Transforming care for people with multiple chronic conditions: Agency for Healthcare Research and Quality's research agenda

Abstract

Care more particularly for the individual patient than for the especial features of the disease. William Osler 1 One of the most daunting challenges confronting the health care system is how to prevent and manage multiple chronic conditions (MCC) effectively and efficiently. MCC are commonly defined as the co-occurrence of two or more chronic physical or mental health conditions. Some use the term multimorbidity as synonymous with MCC, while others define MCC as including additional factors that contribute to the burden of illness, including disease severity, functional impairments and disabilities, syndromes such as frailty, and sometimes social factors such as homelessness. 2 Regardless of definition, MCC are common, costly, and place a high burden on individuals, their caregivers, clinicians, health care teams, and health systems alike. Our fragmented, disease-focused health care system is ill-designed to meet the needs of this growing population.Although prevalence varies with definition, 3 MCC is the most common chronic condition seen in clinical practice. One in three American adults, four in five Medicare beneficiaries, and a growing number of children have MCC. People living with MCC account for a disproportionate share of health care utilization and costs, 64% of all clinician visits, 70% of all inpatient stays, 83% of all prescriptions, 71% of all health care spending, and 93% of Medicare spending. Almost half have functional impairments. Nearly all readmissions among Medicare beneficiaries occur among those with MCC. 4 The prevalence of MCC will grow with our aging population. The need to

Association of Early Physician Follow-up With Readmission Among Patients Hospitalized for Acute Myocardial Infarction, Congestive Heart Failure, or Chronic Obstructive Pulmonary Disease

“… 49 Guidance and tool kits have been developed to address multiple chronic conditions, including by providing appropriate medication management and care integration, while optimizing quality of life. 49 , 50 …”

Comorbidity: From a Confounder in Longitudinal Clinical Research to the Main Issue in Population Management

“…There are many papers stressing that multiple chronic diseases are a "complex, unpredictable, intractable" problem and some strategies to address the issue [47,[65][66][67][68][69]. The results of the few interventions to improve care for patients with multiple chronic disease have been "mixed, and when effective, modest at best" [65].…”

“…There are many papers stressing that multiple chronic diseases are a "complex, unpredictable, intractable" problem and some strategies to address the issue [47,[65][66][67][68][69]. The results of the few interventions to improve care for patients with multiple chronic disease have been "mixed, and when effective, modest at best" [65]. Partly as a result, there is more emphasis on moving away from cost or utilization as the key criteria for identifying and intervening on patients with multiple chronic disease [70].…”

Assessing Progress Toward the Vision of a Comprehensive, Shared Electronic Care Plan: Scoping Review

“…The second purpose is to provide comprehensive data on clinical conditions and management, as well as patient-reported outcomes, social factors, and patient goals and preferences in order to conduct real world research on people living with multiple chronic conditions. Clinical research on the management of different constellations of disease and health service research on the most effective models of care delivery are both needed [ 1 ]. Furthermore, since common risk factors such as smoking, physical inactivity, and unhealthy diets lead to multiple conditions, research on reducing the risk of developing multiple chronic conditions is also needed.…”

“…Other impairments or disabilities are also sometimes included in the definition of multiple chronic conditions, as are syndromes such as frailty and social factors such as homelessness. Providing integrated person-centered care to people living with multiple chronic conditions is a major challenge [ 1 , 2 ]. People with multiple chronic conditions and their caregivers often experience significant burdens associated with coordinating care across multiple disease states, clinicians, and settings, including scheduling multiple medical appointments, managing complex drug and dietary regimens, and integrating multiple sources of (sometimes conflicting) medical advice [ 3 - 6 ].…”