Multimorbidity - presentation, mortality, and structured personal care

Publikation: Bog/antologi/afhandling/rapportPh.d.-afhandlingForskning

Multimorbidity is increasing in the industrialized world partly because of aging populations, developed technologies, and better medical treatments. Multimorbidity is most often defined as the co-occurrence of two or more chronic conditions in the same person. Multimorbidity has consequences in terms of lower quality of life, a higher number of mental health problems, more hospital contacts, higher economic consequences, and mortality that increases with the number of conditions. There is no consensus on how to define multimorbidity, however, with considerable variation in the number and types of conditions to include. Clinical guidelines are difficult to use optimally when caring for patients with multimorbidity and interventions on optimal management are few. In order to improve organization and collaboration in the health care system, and thereby the care of people with multimorbidity, finding prevalent combinations of multimorbidity that have high mortality could be relevant. Since multimorbidity is often a question of complexity rather than diseases and their medical consequences, it could also be relevant to include patients‟ views. In this thesis the concept of multimorbidity, as well as relevant ways of working with it, are explored, in order to improve care for these patients.
The first study is a systematic review where definitions of multimorbidity are explored in the literature. In particular, we look at the role of diseases, risk factors, and symptoms, but also the duration and severity of the conditions included in the definitions. We identified 163 articles for the study, with 115 of them having a uniquely constructed definition of multimorbidity. Diseases occurred in all definitions, with diabetes as the most common. Risk factors occurred in 85% and symptoms in 62% of the definitions. Severity was considered in about a quarter of the definitions and duration was somewhat included in 28% of them.
The second study is a cohort study that includes the adult population of Denmark. The study explored the nationwide prevalence of multimorbidity and estimated mortality for the most prevalent combinations of 1-5 diagnosis groups. We explored the relative excess mortality of the combination of two diagnosis groups compared to the product of mortality associated with the single groups. In this study multimorbidity was defined as having diagnoses from at least two of the following ten diagnosis groups: lung, musculoskeletal, endocrine, mental, cancer, neurological, gastrointestinal, cardiovascular, kidney, and sensory organs. The prevalence of multimorbidity in the Danish population was 7.1%. The cardiovascular-lung combination was both relatively prevalent (0.2%) and had high mortality (OR 5.75). The combination musculoskeletal-cardiovascular was the most prevalent (0.4%), with a doubled mortality (OR 2.03); the neurological-cancer combination had highest mortality (OR 6.35), but was less prevalent (0.07%). Some combinations had high and some low excess mortality, but generally combinations were additive rather than synergistic. Mortality was found to increase with the number of diagnosis groups.
The third study is a post hoc study of a randomized controlled trial, performed in general practice in Denmark. It explores the effect of an intervention of structured care with personal treatment goals on diabetes symptoms and self-rated health (SRH) 6 and 14 years after diabetes diagnosis when multimorbidity gradually develops. The intervention had an effect on diabetes symptoms after 6, but not after 14 years, and this effect was not explained by the level of glycemic control or multimorbidity. The intervention had no effect on SRH, however, at either of the follow-up points.
In summary, partly because of the high numbers of risk factors that are included, many of the existing definitions of multimorbidity may not necessarily target the patients most in need of treatment and care. By using a definition that includes groups of diagnoses collected from the secondary health care system, we estimated that the prevalence of multimorbidity in the Danish population was 7.1%, which may represent the group of patients with more complex multimorbidity. Some of the combinations of multimorbidity we found could be relevant starting points when considering where organizational and collaborative efforts between different parts of the health care sector could be improved. Furthermore, to include the patients‟ own treatment goals and perspectives in this work, may further improve care for patients with multimorbidity.
Based on the findings presented in this thesis and on the need for further research, my vision for the future is first and foremost to prevent multimorbidity from developing. Furthermore, to have continuous multidisciplinary consultations with relevant generalists and specialists for those patients most in need, with patients playing an important role in setting treatment goals and in prioritizing the important aspects of their lives.
Antal sider252
StatusUdgivet - 26 mar. 2019

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