Global Alliance for Chronic Disease researchers' statement on multimorbidity
Authors: John R Hurst, Julia Dickhaus, Pallab K Maulik, J Jaime Miranda, Sonak D Pastakia, Joan B Soriano, Trishul Siddharthan, Rajesh Vedanthan, G Agarwal, CA Aguilar-Salinas, GS Bloomfield, NH Chavannes, M Daivadanam, FX Gómez-Olivé, C Gorre, NS Levitt, LM Lotrean, SA Norris, M Owolabi, G Parker, MJ Postma, A Sheikh, K Siddiqi, V Stratev, AC Trofor, JF van Boven, RM van der Kleij
Journal: The Lancet Global Health (2018)

The Global Alliance for Chronic Disease (GACD) is an alliance of health research funders whose research teams form a network of multidisciplinary health-care professionals and researchers. We aim to reduce the impact of non-communicable diseases (NCDs) through a focus on implementation research in low-income and middle-income countries (LMICs) and vulnerable populations in high-income countries (HICs). The GACD has commissioned research on hypertension, diabetes, chronic respiratory diseases, mental health, and in 2018, the scale up of hypertension and diabetes interventions. We particularly recognise the importance and challenge of coexisting physical and mental health multimorbidity arising from epidemiological transitions (ie, from communicable to non-communicable diseases) and rapid population ageing. Although our initial programmes have not explicitly considered multimorbidity in the context of cancer and chronic infectious diseases such as tuberculosis and HIV, we recognise that multimorbidity in relation to these conditions is also a burgeoning challenge. Notably, very little research has been done to address the coexistence of and potential for reciprocal interactions between the course of NCDs and the natural history of acute or long-term infections. Our collaborative approach resulted in the realisation that multimorbidity was a challenge for all our members. To address this issue, we formed a multidisciplinary multimorbidity working group, listed in the appendix, with the aim of identifying common themes and developing a researchers' statement on multimorbidity. The full version of the GACD Researchers' Statement1Global Alliance for Chronic DiseasesResearchers' statement on multimorbidity.https://www.gacd.org/research/publications-and-references/gacd-researchers-statement-on-multimorbidityDate accessed: October 25, 2018Google Scholar highlights the specific data that we considered when collating these themes, and an exemplar case history that illustrates the challenges for those living with multimorbidity in LMICs. The six common themes identified of importance across all our research programmes are: (1) the relevance of multimorbidity to all health-care professionals; (2) the general under-recognition of multimorbidity in health-care provision and research, including research to explore new models of delivery of care; (3) the absence of evidence-based guidelines on approaches to manage patients with multimorbidity leading to undertreatment, mistreatment, and overtreatment (in part driven by the absence of primary evidence due to exclusion of many people with multimorbidity from efficacy trials); (4) the need to provide greater access to expert, proactive holistic primary care that integrates NCDs; (5) the need for improved integration of health-care education, both to health-care providers and to patients and their families, specifically in relation to multimorbidity and including how to best access current models of care; and (6) the need for further research assessing interventions that address the challenge of multimorbidity in LMIC settings (eg, low-cost combination interventions and holistic prevention programmes). The following statement summarised our deliberations: “The GACD research network believes that a greater focus on multimorbidity is overdue and necessary to successfully improve global health outcomes”.1Global Alliance for Chronic DiseasesResearchers' statement on multimorbidity.https://www.gacd.org/research/publications-and-references/gacd-researchers-statement-on-multimorbidityDate accessed: October 25, 2018Google Scholar To achieve the GACD aim of reducing the impact of multimorbidity in LMICs with a switch to healthy active ageing, we identified three strategic objectives. The first objective is greater policy awareness and focus on multimorbidity through integrated proactive chronic care, rather than systems that address single NCDs. Practical examples of how this objective could be achieved include support for education, training, and guideline development that focus on multimorbidity, and policies that make implementation of simple universal interventions—around diet, exercise, reduced exposure to tobacco, indoor and outdoor air pollution, and alcohol—attractive, effective, and practical to implement. The second objective proposes changes in the way that research is commissioned, funded, and delivered when considering NCDs in LMICs, particularly the promotion of working across and between traditional disease, primary care, and specialist boundaries. Pragmatic trial designs are one approach to ensure the effects of interventions are considered holistically, in the situations in which they are developed and treated with shared data dictionaries of disease and broad outcome definitions. Finally, the third objective aims to have health systems research aligned with universal health coverage. In particular, we aim to improve consideration of the role of proactive primary care and (where appropriate) community health workers in developing knowledge and skills to deliver effective integrated care of multimorbid NCDs. Addressing multimorbidity will help improve health systems and their efficiency, particularly when such systems are weak or fragmented. We present the case for a greater focus on multimorbidity, specifically in relation to non-communicable diseases in LMICs and vulnerable populations in HICs. The current disease-specific approaches hinder research and patient care and the ability to maximise improvements in health outcomes. Only by working collaboratively will we be able to achieve international health targets such as the 2030 Sustainable Development Goals, especially those in relation to NCDs, mental health, and long-term communicable diseases. Success will require working across traditional boundaries and the GACD network provides a practical example of how this can work. With our latest funding call in relation to scale-up of hypertension and diabetes research in partnership with delivery organisations, our shared data dictionaries, and our multidisciplinary working groups, the GACD is leading the development of novel approaches to address multimorbidity in LMICs. This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on December 5, 2018 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on December 5, 2018 This statement reflects the perspectives of researchers from the GACD, but it does not necessarily reflect the perspective of the funding agencies. We declare no competing interests. Download .pdf (.07 MB) Help with pdf files Supplementary appendix Correction to Lancet Glob Health 2018; 6: e1270–71Hurst JR, Dickhaus J, Maulik PL, et al. Global Alliance for Chronic Disease researchers' statement on multimorbidity. Lancet Glob Health 2018; 6: e1270–71—The reference link was incorrect and should be https://www.gacd.org/research/publications-and-references/gacd-researchers-statement-on-multimorbidity . This correction has been made as of Dec 5, 2018. Full-Text PDF Open Access