COLLEGE OF MEDICINE AND HEALTH
Medicine, Nursing and Allied Health Professions

Multimorbidity

The number of people with long-term medical conditions is increasing, and the World Health Organisation has identified this as one of the major challenges facing global healthcare systems, such as the National Health Service here in the United Kingdom. In fact, many people have more than one long-term condition, which researchers call ‘multimorbidity’. Research estimates that multimorbidity affects between 23% to 57% of patients seen by GPs in the UK, and that nearly 80% of GPs’ consultations are with patients with multimorbidity. People with multiple conditions are more likely to have depression, poor physical function, and worse quality of life. They are also more likely to require an emergency hospital admission, and have a higher risk of dying.

These patients have complex health needs and are more likely to require a greater number of healthcare processes, such as tests and treatments, as well as drug prescriptions. Care for these patients may also require the involvement of more health professionals, such as specialists for specific conditions. This increased complexity in their healthcare may threaten the coordination, continuity and safety of treatment, making it less likely that patients receive high standards of care for quality and safety. However, healthcare systems remain focused on treating conditions individually, and it is not currently known if patients with multiple conditions are receiving the same standards of care. 123

Models of care for patients with multimorbidity. University of Exeter, PhD Charlotte Bramwell. PI Prof JM Valderas

Genetic Evaluation of Multimorbidity towards INdividualisation of Interventions (GEMINI). MRC/NIHR Tackling Multimorbidity at Scale. 6 months, £100,000. Role: Co-Appl (PI: Prof. Frayling T, University of Exeter).

Effectiveness of the Multi-PAP PLUS intervention in young-old patients with multimorbidity and polypharmacy aimed at improving physician drug prescription in primary care: cluster RCT. Fondo de Investigaciones Sanitarias, Instituto de Salud Carlos III. PI18/01515. Role: Co-applicant. (PI: Dr. Isabel Del Cura Gonzalez, Servicio Madrileño de la Salud). 36 months.

The SPOtting Cancer among Comorbidities (SPOCC) programme. Supporting clinical decision making in patients with symptoms of cancer and pre-existing confditions. NIHR Programme Grant for Applied Research. Role: Joint PI with Gary Abel, University of Exeter) 5 years (March 2021)

Developing tools for preventing delirium in primary care. RfPB 1/4/2017 (24 months) £235.000. Role: Co-App PI Prof David Melzer, RD&E NHS Foundation Trust, Exeter, UK

Longitudinal analysis of multimorbidity and polypharmacy patterns in indivudals aged 65 or older: electronic health care record based cohort study. Fondo de Investigaciones Santiarias, Instituto de Salud Carlos III. 1/9/2016 (36 months). PI Dr Concepcion Violan, Jordi Gol IDIAP, Spain

Meta-synthesis of patients' and health professionals perceptions of multimorbidity in General Practice. University of Exeter (partly funded through Improving the management of long term conditions with the clinical use of patient reported outcome measures in Primary Care, National Institute for Health Research CSA). PI Prof. Jose M Valderas

Modelling the impact of co-morbidity in the diagnosis of cancer in general practice. Co-PI Prof Jose M Valderas and Prof Willie Hamilton, University of Exeter

Umbrella review of systematic reviews and updated meta-analyses of observational studies on inverse comorbidity between cancer and central nervous system disorders. University of Valencia, Spain. PI Prof Rafel Tabares Seisdedos, University of Valencia, Spain

Development of a conceptual model for the study of co-morbid conditions: an example with hypertension and osteoarthritis. University of Exeter. PI Prof. Jose M Valderas

Determinants and impact of incident multimorbidity in the English Longitudinal Study of Ageing. University of Exeter. PI Prof. Jose M Valderas

Risk-benefit and costs of unicompartmental (compared to total) knee replacement for patients with multiple co-morbidities: a non-randomised study and different novel approaches to minimise confounding. NIHR HTA. 1/2/2017 (24 months) PI Dr Daniel Prieto-Alhambra, University of Oxford, UK

Comorbidity as a predictor of referral to, and outcome from, surgery in primary care patients with newly diagnosed osteoarthritis in the hip:Effectiveness of the multi-PAP intervention in young-old patients with multimorbidity and polypharmacy aimed at improving physician drug prescription in primary care: cluster RCT. Fondo de Investigaciones Sanitarias, Instituto de Salud Carlos III. 1/9/2015 (36 months). PI Dr Isabel Del Cura Gonzalez, Servicio Madrileño de la Salud, Spain

From programme theory to logic models for multi-specialty community providers: a realist evidence synthesis. NIHR HS&DR 1/7/2016 (12 months) PI Prof Rod Sheaff, University of Plymouth, UK

