The Multiple Challenges of Multiple Morbidities

More than half the American population lives with a chronic disease. These ailments include arthritis, asthma and other respiratory conditions, diabetes, heart disease, HIV, hypertension, and some forms of cancer. More than two thirds of older adults are so afflicted and the aging of the population does not portend good news. Neither is the problem particular to the United States. Last year, the World Health Organization acknowledged that, regardless of where one lives in the world, premature death is most likely to be caused by a chronic condition (leaving aside war, other forms of violence, and vehicular injuries). However, recognition of the prevalence and importance of managing multiple morbidities has been slow in coming. Current data are alarming. For example, one in four Americans has two or more concurrent chronic conditions (Anderson, 2010). A study by the Center for Healthcare Research and Transformation in the State of Michigan showed that those older than 65 years had an average of eight chronic physical and/or psychological conditions with a range from 1 to 18 (Udow-Phillips, 2009). Other states are generating similar profiles of those with chronic disease. Even the young are not spared. When obesity, recently determined to be a chronic condition by the Centers for Disease Control and Prevention, is counted, children and adolescents have an increasing number of multiple chronic health problems with asthma and diabetes being frontrunners. Of course, the weaknesses in our health care system are magnified when a person seeks care for more than one chronic condition as the chances of negative outcomes increase. These include death, poor functional status, unnecessary hospitalizations, adverse drug events, duplicative tests, and conflicting medical advice, to name just a few (Institute of Medicine, Committee on Quality of Health Care in America, 2001; Vogeli et al., 2007). The impact of multiple chronic diseases on people and the health care system, in large part, depends on the extent to which clinicians understand how to treat people with several ailments, make the appropriate clinical recommendations, write and implement therapeutic regimens, communicate with other clinicians an individual may see, and counsel patients. At the moment, the evidence base for best practices in clinical management of multiple conditions is very thin and to a great extent comprises expert opinion rather than results of empirical study. A second influence on outcomes is how well services are organized and paid for. Care delivery and payment patterns either facilitate or hinder effective practice. Policies are needed that ensure the patient gets the assistance he or she requires. They must ensure that health care providers practice in a system that rewards them for effective management across chronic conditions. Equally as crucial an influence on health outcomes is the extent to which we understand challenges patients face when trying to manage co morbidities and how they can be helped through education, social support, and resources. Management of a chronic condition (not to mention several at once) occurs outside the health system at home, work, and school. Clinicians are actually just guides or coaches for management. The people with the condition are the managers. What we know about patient management of a single condition has not been adequately translated into day-to-day practice in the health system and many individuals get little or no education for the task. That being said, some progress regarding management of individual illnesses has been made. Several models have been developed, rigorously evaluated, replicated, and are frequently used (see, e.g., Clark, Gong, & Kaciroti, 2001; Glasgow et al., 2005; Lorig et al., 1999). Other proven models have focused on how the clinician and patient educators can become better communicators and counselors of patients with a chronic disease (see, e.g., Clark et al., 2008; Heisler, Bouknight, Hayward, Smith, & Kerr, 2002). The picture is quite different for multiple chronic conditions. One or two intervention models have tried to lump together people with different chronic illnesses to help them improve their skills. This has been done to make self-management education more efficient and assumes disease management is much the same across conditions. These approaches also have been thought to have spillover effect to improve management of other illnesses a person might have. However, such efforts have not proven robust in producing outcomes related to control of symptoms or reduction in the need for health services. Neither have their intended outcomes been reproduced in replication studies nor has the idea of “spillover” to other conditions been proven (Foster, Taylor, Eldridge, Ramsay, & Griffiths, 2007).