Multiple Medical Troubles Stress Patients and Doctors
Posted: Friday, April 03, 2009
by Joel Hirschhorn
http://www.delusionaldemocracy.com
You hear a lot about people living longer. But there is something you don't hear much about. Within the medical community one of the most difficult and interesting areas is the all too common condition of multiple major medical problems in people, especially older persons. This condition is called multimorbidity or comorbidity, neither of which sounds good. Morbidity refers to the presence of illness or disease. Treating patients with a number of serious problems turns out to be a very, very big challenge.
It has been estimated that 57 million Americans had multiple chronic conditions in 2000 and that this number will rise to 81 million by 2020. On average, patients aged 65 years and older have 2.34 chronic medical conditions. In fact, 50 percent of patients with a chronic disease have more than one condition. Two-thirds of people over age 65, and almost three-quarters of people over 80, have multiple chronic health conditions, and 68 percent of Medicare spending goes to people who have five or more chronic diseases. Multimorbidity has a prevalence of 60 percent among people aged 55 to 74. This prevalence is much higher than that of asthma (6.5 percent), hypertension (29.6 percent), and diabetes (8.7 percent). Even worse, a recent Canadian study found the prevalence rate of having 2 or more medical conditions in the 18- to 44-year, 45- to 64-year, and 65-year and older age-groups was, respectively, 68 percent, 95 percent, and 99 percent among women and 72 percent, 89 percent, and 97 percent among men. These are all remarkable figures.
The inescapable point is that multimorbidity should not be thought of as the exception; better to see it as the rule. It is what most people will confront the older they become. Which means that those without any or good health insurance face enormous risks and burdens.
People with multimorbidity linger in hospitals longer, experience more serious preventable health complications and die younger than patients lucky enough to escape these complex medical profiles. They obviously account for a huge fraction of the nation's frighteningly high spending on health care. But virtually all medical, public and political attention is geared toward individual organs and diseases. Missing are champions for patients with multiple illnesses. There is no National Institute on Multimorbidity, no color ribbon or charity races for multimorbidity. You see no celebrities speaking up for getting more research funding for multimorbidity.
However, you may have heard recently about a polypill, still being researched. It has received considerable attention because it contains medicines to treat a number of cardiovascular conditions. One version contains substances to lower cholesterol and blood pressure, aspirin to interfere with blood clotting, and folic acid to help prevent atherosclerosis. Canadian researchers say a single, daily pill combining five generic medicines could potentially cut by half the number of heart attacks and strokes in middle-aged people. The study involved 2,053 people, aged 45 to 80, without cardiovascular disease but with one risk factor for it, such as hypertension, obesity, high cholesterol, diabetes or smoking. Initial short term results were encouraging.
However, what you almost always see is that medical studies on drugs or treatments favor single conditions, because uncomplicated populations are cheapest and easiest to test and interpret. In fact, patients with multiple diseases are routinely shut out of drug trials. A 2007 study found that 81 percent of the randomized trials published in the most prestigious medical journals excluded patients because of coexisting medical problems. So it becomes pretty obvious that treatments for single conditions may not be optimal when a number of them are used for a single patient with multiple conditions. In fact, any patient is unlikely to have a physician that can look at the whole set of problems and figure out what is best for the patient in terms of effectiveness and safety. How can a typical 15-minute visit with a physician provide adequate coverage of a complex set of chronic conditions? How can nursing homes and assisted living facilities provide high quality supervision and care of patients with many health problems and medications?
Dr. Mary E. Tinetti, a geriatrician at the Yale School of Medicine has pointed out some important issues: "Very often, there is nobody looking at the big picture or recognizing that what is best for the disease may not be best for the patient. Doctors know that it's not right for someone to be on 15, 18, 20 medications. But they're being told that that's what's necessary in order to treat each of the diseases that the patients in front of them have."
Does the doctor know best? Not necessarily when that doctor is a specialist dealing with just a part of the overall complex set of conditions a patient has. Most specialists are not eager to get involved with diseases outside their in-depth knowledge. The challenge for patients is to also have access to an internist or geriatrician that can deal with the whole person and all the possible conflicts and interactions among treatments and drugs being used for a number of ailments.
Finally, it is all too common that people with multimorbidity also suffer from chronic depression that just makes their management of their set of health problem all the more difficult. Depression along with persistent chronic illnesses is bound to take a toll on quality of life, which is why living longer is not necessarily the whole story.
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Top-level comments on this article: (3 total)Hi Joel.Those statistics are staggering! What you've written supports my contention that it is always best to treat the whole person, not just a particular disease. Making people aware of the problem as you have done so well is, I believe, the first step to a solution. Great job.Dianne
Thank you for writing this article Joel. Unfortunately, I am a younger 40's person who has had major multi medical problems. I have gone several rounds through the years with some doctors, to treat me as a whole person and not just look at one particular problem.All glory to God that I am even still among the living today. There is no other reason that I can see as to why I am alive.Blessings,Michelle
You got that right.
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