Multiple long-term conditions: multimorbidity register

  • NICE indicator
  • IND205
  • Published:
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Indicator

The practice can produce a register of people with multimorbidity who would benefit from a tailored approach to care.

Indicator type

General practice indicator suitable for use in the Quality and Outcomes Framework.

This document does not represent formal NICE guidance. For a full list of NICE indicators, see our menu of indicators.

To find out how to use indicators and how we develop them, see our NICE indicator process guide.

Rationale

Multimorbidity is associated with reduced quality of life, higher mortality, polypharmacy and higher treatment burden, higher rates of adverse drug events and greater use of health services including unplanned admissions and emergency care.

The register will support interventions that lead to improvement in health-related quality of life, care related decisions and patient safety and reduce adverse outcomes such as unplanned admissions. The indicator is also a measure of case-mix and potentially workload in general practice.

Development

The NICE guideline on multimorbidity defines multimorbidity as the presence of 2 or more long-term health conditions. The NICE indicator advisory committee originally explored creating a register based on presence on 2 or more 'QOF registers', however this limited the number of conditions significantly. It also resulted in a register of people who were likely already under regular review.

Bespoke analysis undertaken by the North East Quality Observatory Service for the NICE indicator advisory committee in a sample of 14 practices using a an adapted list of 30 conditions from the SPIRE project found that when developed into a systematic search of practice data, the number of people with two or more long term conditions was a substantial proportion of practice lists. Publications analysing general practice data (Barnett et al. 2012, Cassell et al. 2018, and Health Foundation, 2018) also found similar results.

Table 1: Percentage of people in general practice with long-term conditions
Number of conditions Barnet et al. 2012 Health Foundation 2018 Cassell et al. 2018 NEQOS analysis SPIRE30 NEQOS analysis SPIRE30

0

57.8%

54.0%

-

43.6%

43.6%

1+

42.1%

46.0%

-

56.4%

56.4%

2+

23.1%

24.0%

27.2%

28.1%

25.8%

3+

13.5%

13.8%

-

13.8%

10.3%

4+

7.8%

7.7%

-

6.8%

3.5%

5+

1.2%

-

-

3.2%

0.96%

6+

2.4%

-

-

1.5%

0.19%

This NICE indicator uses the presence of 4 or more condition clusters as a pragmatic definition of severe multimorbidity that balances clinical validity with the size of the population identified. It reflects an appraisal of international evidence, analysis of primary care data, and discussions with national academic, GP and clinical leads alongside the NICE Indicator Advisory Committee to agree an acceptable and practical population size on which to focus subsequent interventions. The indicator makes use of existing data to allow the register of people with multiple conditions to be constructed.

Table 2: Condition clusters: Multimorbidity register – people with conditions in 4 or more clusters
Cluster Condition

Cancer

Cancer

Chronic pain

Painful condition (4 or more prescription only medicine analgesic prescriptions or 4 or more specified anti-epileptics in the absence of an epilepsy Read code in last 12 months)

Circulatory conditions

  • Coronary heart disease

  • Atrial fibrillation or atrial flutter

  • Heart failure

  • Hypertension

  • Stroke or TIA

  • Peripheral vascular disease

Diabetes

Diabetes

Digestive system conditions

  • Currently treated constipation (Four or more laxative prescriptions in the last 12 months)

  • Diverticular disease of intestine

  • Inflammatory bowel disease

  • Chronic liver disease

Learning disability

Learning disability

Mental health

  • Anorexia or Bulimia

  • Anxiety & other neurotic, stress related and somatoform disorders

  • Dementia (including Alzheimer's)

  • Depression

  • Schizophrenia and related non-organic psychosis

  • Bipolar disorder

  • Alcohol problems

  • Psychoactive substance misuse

Musculoskeletal conditions

  • Rheumatoid arthritis

  • Other inflammatory polyarthropathies

  • Systemic connective tissue disorders

Neurological conditions

  • Currently treated epilepsy

  • Multiple sclerosis

  • Parkinson's (of any cause)

Renal conditions

Chronic kidney disease

Respiratory conditions

  • Currently treated asthma

  • COPD

  • Bronchiectasis

Source guidance

Multimorbidity: clinical assessment and management. NICE guideline NG56 (2016), recommendations 1.1.1 and 1.3.1

Specification

A register of people with 4 or more condition clusters or a determination what they would benefit from a tailored approach to care.

Exclusions: People under 18 years.

ISBN: 978-1-4731-5959-4