heart Failure Pilot Survey. Eur J Heart Fail 2013;16:103-11. http://dx.doi.org/10.1002/ejhf.30

19.  Smith D, Langan J, McLean G, Guthrie B, Mercer S. Schizophrenia is associated with excess multiple physical-health comorbidities but low levels of recorded cardiovascular disease in primary care: cross-sectional study. BMJ Open 2013;3:e002808. http://dx.dor.org/10.1136/bmjopen-2013-002808

20.  Laursen T, Nordentoft M, Mortensen P. Excess early mortality in schizophrenia. Ann Rev Clin Psychol 2014;10:425-48. http://dx.doi.org/10.1146/annurev-clinpsy-032813-153657

21.  Burn D. UK Parkinson's Excellence Network: empowering service improvement across the UK. Neurodegener Dis Manage 2015;5:173-6. http://dx.doi.org/10.2217/nmt.15.18

Archana Dhere
Specialty Registrar (ST6) in Diabetes &
Endocrinology, Wycombe General Hospital, Buckinghamshire Healthcare NHS Trust,
Queen Alexandra Rd, High Wycombe HP11 2TT
E-mail: archanadhere@doctors.org.uk

Br J Diabetes 2016;16:85-87
http://dx.doi.org/10.15277/bjd.2016.081

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The Journal of the Association of British Clinical Diabetologists