• Derek Yach - the US

Addressing the impact of multiple chronic conditions can improve health and reduce morbidity

Patients with two or more comorbidities are at greater risk of hospitalisation and death, and their numbers are considerable, as revealed by the pandemic. Yet the medical fraternity rarely addresses these conditions collectively, as specialists are trained to practise in silos. It is time for corrective action from the WHO, doctors, governments and researchers.


The pandemic has revealed how multiple chronic conditions (MCCs)—two or more chronic medical conditions present together—are widely prevalent and how frequently they have been precursors of hospitalisation and death from covid-19. Yet across the healthcare sector there is little attempt to address these conditions together. Instead, much of the focus is on individual non-communicable diseases (NCDs), such as cardiovascular disease or diabetes, which increases the risk of serious consequences.


The latest CDC update on chronic conditions associated with higher risk for severe covid-19 includes a wide range of NCDs but does not indicate how commonly they occur together. A major cohort study involving 66 million people in France—almost the entire population—provides this evidence.


The authors observed that the more the comorbidities, the higher the risk. Patients with five or more comorbidities are five times more likely to be hospitalised and 10 times more at risk of in-hospital death compared to those without any. Similar findings have been reported from large cohort studies from the UK and Israel.


The impact of MCCs has been overlooked for decades by World Health Organization, governments, researchers, and companies involved in healthcare. It reflects the historical reality that medical specialities, and their associated pharmaceutical interventions and diagnostics tests are taught and practised in siloes. For example, the latest review of NCD progress published in The Lancet has no mention of MCCs.


It’s crucial to highlight gaps in developing an agreed taxonomy for MCCs, the prevalence of MCCs in different countries, how certain diseases cluster in these settings, and the implications for patients and economies.


Sum of the parts


Definitions of MCCs vary but the simplest is when two or more chronic conditions occur together. Conditions are usually defined loosely. Using these definitions, about 25% of all adults meet the criteria for MCCs in the US, as well as 50% of people aged 45-64 and 81% over the age of 65. Equivalent figures for people over the age of 65 are 45% in China and 71% in Russia.


The negative results of unhealthy behaviours in early life often become visible after the age of 50. Many of these translate into elevated risk factors for a range of diseases, explaining why we see a sharp increase in MCCs with age. However, studies have shown that this outcome is not inevitable. Lifelong healthy lifestyles and prevention strategies can substantially reduce MCCs, leading to healthier ageing.


There is limited data on MCCs in most countries but there is some evidence outlining which chronic conditions tend to cluster. For several low- and middle-income countries (LMICs), for example, such a cluster would typically include HIV/AIDS, TB, diabetes, and hypertension. In high-income countries, typical clusters include Alzheimer’s disease and stroke; and chronic renal disease, diabetes and cardiovascular disease. In all countries, NCDs are often comorbid with mental health disorders, especially depression and anxiety.


Clustering occurs due to common risk factors such as smoking and obesity or one condition leading to another. For example, in LMICs, the risks of obesity, smoking and poor access to healthcare combine to increase clusters of MCCs like diabetes, kidney disease, chronic obstructive pulmonary disease (COPD) and late-stage cervical cancer.


The economic costs of MCCs are considerable to individuals and healthcare systems, driven by steep increases in medication, hospitalisation and diagnostic costs. Patients experience significant nonfinancial costs, which impact their overall quality of life and contribute to accelerated functional decline with age.


Towards a collective approach


As populations age we need to seriously consider how to reduce the number, severity, and consequences of MCCs, rather than focusing on individual conditions in isolation.


This entails giving far greater primacy to the prevention of risk factors such as smoking, lack of physical activity, unhealthy diets, and excess alcohol use. As populations age we need to seriously consider how to reduce the number, severity, and consequences of MCCs, rather than focusing on individual conditions in isolation.


As populations age we need to seriously consider how to reduce the number, severity, and consequences of MCCs, rather than focusing on individual conditions in isolation.

We also need to develop an agreed taxonomy for MCCs and have it routinely used in major reports by the WHO, Institute for Health Metrics and Evaluation (IHME) and others that work with NCDs. This involves getting leading clinical medicine experts to agree on whether we should count specific clinical conditions versus organ systems, how we should adapt medical records to routinely measure MCCs, and which determinants of MCCs should be routinely recorded. This data is invaluable for planning more integrated approaches to healthcare.


Putting patients first


Crucially, patients should be placed at the centre when we address MCCs. Medication adherence, for example, drops with every added medication. Yet many patients are routinely required to take five to 10 medications a day—many with side effects made worse by other medications.


Greater focus on fixed-dose combinations is needed. In particular, the data on common clustering could form the basis for deciding which fixed-dose combination to recommend. Substantial work on ‘polypills’—pills that contain a combination of medications—for cardiovascular disease has application here.

Likewise, advances in the use of artificial intelligence (AI) at the bedside allows for pharmaceutical prescriptions with reduced adverse effects and improved quality of life. From robots in the home to less complex systems like pill dispensing devices or prompts from virtual assistants Siri and Alexa, digital technology can help people better manage medications.

Medication adherence, for example, drops with every added medication. Yet many patients are routinely required to take five to 10 medications a day—many with side effects made worse by other medications.

In both LMICs and high-income countries, nurses with prescribing rights and good clinical training are best placed to help patients with MCCs negotiate complex healthcare needs. It is important that these nurses are trained to address MCCs using care guidelines developed for the purpose, and to use smartphone-enabled AI systems to ensure patients receive optimal therapy to maximise their quality of life—and lower the costs for healthcare systems globally.

 

The opinions expressed are those of the author and do not necessarily reflect the position of Re:solve Global Health.


Derek Yach is an independent global health consultant with more than 30 years’ experience with organisations including the World Health Organization (WHO), World Economic Forum and Yale University. He serves on several advisory boards and has authored or co-authored more than 200 articles covering the breadth of global health.