The challenge of multimorbidity in primary care patients with obstructive lung disease

Multimorbidity is a well-recognised problem in primary care and results in challenges for both physicians and patients. The difficulties include lack of organised care for all of the conditions, and disease-specific guidelines can be inadequate: clinical trials typically exclude patients with multimorbidity. These problems are faced in primary care for patients with chronic obstructive lung disease: asthma and chronic obstructive pulmonary disease (COPD).
This research project will identify patterns of morbidity in these patients that are common or represent important risks for future health and wellbeing. This will involve identifying which disease combinations represent the greatest risks, particularly where there are disproportionately greater risks than would be expected from the sum of the two or more conditions. Interactions between diseases could be due to overlapping biological pathways, fragmented healthcare that does not consider all the conditions together, difficulty following treatment guidelines, or polypharmacy and related problems such as poor patient compliance or drug interactions. The outcomes will include cause-specific and all-cause mortality; hospital admission (and diseases associated with admission); inadequate control of COPD and asthma; development of further comorbid conditions; sick-leave, receipt of disability benefits, unemployment, economic inactivity, and retirement; and quality of life.

The project will then identify primary care characteristics that appear to ameliorate the associations of comorbidity combinations with the adverse outcomes. These include continuity of care, where patients tend to see the same physician over time, rather than multiple doctors; use of specialist nurses for management of the chronic pulmonary diseases, as well as other specialists such as for diabetes; involvements of other professionals such as physiotherapists; effective management of polypharmacy; focused treatment of diagnoses such as depression, anxiety and pain to improve other outcomes as treating depression has been shown to improve patients’ self-management of other conditions. Other management and patient characteristics that may modify risk of adverse outcomes associated with multimorbidity will be investigated.