Chronic diseases: what happens when they come in multiples?

Multimorbidity is the coexistence of two or more chronic diseases in an individual.1 Prevalence studies indicate that it is the normal state of affairs, especially in patients over the age of 65 years.1 A smaller sub-group of patients are more severely affected by multimorbidity as the combination and severity of their conditions results in significant loss of function, poor quality of life, and frequent hospital admissions. There is a need to examine the health care of patients with multimorbidity, as they often receive fragmented specialist care which does not meet their needs, or indeed support their professional carers, especially in primary care. Chronic disease care is now based on protocol driven management for a single disease across primary and secondary care.2 The commonly used term ‘comorbidity’ implies that there is an index disease to which coexistent diseases relate and may share an aetiology and perhaps a solution. In clinical practice individual patients often suffer from a collection of chronic illnesses which may or may not have a common aetiology, but which require greatly differing and often incompatible management. This is why we use the term multimorbidity here. Individuals with multimorbidity are more likely to die prematurely, be admitted to hospital, have longer hospital stays, poorer quality of life, and a loss of physical functioning.3,4 They are more likely to suffer from depression, to be receiving multiple medications, and to have consequent difficulties with adherence to treatment and polypharmacy.5,6 Qualitative research indicates that patients with multimorbidity identify loss of function and polypharmacy as key problem areas.7 There are multiple barriers to self-care including physical limitations and aggravation of one condition by treatment of another.8 Research also highlights difficulties accessing care8 and problems with healthcare providers, particularly specialists.7 Analysis …