Table 5.
Optimal care models and teams for managing comorbidity in multiple sclerosis (MS).
| Management Concern | Optimal Approach | Specific MS Considerations |
|---|---|---|
| Single-disease focus adopted by healthcare systems & providers (result: fragmented, inefficient & sometimes discordant care and adverse health/quality of life consequences for person with MS and their family caregivers) |
Reconfigure and technologically enhance healthcare systems – including improved balance & integration of, and communication between, specialists, generalists, and primary care providers Develop & implement healthcare policies that account for comorbidity and facilitate integration/continuity of care and person/family centered approaches Modify existing curricula to better educate new clinicians about comorbidity and its prevention & management |
Include persons with MS and their family caregivers in discussions of what changes are most needed and how best to implement them Focus first on changes to healthcare systems/policies that prioritize complex comorbidity (e.g., affect multiple body systems), prevalent disease clusters (e.g., MS with depression), and/or comorbidity deemed most important to persons with MS/family caregivers Expand MS-focused interdisciplinary care teams that address identified priorities, collaborative (health & social) care needs, and support self-management, medicines management, and healthy behaviours including those relevant to comorbidity Conduct research on implementation efforts and include outcomes important to persons with MS/family caregivers (not only healthcare use, costs, barriers, and facilitators) |
| Single-disease focus adopted by existing clinical practice guidelines (result: failure to modify treatment & clinical/lifestyle recommendations to address disease-disease, disease-drug & drug-drug effects; increased treatment burden for person with MS and their family caregivers) |
Comprehensive person/family-centered approach, considering heterogeneity of comorbidity present and care goals, values, and preferences of person with MS and their family caregivers Consider how management/treatment of a single condition might be modified to mitigate treatment burden and adverse health & quality of life outcomes associated with co-occurring chronic conditions (especially discordant comorbidity), medications and frailty (e.g., UK NICE guideline on multimorbidity, https://www.nice.org.uk/guidance/ng56) |
Conduct research to illuminate MS relevant care gaps/concerns in current MS-specific clinical practice guidelines as well as guidelines for prevalent comorbidity in MS (ensure participation of interdisciplinary healthcare providers, persons with MS/family caregivers throughout research) Examine and modify (where supported by evidence) current MS clinical practice guidelines to acknowledge the complexity and burden of care imposed by comorbidity, medicines management & frailty (including input from interdisciplinary healthcare providers, persons with MS/family caregivers) Examine and recommend areas to modify (where supported by evidence) current clinical practice guidelines for prevalent comorbidity in MS (including input from interdisciplinary healthcare providers, persons with MS/family caregivers) Conduct research on implementation efforts and include outcomes important to persons with MS/family caregivers (including treatment burden, cost, non-adherence, care experience) |
| Socioeconomic and racial, and ethnic inequalities in availability, accessibility, affordability and continuity of care (result: even greater fragmentation of care, treatment burden & poorer health and quality of life outcomes for those who face the highest incidence of comorbidity and at younger ages) |
Consider how changes to healthcare systems & policies and clinical practice guidelines specifically address (or potentially worsen) inequalities in the management of comorbidity among diverse age, sex, racial/ethnic populations Prioritize funding initiatives to address current research gaps in the optimal prevention, treatment & management of comorbidity in younger-aged and racially/ethnically diverse populations (particularly given recent trends in the incidence/prevalence of comorbidity/multimorbidity and unique challenges faced by these populations) |
Ensure that above considerations and implementation research efforts include persons with MS from diverse age, sex, racial/ethnic populations and consider their unique comorbidity care needs (including comorbidity burden, barriers to optimal self-care and medicines management) Conduct research to better understand prevalence of comorbidity clusters in MS and their association with MS care and physical/cognitive/quality of life trajectories among diverse age, sex, racial/ethnic populations |
Important caveats: Evidence base for the most appropriate interventions for the treatment and management of comorbidity/multimorbidity is generally weak and more robust longer-term investigations are needed (though there are many challenges to conducting this research and barriers (at patient, system, provider level) to implementing findings into practice) (95).