For older adults with multiple chronic diseases, such as diabetes, depression, heart disease and others, care coordination appears to have the biggest impact on better health, according to a study published in CMAJ (Canadian Medical Association Journal)
By 2050, there will be 2 billion people worldwide older than 60 years. Seniors are the fastest-growing demographic in Canada, and almost half have multiple chronic conditions and consume a substantial portion of health care spending. There will be a greater number of people with chronic diseases, yet there is a lack of understanding about the impact of effective approaches to managing multiple chronic diseases in patients.
To fill this gap, researchers conducted a systematic review of all studies on the topic published in any language between 1990 and 2017. In the final analysis, they included 25 studies, many of which were randomized controlled trials, with 12 579 older adults (average age 67 years). The authors found that care coordination strategies (i.e., organizing different providers and services to ensure timely and efficient health care delivery) have the greatest potential of improving health in seniors with multiple chronic diseases. For example, care coordination involving case management, patient self-management and education of patients and providers significantly reduced symptoms of depression in adults with combined depression and chronic obstructive pulmonary disease or in those with combined diabetes and heart disease.
"Our study highlights the lack of interventions specifically focused on managing co-existing chronic illnesses in older adults, especially those that appear in clusters, such as diabetes, depression, heart disease and chronic obstructive pulmonary disease. Depression is common in patients with diabetes and, because each can be a risk factor for the other, self-care and taking medications correctly can be challenging for improved health," says lead author Dr. Monika Kastner, North York General Hospital and the University of Toronto, Toronto, Ontario.
The authors point out that clinical guidelines usually focus on a single disease, so management of multimorbidity can be overwhelming for patients and difficult for health care providers because of the complexity of overlapping or conflicting treatments with potential adverse interactions. They suggest that interventions to manage multiple chronic diseases should not only focus on clinical aspects of care, but also consider patients' health priorities and goals and their social and emotional well-being.
In a related editorial, Dr. Ken Flegel, deputy editor, CMAJ, writes "when we are thinking about diagnosis, we usually consider one disease possibility at a time. When we are planning management — investigation or intervention — we do the same. This is essential for clarity of thought, but it does not account for the fact that one disease may influence the course of another co-existing one."
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"Effectiveness of interventions for managing multiple high-burden chronic diseases in older adults: a systematic review and meta-analysis" is published August 27, 2018.
Pre-embargo podcast link: https://soundcloud.com/cmajpodcasts/171391-res (available August 24)
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