Intended for healthcare professionals

Practice Guidelines

Clinical assessment and management of multimorbidity: summary of NICE guidance

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4843 (Published 21 September 2016) Cite this as: BMJ 2016;354:i4843

Infographic 1

Adapting clinical guidelines to take account of multimorbidity

 

Infographic 2

Single condition focused vs multimorbidity approach to management

 

Chinese translation

该文章的中文翻译

  1. Caroline Farmer, senior research fellow1,
  2. Elisabetta Fenu, health economics lead1,
  3. Norma O’Flynn, chief operating officer1,
  4. Bruce Guthrie, professor of primary care medicine2
  1. 1National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
  2. 2Population Health Sciences Division, University of Dundee, Dundee DD2 4BF, UK
  1. Correspondence to: N O’Flynn Norma.oflynn{at}rcplondon.ac.uk

What you need to know

For those with multimorbidity

  • Guidelines on single health conditions may not be applicable

  • Aggressive management of risk factors for future disease is often a major treatment burden and can be inappropriate

  • Assess whether patients may benefit from an approach to care that takes account of their multimorbidity

  • Consider all conditions and treatments simultaneously

  • Easier access to data about the absolute benefit of commonly prescribed treatments is needed

Most people with a chronic condition have one or more other chronic conditions, and multimorbidity is the norm in older people (see infographic 1 and box1).1 Multimorbidity matters because it is associated with reduced quality of life, higher mortality, polypharmacy and higher rates of adverse drug events, and high use of unplanned health care.2 3 4 5 Those with multimorbidity frequently receive care from both primary care and multiple specialists, who may not be communicating effectively with each other.6 7 Clinicians express uncertainty about the balance of benefit and harm of treatments in people with multimorbidity because evidence is largely based on trials of interventions for single conditions, from which people with multimorbidity are often excluded.8 9 Guidelines derived from such trials may lead to burdensome levels of treatment or unfeasible patterns of healthcare use .10

Box 1: What is multimorbidity?

Multimorbidityis the presence of two or more long term health conditions, which can include:

  • Physical and mental health pathologies

  • Ongoing conditions such as learning disability

  • Symptom complexes such as frailty or chronic pain

  • Sensory impairment such as sight or hearing loss

  • Alcohol and substance misuse

There is increasing recognition that care for some people with multimorbidity needs reorganisation,11 12 13 14 although not everyone with multimorbidity will require additional support. This guideline is intended to provide guidance on the optimum management of people with multimorbidity who need an approach to care that takes account of their multimorbidity because the combination of their conditions or the complexity of their treatments and healthcare appointments significantly affect their life (see infographic 2). This guidance is aimed at healthcare professionals in both generalist and specialist settings and summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE).15

Recommendations

NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group's experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

What is an approach to care that takes account of multimorbidity?

  • Offer care that is tailored to the person’s personal goals and priorities and seeks to address the complexities surrounding the person’s multiple conditions and treatments. This might include identifying

    • Ways to maximise benefit from existing treatments

    • Treatment that could be stopped because of limited benefit

    • Treatment and follow-up arrangements with a high burden

    • Medicine with a high risk of adverse events such as falls, gastrointestinal bleeding, or acute kidney injury

    • Non-pharmacological treatments as possible alternatives to some medicines

    • Alternative arrangements for follow-up to coordinate or optimise the number of appointments.

      [Based on low to high quality evidence from qualitative interview and focus group studies with people with multimorbidity, their families and carers, and clinicians, and from previously published guidelines on the management of multimorbidity]

Who might benefit from an approach to care that takes account of multimorbidity?

  • Consider an approach to care that takes account of multimorbidity at the person's request or if the person

    • Finds it difficult to manage treatments or day-to-day activities

    • Receives care and support from multiple services, and particularly if the person needs additional services

    • Has both long term physical and mental health conditions

    • Is frail or prone to falls (see box 2)

    • Frequently seeks unplanned or emergency care (box 2)

    • Is prescribed multiple regular medicines (see box 2)

      [Based on low to high quality evidence from qualitative interview and focus group studies with people with multimorbidity, their families and carers, previously published related guidelines on the management of people with multimorbidity, and consensus of the Guideline Development Group (GDG)]

Box 2: Identifying people for an approach to care that takes account of multimorbidity

  • In primary care:

    • Consider using a validated tool such as eFI, PEONY, or QAdmissions to identify adults with multimorbidity who are at risk of adverse events such as unplanned hospital admission or admission to care homes

    • [Based on low to moderate quality evidence from prospective and retrospective observational studies]

  • Use an approach that takes account of multimorbidity for people of any age with multimorbidity who are prescribed ≥15 regular medicines because they are likely to be at higher risk of adverse events and drug interactions

  • Consider an approach that takes account of multimorbidity for people of any age with multimorbidity who

