To identify targets of potential interventions for management of multi-morbid patients

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Dear partners,

the WP 6 meeting in Vilnius in the last 6th -7th November 2014 has recently concluded and we have prepared a summary of the principal contents.

In accordance with the objectives of TASK 1 data derived by the analysis of current database have been presented by the following partner: AIFA, VULSK, NIVEL, ISCIII, IACS, NCPHA, THL, BIOEF. The data presented identify with age, cardiovascular diseases (VULSK and NCPHA), clusters of disability (ISCIII and NIVEL), mental status (ISCIII, NIVEL, IACS), socioeconomic factors (BIOEFF), lifestyle and multimorbidity (THL) the factors that most affect the welfare needs.
During the meeting partners involved in task 1 and task 2 presented the work done.
In accordance with the Task 1.4 objective papers will be produced by all partners involved in databases analysis, and submitted to European Journal of Internal Medicine by December 2014 to contribute to a monographic issue about multimorbidity. At regards indications for the submission will be sent in the next days.
Following you can find the key point for each partner presentation:

  • AIFA ( G. Onder): the analysis has focused on subjects with multimorbidity (³ 2 diseases). It have been found a non linear association between number of diseases and consumption of medications. In particular an older age (> 85 years) is associated with a reduction in resources utilization and an increasing in number of diseases is associated with a reduced use of medicines.

  • VULSK (R. Navikas): the analysis of the has performed taking into account the following variables: age, gender, area (rural/urban), disease duration, medication usage, Hb1AC levels, frequency and length of hospitalization, number of home visits and consultations (Outpatient), use of facilities and medications during hospital stay. The top 5 conditions identified among outpatients have been: Hypertension without HF, Hypertension with HF, Chest pain/Angina, Atrial Fibrillation (AF) Type II DM, while the top 5 among outpatients have been Heart failure, Stroke/TIA/neurological disorders, AF, unstable angina; unspecified angina. The medication most frequently prescribed, In both groups the medication most prescribed are those related to Hypertension, Angina and AF

  • NIVEL (P. Hopman): the performed analysis shows how subjects with more than 1 chronic disease report more frequently difficulties in mobility, self care, usual activities, cognition and refer pain/discomfort vs ones with a single disease (p < 0.05), in addition people with >1 chronic condition are more frequently: male, older, lower educated, lower health literacy, longer post diagnosis time-span, poorer health status, higher prevalence of diseases, lonelier, less happy than the others one. Regard the healthcare utilization the current results suggest as multimorbid subjects differs from the ones with a single chronic condition in gender (female), age (years), numbers of GP contacts, drug prescriptions (ATC3), ³1 Day admissions, ³1 Clinical admissions. Further cluster analysis (subgroups of multimorbid patients) about health care utilization are to be performed.

  • ISCIII (M. João Forjaz): From the analysis of five Spanish databases, at national and local level, the chronic conditions more frequent found are the osteoarticular ones, asthma, heart conditions, diabetes, hypertension, cancer, neuropshychiatric diseases, with a prevalence of multimorbidity over 70% in all databases.

  • IACS (A. Prados-Torres): The large part of patients with DM (> 80%) present 1 or more comorbidities: mental type and non. The association of DM with conditions with pathophysiologic risk profile different from the diabetes (Discordant conditions-DCs ) or mental conditions is associated with a significant impact on the consumption of resources. In fact DCs strongly impact on the utilization of primary and specialised care while the mental comorbidities highly influence both utilization of care and, in addition, the number of hospital admissions and visits to ER.

  • NCPHA: 79 different diagnoses, categorized into 23 groups, have been identified. The most common diseases are represented by coronary artery diseases (61.7%), diabetes (38.3%), cerebrovascular disease (27.2%), arthropathies (12.3%) and thyroid diseases (9.9%).

Three are the most common identified diseases patterns: A) coronary artery diseases plus cerebrovascular diseases (72.8%), B) coronary artery diseases plus diabetes (82.7%), and C) cerebrovascular diseases plus diabetes (55.6%).

The mean number for GP consultations and examinations for the all the three groups is 10 consultations and 2 examinations, while, the mean number of specialized consultation is 3 for the groups A and B, and 2 for the group C.

  • THL (J. Lindström): Baseline multimorbidity is strongly associated with mortality and days spent in hospital during 10-year follow-up , therefore the prevention of the 2nd disease might have a large impact on premature mortality and cost of treatment.

