Changes

June 2023— reviewed. A literature search was conducted in May 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials conducted since the previous search. No major changes have been made to the recommendations. 

Update

Goals

To support primary healthcare professionals to:

• Identify people who would benefit from a multimorbidity approach.
• Assess people with multimorbidity.
• Manage people with multimorbidity.

Outcome measures

Audit criteria

QOF indicators

No specific QOF indicators for multimorbidity were found during the review of this topic. The indicators relating to specific medical conditions in the Quality and Outcomes Framework (QOF) of the General Medical Services (GMS) contract can be found in the relevant CKS topics.

QIPP - Options for local implementation

NICE quality standards

• Adults with multimorbidity are identified by their GP practice.
• Adults with an individualised management plan for multimorbidity are given opportunities to discuss their values, priorities and goals.
• Adults with an individualised management plan for multimorbidity know who is responsible for coordinating their care.
• Adults having a review of their medicines and other treatments for multimorbidity discuss whether any can be stopped or changed.

[NICE, 2017]

What is multimorbidity?

• Multimorbidity refers to the co-existence of two or more long-term health conditions, which can include:
• • A physical non-communicable disease of long duration, such as diabetes, cardiovascular disease, or cancer.
  • A mental health condition of long duration, such as a mood disorder, schizophrenia, or dementia.
  • An infectious disease of long duration, such as HIV or hepatitis C.
• Additional health conditions that commonly contribute to multimorbidity include:
  
  • Ongoing conditions, such as learning disability.
  • Symptom complexes, such as frailty or chronic pain.
  • Sensory impairment, such as sight or hearing loss.
  • Alcohol or substance misuse.
• Multimorbidity is also referred to as 'multiple long-term conditions', which is often the preferred nomenclature in patient groups.

[NIHR, 2020; Skou, 2022]

How common is it?

• Multimorbidity is almost universal in older adults, and prevalence increases with age.
• The reported population prevalence varies between studies due to the different mean ages of the study populations and variations in the defined core conditions that contribute to multimorbidity.
• A meta-analysis of 193 international studies found that the pooled prevalence of multimorbidity was 42.4% across all age groups, with high heterogeneity between studies.
  • In people aged under 59 years, 59 to 73 years, and 74 years and over, the pooled prevalence of multimorbidity were 28.0%, 47.6%, and 67.0% respectively.
• Studies of adults suggest that globally, approximately one-third have multimorbidity, rising to over 50% of people with chronic health conditions.
• In a good-quality retrospective cohort study in England (n=403,985), the overall prevalence of multimorbidity was 27.2%.
  
  • Prevalence increased significantly with advancing age.
  • Females had a higher prevalence of 30%, compared to 24.4% for males.
  • In people with multimorbidity, 33.8% had both a physical and mental health morbidity.
  • The majority of people with multimorbidity aged 18–24 years had physical–mental comorbidity (56.5%), compared with 23.7% of people aged 75–84 years.
  • The proportion of people with multimorbidity who had a physical–mental comorbidity increased substantially with greater socioeconomic deprivation.
• In a large Scottish study (n=1,751,841), the prevalence of multimorbidity was estimated to be 23.2%.
  • The prevalence of multimorbidity increased substantially with age — half of the people had at least one morbidity by age 50 years, and by age 65 years most were multimorbid.
  • However, more than half of people with multimorbidity and nearly two-thirds with physical–mental health comorbidity were younger than 65 years, and the onset of multimorbidity occurred 10-15 years earlier in people in areas of socioeconomic deprivation.  
  • Socioeconomic deprivation was also associated with multimorbidity, which included mental health disorders. The prevalence of mental health disorders increased with the number of physical disorders.
• For details of the most prevalent morbidities and their associated comorbidities, see Table 1.

Table 1. Ten most prevalent morbidities and associated comorbidities.

[Barnett, 2012; Cassell, 2018; Ho, 2022; Skou, 2022]

What are the risk factors?

• Risk factors for multimorbidity include:
  • Increasing age.
  • Female sex.
  • Lower socioeconomic status.
  • Pre-existing medical conditions (for example hypertension and osteoporosis).
• Other factors that may increase the risk of multimorbidity include:
  • Tobacco and alcohol use.
  • Lack of physical activity.
  • Poor nutrition and obesity. 
• Pregnancy also increases the likelihood of multiple concurrent conditions.

[Willadsen, 2016; AMS, 2018; Cassell, 2018; NIHR, 2020; Ho, 2022; Skou, 2022]

What are the complications?