    • Are prescribed 10-14 regular medicines

    • Are prescribed <10 regular medicines but are at particular risk of adverse events

    • [Based on very low to moderate quality evidence from prospective and retrospective observational studies]

  • In primary and community care settings consider assessing frailty in adults with multimorbidity using one of the following:

    • An informal assessment of gait speed (such as time taken to answer the door or to walk from the waiting room)

    • Self reported health status (that is, “How would you rate your health status on a scale from 0 to 10?” with scores of ≤6 indicating frailty)

    • A formal assessment of gait speed, with >5 seconds to walk 4 metres indicating frailty

    • The PRISMA-7 questionnaire, with scores of ≥3 indicating frailty

    • [Based on low to high quality evidence from diagnostic accuracy studies and GDG consensus]

Establish what is important

  • Encourage people with multimorbidity to clarify what is important to them, including their personal goals, values, and priorities. These may include

    • Maintaining their independence

    • Undertaking paid or voluntary work, taking part in social activities, and playing an active part in family life

    • Preventing specific adverse outcomes (such as stroke)

    • Reducing harms from medicines

    • Reducing treatment burden

    • Lengthening life.

      [Based on low to high quality evidence from qualitative interview and focus group studies with people with multimorbidity, their families and carers, and clinicians, and from previously published guidelines on the management of multimorbidity]

Establish disease and treatment burden

  • Ask people about how their health problems affect their day-to-day life. Include a discussion of

    • Mental health

    • How disease burden affects their wellbeing

    • How their health problems interact and how this affects quality of life.

      [Based on low to high quality evidence from qualitative interview and focus group studies with people with multimorbidity, their families and carers, and clinicians, and from previously published guidelines on the management of multimorbidity]

  • Ask people about how their treatment burden affects their day-to-day life. Include a discussion of

    • The number and type of healthcare appointments they have and where these take place

    • The number and type of medicines they are taking and how often

    • Any harms from medicines

    • Non-pharmacological treatments such as diets, exercise programmes, and psychological treatments

    • Any effects of treatment on their mental health or wellbeing.

      [Based on evidence at low to high risk of bias from cross-sectional studies and GDG consensus]

Review medicines and other treatments

  • Ask people if treatments intended to relieve symptoms are providing benefits or causing harms. If appropriate

    • Discuss reducing or stopping the treatment

    • Plan a review to monitor effects of any changes made and decide whether any further changes to treatments are needed (including restarting a treatment).

      [Based on GDG consensus]

  • When reviewing medicines and optimising treatment, think about any medicines or non-pharmacological treatments that might be started as well as those that might be stopped. [Based on GDG consensus]

  • Think carefully about the risks and benefits for people with multimorbidity of individual preventive treatments recommended in guidance for single health conditions. Discuss changes to treatments that aim to offer prognostic benefit with people, taking into account

    • Their views on the likely benefits and harms from individual treatments

    • What is important to them in terms of personal goals and priorities.

      [Based on GDG consensus]

  • Tell people who have been taking bisphosphonate for osteoporosis for at least three years that there is no consistent evidence of

    • Further benefit from continuing bisphosphonate for another three years

    • Harms from stopping bisphosphonate after three years of treatment.

    [Based on very low to high quality evidence from RCTs]

  • Discuss stopping bisphosphonate after three years and include patient choice, fracture risk, and life expectancy in the discussion. [Based on very low to high quality evidence from RCTs and GDG consensus]

  • When reviewing medicines and other treatments, use the database of treatment effects to find information on

    • The effectiveness of treatments

    • The duration of treatment trials

    • The populations included in treatment trials.

      [Based on GDG consensus. Data provided within the database of treatment effects are derived from previously published NICE guidelines]

Record an individualised management plan

  • Develop and agree an individualised management plan with the person. Agree what will be recorded and what actions will be taken. These could include

    • Starting, stopping, or changing medicines and non-pharmacological treatments

    • Prioritising healthcare appointments

    • Anticipating possible changes to health and wellbeing

    • Assigning responsibility for coordination of care and ensuring this is communicated to other healthcare professionals and services

    • Other areas the person considers important to them

    • Arranging a follow-up and review of decisions made.

  • Share copies of the management plan in an accessible format with the person and (with the person’s permission) other people involved in care (including healthcare professionals, a partner, family members, and carers).

    [Based on low to high quality evidence from qualitative interview and focus group studies with people with multimorbidity, their families and carers, and clinicians, and from previously published guidelines on the management of multimorbidity]

Implementation

The recommendations within this guideline are intended to support better care without requiring a substantial increase in resource. The GDG expect that implementing these recommendations may require a re-organisation in the way care is delivered. There is limited evidence on the effectiveness of different models or formats of care for people with multimorbidity.

