Debate & analysis James Mackenzie lecture 2011: Multimorbidity, goal-oriented care, and equity

Abstract

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Today we face an important demographic and epidemiological transition, confronting us with the challenge of non-communicable diseases (NCDs), which occur more and more in the context of multimorbidity. In the next decade, multimorbidity will become the rule, no longer the exception: 50% of the those aged ≥65 years have at least three chronic conditions, whereas 20% of the ≥65-year group have at least five chronic conditions.1 In the case of COPD, for example, more than half of the patients have at least one comorbid disease.2

In recent years, not only Western countries, but also developing countries started with ‘chronic disease management-programmes’ to improve care. The design of those programmes include most frequently: strategies for case-finding, protocols describing what should be done and by whom, the importance of information and empowerment of the patient, and the definition of process- and outcome-indicators that may contribute to the monitoring of care.

Wagner has described the different components of the Chronic Care Model (CCM) as developed in the context of primary health care.3 The CCM has inspired policy makers and providers all over the world and is widely accepted in the US and Canada, Europe, and Australia. Taking into account the epidemiological transition, we are faced with the question: ‘How will this approach work in a situation of multimorbidity’?

Let us illustrate this with a patient from our general practice, we call her ‘Jennifer’ (Box 1).

#### Box 1. Jennifer

Jennifer is 75 years old. Fifteen years ago she lost her husband. She has been a patient at the practice for 15 years now. During these 15 years she has been through a difficult medical history: hip replacement surgery for osteoarthritis, hypertension, type 2 diabetes, and COPD. She lives independently at home, with some help from her youngest daughter, Elisabeth. I visit her regularly …

