Non-communicable disease, multi-morbidity and ageing
Managing long-term illness is an important and increasingly costly element of health care, accounting for a high proportion of the work in primary care. The GP QOF contract reflects this activity, with the majority of clinical indicators relating to monitoring and management of long-term conditions. Despite recent improvements in quality of care, there are major unanswered questions about how long-term conditions should be monitored and managed, and some of these questions have substantial cost implications for the NHS. The SPCR has developed or tested potential technologies covering better monitoring and management in primary care to improve the quality of care which patients receive, such as BNP guided treatment in heart failure. A potential example for study is the safety and effectiveness of long-term drug therapy for control of symptoms such as chronic pain, a growing challenge to primary care which draws together research interests across the School.
The monitoring and management of long-term conditions have generally been neglected areas of applied research. There is considerable scope for improved practice and the development of specific clinical tools. While poor monitoring may be an expensive waste, good monitoring can improve patient outcomes. For example, effective self-monitoring of warfarin is associated in trials with a reduction in mortality of one third with no increase in haemorrhage rates. Self-management and support for self-management is a critical technology to investigate across a range of chronic diseases and the principles of psychosocial support in the management of chronic disease similarly crosses disease boundaries. There are major opportunities to develop methods to monitor management of chronic disease using GP morbidity and prescription databases, building on expertise and data resources across old and new School member departments. The SPCR will continue to invest in research into patient self-management options.
This is especially the case with the increasingly recognized importance of co-morbidity or more usually multi-morbidity. Demographic changes in the UK and elsewhere are leading to an ageing population, and co-morbidity is now the norm rather than the exception. For example, of Canadian patients with hypertension, only a third of office visits are for that condition, and in the US population as a whole, 40 percent of the population has two or more significant comorbid conditions[i].
A greater understanding of how diseases interact is important for several reasons. One disorder may make it more likely that a second will occur for a variety of different reasons. For example, the likelihood of having a depressive illness is increased in the presence of diabetes[ii]. People with both diabetes and depression are less physically and socially active[iii] and less likely to comply with medical care than people with diabetes alone[iv].These behaviour changes are, in turn, associated with worse long term health outcomes in terms of disease complications and death in both diabetic patients and those with other chronic diseases[v]. Yet the mechanisms by which these diseases interact within individuals are poorly understood, at cellular, organ, and individual and societal levels. Randomised controlled trials of interventions to improve the management of individuals with multiple conditions that appear to adversely affect each other in observational studies are frequently unsuccessful. This implies that current approaches to the characterisation of individuals with multiple conditions are over-simplistic and that a new approach to systematic thinking and development is needed in all these areas.
The rising prevalence of multi-morbidity has implications for the way in which health care, particularly primary care, is organised and assessed. Efforts to improve the quality of care have fuelled a move towards specialisation within general practice and better vertical integration of primary with secondary care. Examples include the introduction of nurse led specialist clinics for asthma, diabetes and cardiovascular disease in most general practices, and the promotion of GPs with Special Interests (GPwSIs). However, this may lead to reduced efficiency, poorly co-ordinated care and a service that is not necessarily based on patients’ preferences or medical need. Understanding multi-morbidity is therefore important in understanding the aetiology of disease and how health services need to be organised to provide continuity of care and co-ordination of care. Research expertise in the clinical themes within the School provides exciting opportunities to continue to build research into the causes, consequences and optimal care of multi-morbidity. The SPCR programme has explored the links between cardiovascular diseases and mental health, and mental health and musculoskeletal and metabolic diseases. It will also use its research on the patients’ experiences of multi-morbidity to develop interventions for better coordination and continuity of clinical care.