International multimorbidity

Almost one fourth of the Danish adult population live with two or more chronic conditions. Like many other countries, our healthcare system is facing a growing challenge in caring for the multimorbid patients. As part of a largescale national project, involving three of the Steno Diabetes Centres (SDC) in Denmark (SDC North Denmark, SDC Aarhus and SDC Odense), we are currently working on projects to understand and handle parts of the multimorbidity healthcare challenge.

We have all heard about the notoriously siloed, disease-focused organization of our healthcare systems. While specialization is still a great way to ensure high quality care, it can lead to care fragmentation for some of the most vulnerable patients through “polydoctoring”, as our Japanese colleagues described in their blogpost. This term is very fitting for the unfortunate mechanisms at play when multimorbid people are tossed around from one specialist to another. Our project aims to flip this pattern, put the patients in the centre, and have multiple specialists gather around them.

A clinical initiative

Over the last couple of years, we have developed a clinical initiative following the Medical Research Council framework for developing and evaluating complex interventions. The initiative is an ambitious multidisciplinary team conference (MDT) for people with diabetes and multimorbidity and/or comorbidity. However, the three SDCs have operationalized their MDTs in three different ways, although with the same overall purpose of increasing quality of life of multimorbid patients through optimized coordination in care.

 

At one SDC, the multimorbidity-MDTs occur every two weeks, last for two hours, and can discuss up to four patients every time. The patients can be referred from either hospital or general practice. Doctors from endocrinology, cardiology, respiratory medicine, nephrology, pharmacology, and general practice have all read and prepared for the specific patient cases and give their speciality-specific assessment of the patient. Furthermore, competencies within palliative medicine, social medicine and geriatrics are often represented at the MDT. The pharmacologist conducts a thorough medication review to optimize the medical treatment and remove inappropriate prescriptions. The MDT is an on-site meeting for the hospital doctors with external specialists, such as general practitioners, participating online on video-call.

In another SDC, a more flexible MDT model is used where meetings and specialist teams are organized on an ad hoc and customized basis. Here, both patients and specialists have the ability to activate the flexible MDT. Patients are informed about the service through a mailed postcard or during their visit to the local SDC clinic. The service can be initiated when patients contact the MDT team, which subsequently assembles relevant specialists to discuss the issue with the patient and their relatives. Specialists from different disciplines can also initiate the MDT and thereby assemble a team to discuss cases that require collaboration in order to develop or improve a shared treatment plan in consultation with the patient. Often, a clinical pharmacologist conducts a medication review as part of the flexible MDT, aiming to ensure patient safety through the identification and management of polypharmacy.

These MDT models represent innovative ways of coordinating patient care in the Danish healthcare system, being more multidisciplinary, patient-centred, and long-term focused than many existing MDT models, where two specialties usually discuss a specific here-and-now issue, not considering the full picture of multimorbid patients (Henriksen et al. 2022). We have put great effort in promoting this new initiative among clinicians and patients at hospitals and in primary care, and we need to continue doing so, because changing a healthcare practice is challenging and takes time.

So far, the responses from patients and clinicians are positive. They find it meaningful and worthwhile. The fact that specialists can discuss, negotiate, coordinate, and agree on treatment plans across different specialities and sectors seems very helpful and pertinent.

The research

Concurrent research activities in relation to the MDT-initiatives take place, both locally at the three SDCs and in a collaboration across the three centres. Overall, the local research projects comprise literature reviews (some of them already published, see references), feasibility testing of the interventions (protocol submitted, currently in review), qualitative aspects from both clinicians and patients, and development of prediction models to assist in patient identification and multimorbidity management. The national cross-centre collaboration aims to establish a common terminology and core outcome set in multimorbidity; investigate multimorbidity trajectories and patterns in the Danish population; develop algorithms to predict outcome of using MDT on individual patients; and conduct a context-mechanism-outcome study of the implementation process across the three centres. We are a group of researchers with different backgrounds ranging from nursing and medicine, over physiotherapy and public health, to biomedical engineering and sociology.

Right now, we are at the point where the teams have been set, we are getting to know each other through regular meetings, and have started to define our respective studies. In the process of networking and establishing our group and subgroups, we were delighted to come across the International multimorbidity research community and this blog. We are hoping to learn about and from colleagues around the world who share our interest in this pressing topic.

               

                                               

On behalf of the Multimorbidity cross-collaboration group: Andreas K. Stage, Ann-Cathrine D. Dunvald, Anne-Maj Knudsen, Charlotte G. Pedersen, Danny Anthonimuthu, Jonas D. Andersen, Rikke B. Rokkjær and Stine J. Bugge.   

 

Author: Stine Jorstad Bugge, MD, PhD student, Steno Diabetes Centre Odense and Pharmacology, Odense University Hospital and University of Southern Denmark.

 

Articles:

1. Henriksen DP, Ennis ZN, Panou V, et al. Physician-led in-hospital multidisciplinary team conferences with multiple medical specialities present - A scoping review. Journal of Multimorbidity and Comorbidity. 2022;12. doi:10.1177/26335565221141745
2. Andersen JD, Jensen MH, Vestergaard P, Jensen V, Hejlesen O, Hangaard S. The multidisciplinary team in diagnosing and treatment of patients with diabetes and comorbidities: A scoping review. Journal of Multimorbidity and Comorbidity. 2023;13. doi:10.1177/26335565231165966

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First published: 18 December 2023