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Full text

INTRODUCTION
Today we face an important demographic
and epidemiological transition, confronting
us with the challenge of non-communicable
diseases (NCDs), which occur more and
more in the context of multimorbidity. In the
next decade, multimorbidity will become the
rule, no longer the exception: 50% of the
those aged ≥65 years have at least three
chronic conditions, whereas 20% of the ≥65-
year group have at least five chronic
conditions.1In the case of COPD, for
example, more than halfof the patients have
at least one comorbid disease.2
HOW DO WE ADDRESS PATIENTS WITH
MULTIMORBIDITY TODAY?
In recent years, not only Western countries,
but also developing countries started with
‘chronic disease management-
programmes’ to improve care. The design of
those programmes include most frequently:
strategies for case-finding, protocols
describing what should be done and by
whom, the importance of information and
empowerment of the patient, and the
definition of process- and outcome-
indicators that may contribute to the
monitoring of care.
Wagner has described the different
components of the Chronic Care Model
(CCM) as developed in the context of primary
health care.3The CCM has inspired policy
makers and providers all over the world and
is widely accepted in the US and Canada,
Europe, and Australia. Taking into account
the epidemiological transition, we are faced
with the question: ‘How will this approach
work in a situation of multimorbidity’?
Let us illustrate this with a patient from
our general practice, we call her ‘Jennifer’
(Box 1).
According to the actual guidelines,
Jennifer is faced with a lot of tasks4: joint
protection, aerobic exercise, muscle
strengthening, a range of motion exercising,
self-monitoring of blood glucose, avoiding
environmental exposure that might
exacerbate COPD, wearing appropriate foot
wear, limiting intake of alcohol, maintaining
body weight. Her medication schedule
includes 11 different drugs, with a total of 20
administrations a day. The clinical tasks for
the GP include vaccination, blood pressure
control at all clinical visits, evaluation of self-
monitoring of blood glucose, foot
examination, and laboratory tests. Moreover,
referrals are needed to physiotherapy, for
ophthalmologic examination, and pulmonary
rehabilitation. So, Jennifer’s reaction is not
unexpected.
Jennifer’s case clearly illustrates the need
for a paradigm-shift for chronic care: from
problem-oriented to goal-oriented care. In
1991, Mold and Blake5recognised that the
problem-oriented model, focusing on the
eradication of disease and the prevention of
death, is not well suited to the management
of a number of chronic illnesses. Therefore
they proposed a goal-oriented approach that
encourages each individual to achieve the
highest possible level of health as defined by
that individual. Goal-oriented care assists an
individual in achieving their maximum
individual health potential in line with their
individually defined goals. The evaluator of
successis the patient, not the physician. And
what really matters for patients is their
ability to function (functional status), and
social participation. So, certainly in the
context of multimorbidity, there is a need for
a shift from ‘chronic disease management’
towards ‘participatory patient management’,
with the patient at the centre of the process.
For many people, giving meaning to the
chronic illness process they are going
through, is of the utmost importance. Safety
and avoiding side-effects (not having to
suffer more from the treatment than from
the disease) is very important. Patients
expect comprehensiveness in their care
instead of fragmentation.
A recent survey of ‘chronic disease
management’ in 10 European countries6
illustrated that most of the programmes use
a vertical disease-oriented approach.
Although much hasbeen learnt from vertical
disease-oriented programmes, evidence
suggests that better outcomes occur by
addressing diseases through an integrated
approach in a strong primary care system.
Vertical disease-oriented programmes for
HIV/AIDS, malaria, tuberculosis, and other
infectious diseases foster duplication and the
inefficient use of resources, produce gaps in
the care of patients with multimorbidity, and
James Mackenzie Lecture 2011:
multimorbidity, goal-oriented care, and equity
Debate & Analysis
e522 British Journal ofGeneralPractice, July 2012
Box 1. Jennifer
Jennifer is 75 years old. Fifteen years ago she lost her husband. She has been a patient at the practice
for 15 years now. During these 15 years she has been through a difficult medical history: hip
replacement surgery for osteoarthritis, hypertension, type 2 diabetes, and COPD. She lives
independently at home, with some help from her youngest daughter, Elisabeth. I visit her regularly and
each time she starts by saying: ‘Doctor, you must help me’. Then follows a succession of complaints
and feelings: sometimes it has to do with her heart, another time with lungs, then the hip, … Each time I
suggest — according to the guidelines — all sorts of examinations that do not improve her condition.
Her request becomes more and more explicit, my feelings of powerlessness, inadequacy, and irritation,
increase. Moreover, I have to cope with guidelines that are contradictory: for COPD she sometimes
needs corticosteroids, which always worsens her diabetes control. The adaptation of the medication for
the blood pressure (once too high, once too low) does not meet with her approval, and nor does my
interest in her HbA1C and lung-function test results. After so many contacts, Jennifer says:
‘Doctor, I want to tell you what really matters to me. On Tuesday and Thursday, I want to visit my friends
in the neighbourhood and play cards with them. On Saturday, I want to go the supermarket with my
daughter. Foremost, I just want some peace. I do not want to continually change the therapy anymore,
especially not having to do this and to do that’.
In the conversation that followed, it became clear to me how Jennifer had formulated the goals for her
life. I felt challenged to identify how the guidelines could contribute to the achievement of Jennifer’s
goals. I have visited Jennifer with pleasure ever since. I know what she wants and how much I can
(merely) contribute to her life.