Person Centred Coordinated Care. National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula. PI: Prof Richard Byng 1/1/2014-31/12/2019 

Innovating care for people with multiple chronic conditions in Europe. The ICARE4EU project. European Commission 7 Framework Programme. 2013-2016. PI François Schellevis, NIVEL, Netherlands

Improving the management of long term conditions with the clinical use of patient reported outcome measures in Primary Care, National Institute for Health Research PI Prof. Jose M Valderas 1/3/2011-29/2/2016

Agent Based Simulation as a tool to support polypharmacy prescribing practice in multimorbidity. National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula. PI Dr Daniel Chalk. 9/3/2015-31/1/2016

Quality and Outcomes of Care for Chronic Conditions in Older Patients Diagnosed with Breast, Colorectal, or Prostate Cancer Compared to Non-Cancer Controls:  An Observational Study Using the Clinical Practice Research Datalink (CPRD). Cancer Research UK. Co-PI Prof. Jose M Valderas 1/7/2013-31/12/2015

Prioritising and optimising multiple medications in elderly multi-morbid patients in general practice (PRIMUM). - A pragmatic cluster-randomised controlled trial. BundesMinisterium fuer Bildung und Forschung. PI Dr Christiane Muth, University of Frankfurt, Germany 1/3/2010-28/2/2014

Valderas JM, Gangannagaripalli, Nolte E, Boyd CM, Roland M, Sarria A, Jones E, Rijken M. Quality of care assessment for people with multimorbidity. J Intern Med 2019;285(3):289-300. doi: 10.1111/joim.12881. PubMed

Muth C, Blom J, Smith S, Johnell K, Gonzalez-Gonzalez A, Nguyen T, Brueckle M-S, Cesari M, Tinetti ME, Valderas JM. Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus. J Intern Med 2019;285(3):272-288. doi: 10.1111/joim.12842. PubMed

Catalá-López F, Forés Martos J, Driver JA, Page M, Hutton B, Ridao M, Alonso-Arroyo A, Saint-Gerons, DM, Genova-Maleras R, Valderas JM, Vieta E, Valencia A, Tabares-Seisdedos R. Anorexia nervosa and risk of cancer: a systematic review with meta-analysis. JAMA Network Open 2019;2(6):e195313 doi: 10.1001/jamanetworkopen.2019.5313 Pubmed

Violan C, Foguet-Boreu Q, Fernández-Bertolín S, Guisado-Clavero M, Cabrera-Bean M, Formiga  F, Valderas JM, Roso-Llorach A. Soft clustering using real-world data for the identification of multimorbidity patterns in an elderly population: cross-sectional study in a Mediterranean population. BMJ Open 2019;9(8):e029594  doi: 10.1136/bmjopen-2019-029594. Pubmed

Mounce LTA, Campbell JL, Henley WE, Tejerina Arreal MC, Porter I, Valderas JM. Predicting incident multimorbidity. Ann Fam Med 2018; 16(4):322-9. doi: 10.1370/afm.2271. Pubmed

Roso-Llorach A, Violán C, Foguet-Boreu Q, Rodriguez-Blanco T, Pons-Vigués M, Pujol-Ribera E, Valderas JM. Comparative analysis of methods for identifying multimorbidity patterns: a study of 'real-world' data. BMJ Open 2018;8:e018986. doi:10.1136/bmjopen-2017-018986 BMJOPEN

Violán C, Roso-Llorach A, Foguet-Boreu Q, Guisado-Clavero M, Pons-Vigués M, Pujol-Ribera E, Valderas JM. Multimorbidity patterns with K-means nonhierarchical cluster analysis. BMC Fam Pract. 2018 Jul 3;19(1):108. doi: 10.1186/s12875-018-0790-x. PubMed

Muth C, Uhlmann L, Haefeli W, Rochon J, van den Akker M, Perera R, Güthlin C, Beyer M, Oswald F, Valderas J, Knottnerus A, Gerlach F, Harder S. Effectiveness of a complex intervention on PRIoritising MUltimedication in Multimorbidity (PRIMUM) in primary care: results of a pragmatic cluster-randomised controlled trial. BMJ Open 2018;8(2):e017740 doi: 10.1136/bmjopen-2017-017740. PubMed

Palmer K, Marengoni A, Forjaz MJ, Jureviciene E, Laatikainen T, Mammarella F, Muth C, Navickas R, Prados-Torres A, Rijken M, Rothe U, Souchet L, Valderas JM, Vontetsianos T, Zaletel J, Onder G. Multimorbidity care model: Recommendations from the consensus meeting of the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS). Health Policy 2018 Jan;122(1):4-11. doi: 10.1016/j.healthpol.2017.09.006 PubMed