Guidelines into practice

  • Consider

  • Routinely asking yourself if a person consulting you needs an approach to care that accounts for their multimorbidity because of high impact of their conditions or their care on their life

  • Combining appointments that may previously have been conducted separately

  • Using screening tools such as the STOPP/START tool in older people to identify medicine related safety concerns and any medications that people may benefit from but aren’t currently taking

  • A planned, regular review with selected people with multimorbidity to plan care and anticipate needs

  • Taking advantage of electronic care records where available to facilitate communication between healthcare professionals involved in the care of a patient

  • Seeking support to interpret treatment effectiveness data and apply this to people with multimorbidity

  • The health literacy of patients and adapt communication about care and treatment options to each person’s needs

How patients were involved in the creation of this article

Committee members involved in this guideline included lay members who contributed to the formulation of the recommendations summarised here. Patient organisations were among the registered stakeholders who were consulted at both scoping and development stages.

Further information on the guidance

Methods

The Guideline Development Group (GDG) comprised a professor of primary care medicine (chair), three general practitioners, two consultant pharmacists, two consultant geriatricians, a consultant in palliative care, a clinical lecturer in general practice, a senior admiral nurse, and two patient members.

The guideline was developed using standard National Institute for Health and Care Excellence (NICE) guideline methodology (www.nice.org.uk/article/pmg20/chapter/1%20introduction%20and%20overview). The GDG developed clinical questions, collected and appraised clinical evidence, and evaluated the cost effectiveness of proposed interventions and management strategies through literature review and economic analysis. Quality ratings of the evidence were based on GRADE methodology (www.gradeworkinggroup.org). These relate to the quality of the available evidence for assessed outcomes rather than the quality of the clinical study. Where standard methods could not be applied, a customised quality assessment was done. These were either presented as a narrative summary of the evidence or in customised GRADE tables (for example, for observational studies). Customised quality assessment was done for the assessment of questionnaires to assess treatment burden; for the prognostic reviews on risk prediction rules/tools; for the meta-synthesis of previously published guidelines on the management of multimorbidity; and for the meta-synthesis undertaken on qualitative studies for the chapter on the barriers to optimal care for people with multimorbidity.

The draft guideline went through a rigorous review process, in which stakeholder organisations were invited to comment; the GDG took all comments into consideration when producing the final version of the guideline. NICE has produced three different versions of the guidance: a full version; a summary version known as the “NICE guidance”; and a version for people using NHS services, their families and carers, and the public (http://www.nice.org.uk/guidance/NG39/ifp/chapter/about-this-information). A formal review of the need to update a guideline is usually undertaken by NICE after guideline publication.

Economic analysis

An original economic model was developed to assess the cost effectiveness of holistic assessment of older adults in the community with multimorbidity. This analysis showed that holistic assessment is cost effective compared with usual care, but this conclusion was driven by the high reduction in mortality observed in the clinical study informing this parameter; the GDG agreed that this was likely an overestimate, and where only a marginal reduction in mortality was observed the intervention was no longer cost effective. For this reason the GDG decided not to make a recommendation in favour of holistic assessment for every patient with multimorbidity.

Future research
  • What is the clinical and cost effectiveness of alternative approaches to organising primary care for people with multimorbidity?

  • What is the clinical and cost effectiveness of stopping preventive medicines in people with multimorbidity who may not benefit from continuing them?

  • Can primary care data be used to predict reduced life expectancy in people with multimorbidity in order to inform care?

Footnotes

  • The members of the Guideline Development Group were: Bruce Guthrie (chair), Nina Barnett, Sam Barnett-Cormack, Julia Botsford, Carolyn Chew-Graham, Andrew Clegg, John Hindle, Jonathan Inglesfield, David Kernick, Emily Lam, Rupert Payne, Alaster Rutherford, Cate Seton-Jones. The technical team at the National Guideline Centre included Joanna Ashe, Kate Ashmore, Neil Askew, Katie Broomfield, Tamara Diaz, Caroline Farmer, Elisabetta Fenu, James Gilbert, Hannah K, Sophia Kemmis-Betty, Emma Madden, Norma O’Flynn.

  • Contributors: CF drafted the summary, and all authors were involved in writing further drafts and reviewed and approved the final version for publication. BG is the guarantor.

  • Funding: The National Guideline Centre was commissioned and funded by the National Institute for Health and Care Excellence to write this summary.

  • Competing interests: We declare the following interests based on NICE's policy on conflicts of interests (available at www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf): CF no declarations; EF no declarations; NOF no declarations; BG has received funding for research in multimorbidity from the NIHR Health Services and Delivery Research Programme and the Scottish Government Chief Scientist Office. The authors’ full statements can be viewed at www.bmj.com/content/354/bmj.i4843/related#datasupp.

References

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