MULTIMORBIDITY: THE MOST COMMON CHRONIC CONDITION Katherine Thompson, MD; Mariko Wong, MD; Megan Huisingh-Scheetz, MD, MPH University of Chicago, Pritzker School of Medicine Clinical Skills

MULTIMORBIDITY Goal: Learn to balance competing recommendations for management of multiple different conditions while simultaneously incorporating patient preferences and available resources WHEW!! How best to do this? Why is it so important? Emphasize that most of the didactic education learners have received throughout their medical training has been focused on single disease or organ-specific management. This does not accurately reflect the “real world” of medicine today. In order to best care for multimorbid patients, it is helpful to have an approach to decision-making in this patient population.

OBJECTIVES Describe impact of multimorbidity on health care system Practice 5 step approach to multimorbid patients Elicit patient preferences Consider evidence-based treatment options Estimate prognosis Determine clinical feasibility Prioritize plan

MULTIMORBIDITY Definition: Importance: Coexistence of multiple chronic diseases Importance: What percentage of Medicare recipients (>65yo) have multimorbidity? (guesses?) ~70%! How much of our annual healthcare budget is spent on multimorbid patients? ~2/3 (over 300 BILLION dollars annually) Most of the adult patients that learners will encounter during their training are multimorbid. Guidelines and evidence-based medicine fall short when trying to make decisions for multimorbid patients…. What to do? There is usually not one right answer, but it helps to have an approach. Lochner KA, Cox CS. Prevalence of Multiple Chronic Conditions Among Medicare Beneficiaries, United States, 2010. Prev Chronic Dis 2013;10:120137 http://www.fightchronicdisease.org/sites/fightchronicdisease.org/files/docs/ChronicCareChartbook_FINAL_0.pdf Accessed September 3, 2013.

MULTIMORBIDITY: 5 STEP APPROACH Step 1: Elicit Patient Preferences Does the patient prefer to make decisions alone? With caregivers? Does the patient defer decisions to the physician? Recognize that general preferences may not apply to specific situations. Preferences need to be applied to decision at hand Shout out to The American Geriatrics Society’s Guiding Principles for Care of Older Adults with Multimorbidity from which this approach is adapted. The article can be provided to learners prior to the session for background reading or after the session for review: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc. 2012 Oct;60(10):1957-68.

STEP 2: CONSIDER EVIDENCE-BASED TREATMENT OPTIONS What evidence is available (if any)? Does it apply to my patient? What benefits might be expected? What are the harms? How long does the treatment take to achieve benefit? Depending on audience, can keep this explanation simple: “Many clinical trials exclude older, multimorbid patients” Or have a more in-depth discussion of generalizability, meaningful outcomes for older adults, ARR vs. RRR, potential harms, etc.

STEP 3: ESTIMATE PROGNOSIS Does estimated prognosis or remaining life expectancy affect treatment considerations? Consider time to treatment benefit For instance, what is the time to treatment benefit for bisphosphonates? Are they the best choice to reduce fracture risk in someone with a remaining life expectancy of less than one year? Case 1 asks learners to use eprognosis.org to estimate 4-year mortality risk, Case 2 asks learners to estimate remaining life expectancy.

STEP 4: DETERMINE CLINICAL FEASIBILITY Consider patient ability to adhere to plan Treatment regimen complexity Patient education? Non-pharmacologic measures? Discuss limitations to adherence: health literacy, cognitive deficits, functional limitations, financial issues, caregiver availability, etc.

STEP 5: PRIORITIZE CARE PLAN Putting it all together Use strategies for choosing therapies that align with patient preferences, optimize benefit, minimize harm, and enhance quality of life for multimorbid patients This involves weighing all four of the previous steps. Also emphasize that plans should be frequently re-evaluated & revised as necessary.

PRACTICE! Review multimorbid patient case in small groups Work through your 5-step process to create a plan for your patient Break large group in to smaller groups (3-5 learners) and hand out case 1/decision tool 1 to half of the groups and case 2/decision tool 2 to the other half. Participants using case 1 will need a computer/ipad/smart phone to access eprognosis.org. Facilitator(s) can circulate amongst groups to answer questions and provide guidance as needed.

Summary/wrap up Managing multimorbid patients: Not one right answer! Use patient preferences as starting point and guide Use decision model to help create an individualized, prioritized plan Re-evaluate your plan at intervals and adjust as needed Emphasize that going through the process & having an approach is more important than coming to one right answer. The plan will be different for every patient depending on their individual conditions, preferences, and resources. Starting with patient preferences will help promote shared decision-making as well as adherence.