Chalk D, Manzi S, Britten N, Kluettgens B, Magura R, Valderas J. Can agent-based simulation be used as a tool to support polypharmacy prescribing practice? BMJ Stel 2017;3(3):94–98.  Access 

Griffiths RI, Valderas JM, McFadden EC, Bankhead CR, Lavery BA, Khan NF, Stevens RJ, Keating NL. Outcomes of preexisting diabetes mellitus in breast, colorectal, and prostate cancer. J Cancer Surviv. 2017 Oct;11(5):604-613. doi: 10.1007/s11764-017-0631-2.  PubMed

Mounce LTA, Price S, Valderas JM, Hamilton W. Comorbid conditions delay diagnosis of colorectal cancer: a cohort study using electronic primary care records. Br J Cancer 2017;116(12):1536-1543. doi: 10.1038/bjc.2017.127. PubMed

Foguet-Boreu Q, Violán C, López Jiménez T, Pons-Vigués M, Rodríguez-Blanco T, Valderas JM, Guisado Clavero M, Pujol-Ribera E. Pharmacological control of diabetes and hypertension comorbidity in the elderly: A study of "real world" data. Prim Care Diabetes. 2017;11(4):348-359. doi: 10.1016/j.pcd.2017.03.007 PubMed

Violan C, Foguet-Boreu Q, Roso-Llorach A, Rodriguez-Blanco T, Pons-Vigues M, Pujol-Ribera E, Valderas JM. [Multimorbidity patterns in young adults in Catalonia: an analysis of clusters.] Aten Primaria  2016;48(7):479-92. PubMed

Muth C, Harder S, Uhlmann L, Rochon J, Fullerton B, Guthlin C, Erler A, Beyer M, van den Akker M, Perera R, Knotternerus A, Valderas JM, Gerlach FM, Haefeli WE. Pilot study to test the feasibility of a trial design and complex intervention on PRIoritising MUltimedication in Multimorbidity in general practices (PRIMUMpilot). BMJ Open 2016;6(7):e011613. doi: 10.1136/bmjopen-2016-011613. PubMed 

Ricci-Cabello I, Stevens S, Kontopantelis E, Dalton ARH, Griffiths RI, Campbell JL, Doran T, Valderas JM. Impact of the prevalence of concordant and discordant conditions on the quality of diabetes care in family practices in England. Ann Fam Med 2015;13(6):514-22. doi: 10.1370/afm.1848. PubMed

Ricci-Cabello I, Violan C, Foguet Q, Valderas JM. Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review. Eur J Gen Pract 2015;21(3):192-202.  doi:10.3109/13814788.2015.1046046. PubMed

Foguet-Boreu Q, Violan C, Rodriguez-Blanco T, Roso-Llorach A, Pons-Vigues M, Pujol-Ribera E, Valderas JM. Multimorbidity patterns in elderly primary health care patients in a South Mediterranean European Region: A cluster analysis. PLoS One   2015;10(11):e0141155. doi: 10.1371/journal.pone.0141155 PubMed

Islam MM, McRae I, Yen L, Jowsey T, Valderas JM. Time spent on health related activities by the senior Australians with chronic diseases: what is the role of multimorbidity and comorbidity? Aust N Z J Pub Health 2015;39(3):277-83. doi: 10.1111/1753-6405.12355. PubMed

LeReste JY, Nabbe P, Lingner H, Kasuba Lazic D, Assenova R, Munoz M, Sowinska A, Lygidakis C, Doerr C, Czachowski S, Argyriadou S, Valderas JM et al. What research agenda could be generated from the European General Practice Research Network concept of multimorbidity in family practice? BMC Family Practice 2015;16:125. doi: 10.1186/s12875-015-0337-3. PubMed

Vos R, van den Akker M, Boesten J, Robertson C, Metsemakers J. Trajectories of multimorbidity: exploring patterns of multimorbidity in patients with more than ten chronic health problems in life course. BMC Fam Pract 2015; Jan 22:16(1):2 doi: 10.1186/s12875-014-0213-6. Pubmed

Violan C, Foguet-Boreu Q, Flores-Mateo G, Salisbury C, Blom J, Freitag M, Glynn L, Muth C, Valderas JM. Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies. PLoS One  2014;9(7):e102149. doi: 10.1371/journal.pone.0102149. PubMed

Foguet-Boreu Q, Violan C, Roso-Llorach A, Rodriguez-Blanco T, Pons-Vigués M, Muñoz-Pérez MA, Pujol-Ribera E, Valderas JM. Impact of multimorbidity: acute morbidity, area of residency and use of health services across the life span in a region of south Europe. BMC Fam Pract. 2014 Mar 26;15:55. doi: 10.1186/1471-2296-15-55. PubMed