• Multimorbidity is associated with:
  • Reduced quality of life.
  • Reduced life expectancy.
  • High treatment burden — understanding and self-managing conditions, attending multiple appointments, managing complex drug regimens and adhering to lifestyle changes, in addition to engaging with multiple healthcare professionals.
  • Mental health difficulties. 
    • Anxiety and depression are more common in people with multimorbidity, which can impact their ability to manage their conditions.
    • People with cognitive impairment are particularly vulnerable and may have added difficulties in managing their conditions.
  • Fragmentation and potential problems with coordination of care — managing contact with multiple health professionals in primary and secondary care.
  • Functional difficulties — these increase with an increasing number of conditions and in people aged over 75 years.
  • Polypharmacy and higher rates of adverse drug events — the risks may be higher in people who are older, disabled, or people with mental health conditions that may limit self-care and adherence to treatment.
    • The greater the number of chronic conditions, the greater the likelihood of patient-reported safety incidents. Evidence from populations aged 65 years or over also suggests that treatment by multiple prescribers is an independent predictor of reports of adverse drug events. 
  • Increased use of health services (including unplanned or emergency care). 
• Multimorbidity also has a negative impact on the health and wellbeing of carers.

[Wallace, 2015; AMS, 2018; Damarell, 2020; Skou, 2022]

Who should I assess for multimorbidity?

• Identify people who may benefit from an approach to care that takes account of multimorbidity:
  • Opportunistically during routine care.
  • Proactively using healthcare records, for example, assessing the number of regular medicines a person is prescribed. 
    • People taking 15 or more regular medicines are likely to be at higher risk of adverse events and drug interactions.
• Consider that people may need a multimorbidity approach if they:
  • Find it difficult to manage their treatments or day-to-day activities.
  • Receive care and support from multiple services and need additional services.
  • Have both long-term physical and mental health conditions.
  • Have frailty or are at risk of falls.
  • Frequently seek unplanned or emergency care.
  • Are prescribed 10–14 regular medicines, or are prescribed fewer than 10 regular medicines but are at particular risk of adverse events.
• Consider using a validated tool such as the electronic frailty index (eFI), predicting emergency admissions over the next year (PEONY) or QAdmissions (if available in primary care electronic health records) to identify adults with multimorbidity who are at risk of adverse events, such as unplanned hospital admission or admission to care homes.

How should I assess people with multimorbidity?

• Establish the extent of the disease burden — ask how the 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.
• Establish the treatment burden — ask how treatments affect their day-to-day life. Include a discussion of:
  • The number and type of healthcare appointments and where these take place.
  • The number and type of medicines they take and how often they experience harm from medicines.
  • Non-pharmacological treatments such as diets, exercise programmes, and psychological treatments.
  • Any effects of treatment on their mental health or wellbeing.
• Explore the person's attitudes to their treatments and the potential benefits and harms of those treatments — follow the recommendations on patient involvement in decisions about medicines and understanding the person's knowledge, beliefs, and concerns about medicines in the NICE guideline on medicines adherence.
• Also ask about and consider:
  • Social circumstances, financial constraints, living conditions, and social support.
  • Health literacy.
  • Functional autonomy.
  • Coping strategies.
• Be alert to the possibility of:
  • Depression and anxiety — consider identifying, assessing, and managing these conditions. For more information, see the CKS topics on Depression and Generalized anxiety disorder. 
  • Chronic pain and the need to assess this, and the adequacy of pain management.
• Encourage people with multimorbidity to clarify what is important to them, including their personal goals, values, and priorities — these may include:
  • Maintaining their independence.
  • Participating in family life, work, or social activities.
  • Preventing specific adverse outcomes (for example stroke), reducing harms from medicines.
  • Reducing treatment burden.
  • Improving the quality and length of life.
  • Pain and symptom relief, including palliative care needs.
• Consider assessing frailty in people with multimorbidity.
  • Be cautious about assessing frailty in people who are acutely unwell.
  • Do not use a physical performance tool to assess frailty in people who are acutely unwell.
• Clarify whether, and how, they would like their partner, family members, and/or carers to be involved in key decisions about the management of their conditions and review this regularly. 
  • If applicable, consider preferences of informal caregivers or family.

Scenario: Management

From age 18 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of multimorbidity.

Search dates

May 2018 - May 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for EBSCO Medline.

• MH "Multimorbidity"
• TI ((multimorbid* or multi-morbid* or comorbid* or co-morbid* or polymorbid* or poly-morbid* or multidisease* or multi-disease* or (disease cluster*))) 
• TI ((multiple or concurrent* or coexist* or co-exist* or cooccur* or co-occur*) N1 (disease* or condition* or syndrome* or disorder*)) 
• MH "Polypharmacy+" 
• TI (polypharmacy or poly-pharmacy or deprescribing) 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.