Important risk factors for multimorbidity include smoking, high BMI, high blood pressure and low education. Among people with diabetes, factors increasing the risk of multimorbidity include smoking, BMI, and hypertension. Among people with CVD, factors increasing the risk of multimorbidity include smoking and low fruit and vegetable consumption.

More attention should be paid on modifiable risk factors.

  • BIOEF (R. Nuno): the prevalence of multimorbidity in patients with Type 2 Diabetes Mellitus with the related and unrelated complications, and the direct healthcare costs have been estimated. In all age ranges, healthcare costs in patients with T2DM appear higher than that for chronic patients without this condition and costs increase with age until the range of 80-84 years. In particular the analysis suggests that in the general population: 1) multimorbidity is the norm: it was found in 66.13% of the population aged 65 and over, and increases with age until 85 years. multimorbidity is linked to inequalities: the prevalence of multimorbidity was higher in deprived (69.94%) than better-off (60.22%) areas. 3) tackling multimorbidity is expensive: multimorbid patients account for 63.55% of total healthcare expenditures.

BIOEF and AIFA (E.A. Morán): the identification and summarization of tools able to predict disability, hospital admission, healthcare utilization and costs have been performed through the revision of MEDLINE and Cochrane Library databases referring the period between July 1994 and July 2014. Studies focusing on surgical and paediatric populations and studies from developing countries, have been excluded. Any language restriction have been applying. Of 3.853 records initially identified through electronic database search, only 52 have met publications meeting inclusion criteria. It

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is required little further work to finalize the review.

NIVEL (M. Rijken – P. Hopman) the review of existing care pathways for multimorbid patients has been performed in multiple electronic databases (Medline, Cochrane, Cinahl, EMBASE, PsycINFO, and SciSearch) published between January 2011 and March 2014. Extra data collection and analysis have been derived from the ICARE4EU project and further information about current care programmes / practices targeting people with multi-morbidity have been collected from other European projects traced by CHRODIS WP6 partners. Five preliminary conclusions have been provided: 1) There are many recent initiatives/care programmes in Europe targeting patients with multimorbidity and/or frailty. 2) These programmes aim to increase cooperation, improve coordination of care and reduce use of care services 3) Positive outcomes are often reported or perceived, but there are not much strong evidence based on scientific literature. 4) Strong evidence that Chronic Care (CC) programmes can improve frail patients’ physical and mental health status are available. 5) There aren’t consistent evidence that CC programmes targeting patients with frailty of multimorbidity decrease health care utilization.
TUD (U. Rothe): Two databases have been analyzed (The NBLIII-database of 1.000 employees in Saxony (2008) and the Saxon Diabetes Management Program (SDMP) database of the Saxonian integrated care model with 300.000 patients for the period 2000-2002. In particular in regard to the SDMP database cross-sectional data were evaluated at the beginning of 2000 (group Al) and at the end of 2002 (group A2), and a subcohort of 105,204 patients was followed over a period of 3 years (group B). The statewide implementation of the SDMP resulted in a change in therapeutic practice and in better cooperation. The median HbA1c at the time of referral to DSPs decreased from 8.5 to 7.5%, and so did the overall mean. At the end, 78 and 61% of group B achieved the targets for HbA1c and blood pressure, respectively, recommended by the guidelines compared with 69 and 50% at baseline. Patients with poorly controlled diabetes benefited the most. Preexisting regional differences were aligned. These data seam suggest that the integrated care disease management with practicable integrated quality management including collaboration between GPs and specialist services is an efficient way to improve diabetes care continuously.


In the next year interventions for management of multimorbidity selected by tasks 1 and 2 will be discussed by experts and partners, combined (if possible) and harmonized in a unique innovative approach which will be adapted to local/regional needs implemented in the target population. Implementation will not be performed, but a document with guidelines for replicating the practices in different regions and settings will be produced. In particular Task 3 aims to “Assess and select good practices” using a Delphi consultation process in collaboration with WP4.

Finally the next WP6 meeting in joint with WP7 is likely to be held in Greece in October, 2015 (Data is to be confirmed).

You will find more details in meeting presentations.


All publications, presentations or any other action, involving dissemination and advertising of CHRODIS-JA project, is welcome and should be reported to WP6 leader/co-leader, copying Anna

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