Griffiths RI, Gleeson ML, Valderas JM, Danese MD. Impact of undetected comorbidity on treatment and outcomes of breast cancer. Int J Breast Cancer 2014;2014:970780. doi: 10.1155/2014/970780. PubMed

Violán C, Foguet-Boreu Q, Roso-Llorach A, Rodriguez-Blanco T, Pons-Vigués M, Pujol-Ribera E, Muñoz-Pérez MA, Valderas JM. Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study.  BMC Public Health 2014 May 29;14:530. doi: 10.1186/1471-2458-14-530. PubMed

Prados-Torres A, Calderón-Larrañaga A, Hancco-Saavedra J, Poblador-Plou B, van den Akker M. Multimorbidity patterns: a systematic review. J Clin Epidemiol 2014;67(3):254-66 doi: 10.1016/j.jclinepi.2013.09.021. Pubmed

Vos R, Aarts S, van Mulligen E, Metsemakers J, van Boxtel MP, Verhey F, van den Akker M. Finding potentially new multimorbidity patterns of psychiatric and somatic diseases: exploring the use of literature-based discovery in primary care research. J Am Med Inform Assoc 2014;21(1):139-45 doi: 10.1136/amiajnl-2012-001448. Pubmed

Islam MM, Valderas JM, Yen L, Dawda P, Jowsey T, McRae IS. Multimorbidity and comorbidity of chronic diseases among the senior Australians: prevalence and patterns. PLoS One. 2014 Jan 8;9(1):e83783. doi: 10.1371/journal.pone.0083783. PubMed

Mavaddat B, Valderas JM, van der Linde R, Khaw KT, Kinmonth AL. Association of self-rated health with multimorbidity, chronic disease and psychosocial factors in a large middle-aged and older cohort from general practice: a cross-sectional study. BMC Fam Pract 2014;15:185. doi: 10.1186/s12875-014-0185-6. PubMed

Violán C, Foguet-Boreu Q, Hermosilla-Pérez E, Valderas JM, Bolíbar B, Fàbregas-Escurriola M, Brugulat-Guiteras P, Muñoz-Pérez MÁ. Comparison of the information provided by electronic health records data and a population health survey to estimate prevalence of selected health conditions and multimorbidity. BMC Public Health 2013 Mar 21;13:251. doi: 10.1186/1471-2458-13-251. PubMed

Jowsey T, McRae IS, Valderas JM, Dugdale P, Phillips R, Bunton R, Gillespie J, Banfield M, Jones L, Kljakovic M, Yen L. Time's up. Descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: a time use survey.  PLoS One 2013;8(4):e59379. doi: 10.1371/journal.pone.0059379. PubMed

Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury C. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med 2012 Mar-Apr;10(2):134-41. doi: 10.1370/afm.1363. PubMed

Griffiths RI, Danese MD, Gleeson ML, Valderas JM. Epidemiology and outcomes of previously undiagnosed diabetes in older women with breast cancer: an observational cohort study based on SEER-Medicare. BMC Cancer 2012 Dec 22;12:613. doi: 10.1186/1471-2407-12-613. PubMed

Harrison M, Reeves D, Harkness E, Valderas J, Kennedy A, Rogers A, Hann M, Bower P. A secondary analysis of the moderating effects of depression and multimorbidity on the effectiveness of a chronic disease self-management programme. Patient Educ. Couns 2012 Apr;87(1):67-73. doi:10.1016/j.pec.2011.06.007 PubMed

Aarts S, van den Akker M, Bosma H, Tan FES, Verhey FRJ, Metsemakers JFM, van Boxtel MPJ. The effect of multimorbidity on health related functioning: temporary or persistent. Results from a longitudinal cohort study. Journal of Psychosomatic Research 2012;73:211-7. doi: 10.1016/j.jpsychores.2012.05.014.  Pubmed

Tabarés-Seisdedos R, Dumont N, Baudot A, Valderas JM, Climent J, Valencia A, Crespo-Facorro B, Vieta E, Gómez-Beneyto M, Martínez S, Rubenstein JL. No paradox, no progress: inverse cancer comorbidity in people with other complex diseases. Lancet Oncol 2011 Jun;12(6):604-8. doi: 10.1016/S1470-2045(11)70041-9. PubMed

Bower P, Macdonald W, Harkness E, Gask L, Kendrick T, Valderas JM, Dickens C, Blakeman T, Sibbald B. Multimorbidity, service organization and clinical decision making in primary care: a qualitative study.  Fam Pract 2011 May 25;28(5):579-87 doi: 10.1093/fampra/cmr018. PubMed

Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for the understanding of health and health services. Ann Fam Med 2009;7:357-63. doi: 10.1370/afm.983. Pubmed