Title: Multimorbidity-associated emergency hospital admissions: a “screen and link” strategy to improve outcomes for high-risk patients in sub-Saharan Africa
Funder: Department of Health and Social Care

Abstract: RESEARCH QUESTION What is the optimal structure for healthcare systems to effectively recognise and treat adults admitted to hospital with multimorbidity in sub-Saharan Africa? BACKGROUND Sub-Saharan Africa suffers from an interplay of high rates of infectious disease and rising prevalence of non-communicable diseases, resulting in multimorbidity. Importantly, HIV (and anti-retroviral treatment) can accelerate non-communicable disease. Patients frequently delay seeking treatment until they are severely ill and require emergency management. Hospital care then predominantly focusses on the primary presenting problem, overlooking multimorbidity. This oversight precipitates frequent hospital admissions, increases health system and out-of-pocket expenses, and leads to disability and death. AIM To design and test a system which identifies patients suffering from multimorbidity during emergency assessment in sub-Saharan African hospitals, optimises immediate treatment, and ensures post-discharge linkage to appropriate care. OBJECTIVES To confirm the prevalence of multimorbidity in patients attending acute hospital services in Malawi and Tanzania. To create a strategy to recognise and treat multimorbidity using point-of-care tests incorporated into the emergency care pathways in Malawi and Tanzania, maximising acceptability to patients and healthcare workers, and optimising the impact of available resources. To test the optimised emergency care pathway intervention with a primary outcome of hospital admission-free survival three months after hospital admission. METHODS In Malawi and Tanzania, we will research the most efficient pathway to improve the early diagnosis of common medical presentations (including hypertension, diabetes, HIV treatment failure) using point-of-care tests in emergency departments. We will develop a rich understanding by studying patient experience, diagnostic performance, and implementation costs. We will build capacity amongst future African research leaders through PhD training in health systems, social science, health economics and clinical research. Stage one will confirm multimorbidity prevalence in patients attending hospital, and observe how additional tests add or change management. Working with patients, community groups, and healthcare professionals, we will investigate how treatment pathways could be more efficient and responsive [Year1]. Stage two incorporates this multi-source evidence into a theoretical model of the hospital system to investigate the value of enhanced testing in emergency care. For example, we will compare alternative approaches using applicability, cost and efficiency trade-offs. With key stakeholders, we will select, pilot and refine the intervention. [Year2]. Stage three evaluates this intervention in a cluster randomised trial of approximately 2800 patients in twenty hospitals, determining rates of survival, hospital readmission, and disease control. This will provide us, and national policymaker-colleagues, rigorous evidence of intervention effectiveness [Year3 + Year4]. IMPACT Through identifying common, poorly controlled and undiagnosed multimorbidity, we aim to improve patient outcomes and optimise resource use through early and appropriate treatment (reducing death), and effective linkage to long-term care (preventing complications, disability, and hospital readmission). By enhancing capacity to lead and conduct research (students, clinicians, patient advisors, and support staff), the project builds skills and partnerships to sustainably transform the treatment of acute multimorbidity in sub-Saharan Africa. Incorporating policymakers and economic analysis into our project from the outset will ensure relevance, assess value and provide a pathway for evidence uptake.

Lay abstract: AIM To design and test a system which identifies patients suffering from multiple diseases (multimorbidity) when they seek emergency care in sub-Saharan African hospitals. This could improve early disease treatment (reducing death), and ensure better follow-up (preventing complications, disability, and hospital readmission). BACKGROUND In sub-Saharan Africa, multimorbidity is increasing due to high burdens of infectious diseases (such as HIV) and rising rates of non-communicable diseases (such as high blood pressure and diabetes). Multimorbidity increases as people live longer, and can be worsened by HIV and the drugs required to treat it. Patients delay seeking help until they are severely ill, affecting the poorest people most, and meaning that emergency departments are often key to healthcare delivery. In hospitals, doctors often focus on a single disease. Treating the immediate problem is important, but failure to identify and treat multimorbidity leads to frequent hospital readmissions, high costs to patients, and preventable disability and death. DESIGN In Malawi and Tanzania, we will research ways to identify multimorbidity (high blood pressure, diabetes and HIV) by improving diagnostic tests in emergency departments. Working with patients and healthcare professionals, we will investigate how test results could be most effectively deployed in hospital. With the help of community groups and primary healthcare facilities we will find how best to link patients with long-term care. After mapping how the health system works, we will work with policymakers and patients to find the most efficient and preferred approach to testing. We will then test the new system in a pragmatic trial including approximately 2800 patients in twenty hospitals. To see if the intervention works, we will follow-up patients for three months to record deaths, hospital readmissions, and how well the multimorbid diseases are controlled. This will give policymakers the highest quality of evidence for the effectiveness, and the costs and benefits of roll-out. COMMUNITY INVOLVEMENT Our leadership team includes a community group leader to ensure patient s voices drive our research agenda. Throughout, we will liaise with patient and community groups to co-create educational materials, and participate in programme management meetings. Our community groups partners will provide peer-support and encourage healthy lifestyles in the longer term. IMPACT Training the next generation of African research leaders is vital. We will offer four PhD training posts, one each in health systems, social science, health economics and clinical care. We will also build capacity through education of all levels of healthcare professionals, support patient self-management, and enhance links with community groups and policymakers. These collaborations give our results the best chance of impact, and we hope our intervention could sustainably transform the recognition and treatment of multimorbidity in sub-Saharan Africa, and improve outcomes for the most vulnerable patients.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: INFECTION;METABOLIC AND ENDOCRINE;CARDIOVASCULAR