Living with multiple chronic conditions: how we achieve holistic care and optimize health outcomes

Editorial note:

Editorials are opinion pieces. This piece has not been subject to peer review and the opinions expressed are those of the authors. None of the authors have relevant political or other affiliations to declare.

Multimorbidity or living with two or more chronic conditions is a growing concern and poses not just a major challenge to health care systems around the world but also calls into question how we approach the design and evaluation of clinical interventions and models of care. Cardiovascular disease (CVD) is a leading cause of death globally and an exemplar condition where individuals live with multimorbidity. A typical individual with CVD aged 65 years and older has multiple conditions, yet the clinical practice and research still focus on a single risk factor or disease condition in isolation (Rahimi et al., 2018). The proportion of individuals living with multimorbidity including CVD is projected to increase globally as the population ages and advances in medical care improve longevity. With increasing multimorbidity, the current healthcare system is in danger of being overwhelmed and rendered less effective as the current single disease-focused model becomes obsolete (Ong et al., 2020). Individuals living with multiple chronic conditions live with a high symptom burden and an increased vulnerability to stressors that affect their health status and overall quality of life (Corwin et al., 2021). Multimorbidity impacts beyond the individual. Living with multiple chronic conditions leads to greater caregiver burden, higher healthcare utilization and more critical care admissions, increased healthcare costs, and a higher likelihood of mortality (Salive, 2013). The health care costs associated with multimorbidity can be extremely high due to disproportionate rates of primary and secondary care visits and unplanned hospitalizations.

There is limited research that explores significant determinants, challenges, and management strategies in patients with multimorbidity. This is potentially related to the challenges of identifying and recruiting patients with general multimorbidity for clinical research. Many clinical trials focus on single diseases and often specifically exclude individuals with comorbidities (Boyd et al., 2012). Similarly, practice guidelines and performance indicators are commonly disease-specific and oftentimes fail to consider the interaction between multiple chronic conditions, medications, and environmental stressors. Often for individuals living with multimorbidity, services tend to be highly specialized, often duplicative, fragmented and can be inaccessible, particularly to traditionally underserved patient populations. Healthcare systems need to radically change their approaches to combat the challenges and complexity that multimorbidity presents (Szanton et al., 2020).

Example: heart failure, multimorbidity, and COVID-19 pandemic

Heart failure (HF) is a manifestation of CVD and is a leading cause of hospitalization (Salah et al., 2022) and one of the most common diagnoses at discharge for people aged 65 years and older. HF also represents a group in which almost all individuals experience multimorbidity and the impact of multimorbidity on disease trajectory and outcomes of heart failure is increasingly acknowledged (Rahimi et al., 2018). There is a higher prevalence of hospital readmissions and other health outcomes among people living with HF and multimorbidity (Reddy & Borlaug, 2019). People diagnosed with HF have an average of six co-morbid conditions, and about 65% of their hospital readmissions are for diagnoses other than HF (Caughey et al., 2019). This highlights the pervasiveness of multimorbidity among people living with HF and the effect that it has on patient outcomes, quality of life, healthcare utilization and costs. The presence of multiple chronic conditions along with HF increases the risk for poor health outcomes, which significantly affects the severity and progression of HF as well as the complexity of the management and care (Caughey et al., 2019). Treatment conflicts, for example, the use of medicine for other comorbid conditions may worsen HF, and drug-to-drug interaction are also common issues among patients with HF (Caughey et al., 2019). Furthermore, the COVID-19 pandemic has intensified the problem. There are significant links between HF, multimorbidity, and the COVID-19 pandemic. First, the COVID-19 pandemic has had an impact on HF and other chronic condition management due to reductions of preventative care visits and hospitalizations during the pandemic that could possibly lead to an increased likelihood of worse health outcomes and mortality (Italia et al., 2021). Second, living with HF and other chronic diseases is one of the risk factors for the more severe clinical course of COVID-19. Lastly, HF can be a consequence of COVID-19-associated myocardial damage and may lead to poor health outcomes among patients living with multiple chronic conditions (Italia et al., 2021).

Complexity of care in current system

Individuals living with multiple chronic conditions often have multiple medical and social issues, and consequences are exacerbated by both the types and numbers of conditions. Although the challenges of efficiently and effectively managing care among individuals living with multimorbidity have been recognized, the complexity of the phenomenon is not well understood. There are various individual, societal, and system complexities that patients and caregivers face while navigating care that can make it difficult to understand each condition, each treatment, and the interactions among conditions and treatments. Individuals with multimorbidity have reported higher disease burden, symptom burden and treatment burden due to complex consultations and disease management needs (Caughey et al., 2019). In the general population, individuals living with five or more chronic diseases have an average of about 14 physician visits per year compared with only 1.5 physician visits per year for those with no chronic diseases (Page et al., 2016). Further, mental health issues compound other comorbid conditions increasing the complexity of care, healthcare utilization, and cost. These factors increase the chances for patients with multiple care needs to fall through the cracks. Current evidence highlights key overarching themes among patients living with multiple chronic conditions; themes include a lack of holistic care; the higher burden for patients, caregivers, and healthcare providers; insufficient guidance for treatment plans; a limited understanding of the preferences of patients and their family members; and poor communication (van der Aa et al., 2017). Advancing the quality of care for individuals with multiple conditions is challenged by current approaches that silo individual diseases and specialists (Ong et al., 2020).

Future directions

Because most clinical guidelines or management programs for chronic conditions management focus on specific and single diseases, there is a rising concern that these guidelines and strategies may not be adequate or effective for people living with multiple chronic conditions (Ong et al., 2020). General practitioners and primary and acute care teams, including nurses, have a vital role in managing individuals with multimorbidity, using a patient-centered generalist approach (Rahimi et al., 2018). However, we recognize that patients have frequent interactions with the acute care system challenging care coordination. Patients’ experiences and healthcare preferences in the context of multimorbidity need to be further explored as these can contribute to improving care models for the future (van der Aa et al., 2017). This will not only require an essential change in how health care systems are organized and funded in order to understand and successfully manage the challenges of multimorbidity but also how we develop and test interventions and monitor outcomes.

Conclusion

There are many challenges in the management of multimorbidity exacerbated by multifaceted patient, provider and system issues. Individuals living with multiple chronic conditions require a holistic approach to their care that balances often-competing priorities, needs and treatment goals. Constituting one of the most substantial challenges for health care in the current century, more research is needed to explore and evaluate the several determinants, outcomes, and consequences of multimorbidity.