The NICE Response to Multimorbidity
Professor Mark Barker
Director, Centre for Clinical Practice, National Institute for Health and Care Excellence (NICE)
Professor David Haslam
Dr Martin Allaby
Consultant Clinical Advisor, Centre for Clinical Practice, NICE
'How can you expect me to use your guidelines when they don't take account of multimorbidity?' This is an accusation that many GPs make about NICE, however, this is an issue that NICE fully understands, and is working hard to address.
A number of existing NICE guidelines set out to specifically assist the health and care services to address the needs of people with multiple conditions. This is hampered, however, by the paucity of direct evidence. The clinical management issues are complex and challenging and current care, dominated by single disease system guidance, does not always serve patients well1. The challenges of managing people with complex needs are widespread, increasingly well understood, but no nearer a resolution.
Depending on how multimorbidity is defined, people with multiple long-term conditions comprise of 30% to 80% of GP consultations2 and more than half of acute medical admissions. Multimorbidity is most common in older people but at least one fifth of people with multimorbidity are aged under fifty.
People with multiple conditions are likely to be receiving long-term medical treatment for most or all of them. Effective treatments have a reduced effect because of comorbidities but patients are exposed to all the adverse effects, often with added interactions3. The net benefit of any given treatment is reduced and the added value of new ones is minimised.
The problem for guidance developers
Most clinical guidance has perhaps inevitably been based on single system diseases. The evidence which is applied to the construction of guidance is typically based on randomised clinical trials which exclude people with confounding risk or conditions in order to clarify the effects of the intervention. Most of the people with a condition, and who can benefit from approved treatments for that condition, would not have been eligible for entry to the key trials which determine the optimum treatment. However, direct evidence of the benefits of treatment for people with multiple conditions is not emerging.
Treatments which are effective in a single system disease are likely to be effective in people with multimorbidity including that condition. However, the realisable benefits may be reduced (compared with the trial outcomes) because of limited life expectancy and reduced quality of life due to intercurrent comorbidities. Cost-effectiveness of treatments in these circumstances is also likely to be reduced.
The conclusion from the above is that there is unlikely to be a reliable evidence base to inform guidance on the management of people with multimorbidity, although this is starting to improve4, and that a combination of sources and processes will have to be applied. These may include single system studies, specific multi-system studies, including sub-set analysis and complex modelling and consensus methods.
We might also stress that all our guidance includes the sentence: 'Treatment and care should take into account people's needs and preferences'. Guidelines are, as the name implies, GUIDE-lines, and doctors should work with their patients to avoid over-treatment and excessive polypharmacy.
NICE guidance in development
A number of specific topics for guidelines have already been referred to the clinical, public health and social care programmes at NICE. The following three topics, currently being developed by NICE, are especially relevant to improving the management of people with complex needs:
- Disability, dementia and frailty in later life - mid-life approaches to prevent or delay the onset of these conditions: This covers preventive interventions in people under the age of 65.
- Medicines Optimisation: This includes medicines review and other aspects of the management of polypharmacy.
- Assessment, prioritisation and management of care for people with commonly occurring multimorbidities; Provided the evidence allows, this will include guidance on ranking the absolute risks and benefits of interventions for prevention or improving prognosis of common morbidities, and the effects of stopping common drug treatments. These topics will be considered in the context of strategies for managing healthcare for people with multimorbidity, and principles for assessing and prioritising health care interventions for individuals with multimorbidity, including the values and preferences of the individual. The final scope document for this guideline can be found here.
Potential future guidance
Pending the development of other related work being produced by NICE, we will commission a guideline on 'Organisational and system integration between primary, secondary and social care: meeting the needs of population with complex health problems'. There are also proposals to consider specific comorbidities through the updating of existing guidelines by targeted extension of the scope. Suggested examples include:
- Medical comorbidities in people with dementia.
- Reducing the survival gap between people with learning disabilities and people with normal cognitive function.
- Medical comorbidities and autism spectrum disorder.
The sensible management of people with multimorbidity constitutes the greatest challenge to the conventional approach to guideline development. Getting the right balance between optimising the treatment of specific life-limiting conditions and avoiding polypharmacy with minimal return is the holy grail of modern medicine.
Author responsible for correspondence:
Dr Martin Allaby. Centre for Clinical Practice, National Institute for Health and Care Excellence, 21 Spring Gardens, London, SW1A 2BU. firstname.lastname@example.org, 07760 172 671.
 Hughes LD, McMurdo ME, Guthrie B. Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age and ageing. 2013;42(1):62-9.
 Salisbury C, Johnson L, Purdy S, Valderas JM, Montgomery AA. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. The British journal of general practice : the journal of the Royal College of General Practitioners. 2011;61(582):e12-21.
 Guthrie B, Payne K, Alderson P, McMurdo ME, Mercer SW. Adapting clinical guidelines to take account of multimorbidity. BMJ (Clinical research ed). 2012;345:e6341.
 Guthrie B, McCowan C, Davey P, Simpson CR, Dreischulte T, Barnett K. High risk prescribing in primary care patients particularly vulnerable to adverse drug events: cross sectional population database analysis in Scottish general practice. BMJ (Clinical research ed). 2011;342:d3514.
 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43.
 Bunker J. Medicine matters after all: measuring the benefits of medical care, a healthy lifestyle, and a just social environment. London: Nuffield Trust, 2001.
 Payne RA, Abel GA, Guthrie B, Mercer SW. The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2013;185(5):E221-8.
 Salomon JA, Wang H, Freeman MK, Vos T, Flaxman AD, Lopez AD, et al. Healthy life expectancy for 187 countries, 1990-2010: a systematic analysis for the Global Burden Disease Study 2010. Lancet. 2012;380(9859):2144-62.
 Smolina K, Wright FL, Rayner M, Goldacre MJ. Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study. BMJ (Clinical research ed). 2012;344:d8059.