British Journalof GeneralPractice, July2012 e523
reduce, especially in developing countries,
government capacity by pulling the best
healthcare workers out of the public health
sector to focus on single diseases.7
Moreover, vertical programmes cause
inequity for patients who do not have the
‘right’ disease.8Horizontal primary care
provides the opportunity for integration and
addresses the problem of inequity, providing
access to the care of all health problems,
thereby avoiding ‘inequity by disease’.9
NEED FOR NEW TYPES OF EVIDENCE:
MEDICAL, CONTEXTUAL, AND POLICY
EVIDENCE
As far as medical evidence is concerned,
within primary health care, we are
confronted with the tension between the
results of clinical research on the one hand
and the needs of daily clinical practice on the
other hand.10 The available research
generally does not include a representative
sample of patients with respect to age and
ethnic origin or comorbidity, and does not
take into account the typical non-specific
presentation of symptoms at an early
disease stage. As the case of Jennifer (Box 1)
illustrates, within primary care, questions
arise on which evidence to follow in the case
of multimorbidity.
If we want to take the goals of the patient
into account, weneed a newtype of evidence:
‘contextual evidence’, to assist doctors in
addressing the challenge of how to treat a
particular patient in a specific situation.
Contextualevidencedeals withthe principles
of good doctor–patient communication to
create trust in the interpersonal
relationships, the exchange of pertinent
information, exploration of the goals of the
patient, and negotiation of treatment-related
decisions.
To better understand the goals of the
patients, weneednew research frameworks:
patients with multimorbidity will be the rule
(instead of an exclusion criterion) and
complexity will be embraced instead of
avoided.11 The International Classification of
Function (ICF)12 might become as important
as the International Classification of
Diseases, as it provides a conceptual
framework in which different domains of
human functioning are defined. These
domains are classified from an eco-bio-
psychosocial viewpoint by means of a list of
body functions and structures, and a list of
domains of activity and participation. As an
individual’s functioning and disability involves
a context, the ICF includes a list of
environmental factors and the concept of
personal factors in its framework.
Finally, there is a need to enrich daily
practice in primary care with more ‘policy
evidence’, which entails efficiency and equity.
MULTIMORBIDITY, GOAL-ORIENTED
CARE, AND EQUITY
When implementing goal-oriented care,
there may be a threat to equity, as the way
goals are formulated by patients may be
determined by, for example, social class.
Moreover, integrating ‘contextual evidence’,
implies the risk of taking the context for
granted: people livingin poverty will generally
have been obliged to take on lower
expectations in terms of quantity and quality
of life than well-educated people. So, ‘goal-
oriented medical care’ could contribute to an
increase in social inequities in health. This
challenges primary healthcare providers with
the question of how to deal with an
‘unhealthy’ and ‘inequitable’ context. It is
obvious that this cannot be the responsibility
onlyof primary care providers. They mayhave
an important ‘signalling’ role to document
and draw attention to the problems that
patientsarefacing.This is where community-
oriented primary care (COPC) comes into the
picture. COPC integrates individual and
population-based care,blending clinicalskills
of practitioners with epidemiology, preventive
medicine, and health promotion.13 Starting
from observations in daily patient care, COPC
makes a systematic assessment of
healthcare needs in practice populations,
identifies community health problems,
implements systematic interventions,
involving a target population (for example,
modification of practice procedures, and
improvement of living conditions), and
monitoring the effect of changes to ensure
that health services are improved and
congruent with the needs of individual
patientsandof thecommunity. COPCdesigns
specific interventions to address priority
health problems. Teams consisting of
primary healthcare workers and community
members assess resources and develop
strategic plans to deal with problems that
havebeenidentified.So, COPC is anessential
part of a strategy to re-orientate care towards
the needs and the goals of the individual and
of the community. It will help to identify the
‘upstream causes’ that lead to social
inequities in health.14
CONCLUSION
Approaching a patient with multimorbidity
challenges both practitioners and
researchers. It challenges institutions for
health professionals’ education to train
providers that are not only ‘experts’, or
excellent ‘professionals’, but that are also
‘change agents’ that continuously improve
the health system and question the reality of
knowledge and care, as did James
Mackenzie. It requires fundamental
reflection on the individual provider–patient
interaction, on the need for a paradigm-shift
from problem-oriented to goal-oriented
care, on the organisation of the healthcare
services and the features of the health
system. Most fundamentally, it will also
require dialogue and communication
methodologies between the health sector
and people in need of health care and with
other stakeholders within society involved in
health care at the practice-, research-, and
policy-level, in order to guarantee the
essential characteristics of an effective
health system: relevance, equity, quality,
cost-effectiveness, sustainability, people-
centeredness, and innovation.
JanDe Maeseneer,
Professor, Department of General Practice and
Primary Health Care, Ghent University, Belgium and
Chairmanof the European Forum for Primary Care.
Pauline Boeckxstaens,
Department of Family Medicine and Primary Health
Care, Ghent University, Belgium.
This text is basedon the James Mackenzie Lecture
given at the Royal College of General Practitioners
Annual General Meeting on 18November 2011.
Acknowledgement
We thank Iona Heath for suggestions to improve the
text.
“Moreover, vertical programmes cause inequity for
patients who do not have the ‘right’ disease.”
ADDRESS FORCORRESPONDENCE
Jan De Maeseneer
Department of General Practice and Primary,
Health Care, Ghent University, UZ–1K3, De
Pintelaan 185, Ghent, B–9000, Belgium.
E-mail: jan.demaeseneer@ugent.be
©British Journalof GeneralPractice
This is the full-length article (published online
25 Jun 2012) of an abridged version published in
print. Cite this article as: BrJ Gen Pract 2012;
DOI: 10.3399/bjgp12X652553.

e524 British Journal ofGeneralPractice, July 2012
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