Multi-morbidity, defined as co-occurrence of more than one chronic disease in an individual, is a major challenge for many health systems, including the NHS. One in three adults in the UK have a long-term condition, which account for half of GP appointments, 70% of inpatient bed days and 70% of the acute care budget; in other words, over two-thirds of NHS expenditure for one-third of the population.
Multi-morbidity is also on the increase – effective interventions delay mortality and increase prevalent disease, and overall life expectancy is rising. Evidence is limited on which co-morbidities are concordant (inter-linked, with common therapies) or discordant (high risk of interactions, worse prognosis), prompting the NIHR to designate multi-morbidity a research priority in 2015.
Our research with groups of patients with similar characteristics has helped to predict more extreme expressions of disease, such as degree of variability in blood pressure predicting the likelihood of major vascular events, such as strokes.
Our analyses of large sets of clinical data showed that increasing body mass index (BMI) was associated with the progression of chronic kidney disease, independent of known risk factors. New technologies to monitor patients with multiple conditions have been explored in home-based care of patients with heart failure, the management of patients with high blood pressure, and initiatives to detect atrial fibrillation, a condition that causes abnormal heart rhythms.
We will expand our BRC Theme to focus on more effective identification and management of multi-morbidity and long-term chronic disease by developing and testing new diagnostic and disease management technologies, by analysing interactions between co-morbidities in groups of patients, and by testing the effectiveness of new smart data platforms based on real-time analyses of routine clinical databases.
In the first two years of the BRC3 programme, we focused mainly on how to integrate and then analyse our routine electronic health records (EHRs) and bespoke ‘well-phenotyped disease cohort’ databases, and modelling the potential for promising clinical interventions.
Our objectives for years 1 & 2:
1 – Integrate databases of patient cohorts with long-term conditions
- A modification to our original plan was required due to the introduction of GDPR and other regulations. Our current focus is on individual analysis and combination of results through meta-analysis.
- We are developing a new approach to study follow-up based on linking GP practices with Royal College of General Practitioners Research and Surveillance Centre which could facilitate long-term low-cost follow up of our cohorts (feasibility stage).
2 – Novel analyses of EHR to identify multi-morbidities that matter most and why.
- Analysis of EHR to quantify burden of multi-morbidities has been carried out.
- Our current work is based on novel data-driven approaches: how multi-morbidity develops and which clusters of conditions matter most.
3 – Research better methods for early detection and monitoring of discordant multi-morbidities.
- We collaborated on a project with Oxford Health and Oxford University Hospitals NHS Foundation Trusts to support the delivery of ‘TrueColours’, which is an example of digital healthcare enabling people to track their mental health status to allow for early detection of episodes and for monitoring of their condition.
4 – Develop feasibility for wearable or diagnostic devices in a major clinical impact disorder
- An IT-enabled system for heart failure patients was developed. It supports an integrated, patient-centred and proactive management system from home.
- The technology has been licensed to a commercial partner for wider adaptation throughout the NHS and internationally.
Our objectives for years 3-5(+):
1 – We will examine methods to model areas of complex care where interventions could be beneficial
- Through the creation of a complexity score model to impact on clinical outcomes.
- By developing a toolkit to support policymakers in: planning of healthcare resourcing, facilitating communication of primary care workload, and identify cost savings.
2 – We will explore new interventions/technologies to mitigate the burden of long-term conditions
- By developing artificial intelligence-led analytics for characterising patterns, trajectories and prognosis of multi-morbidity.
- Through extending a novel trial design (pilot) on treatment to lower blood pressure in elderly and multi-morbid patients to large-scale, multi-centre trial involving national (UK) and international (Norway) collaborating centres.
- By carrying out a variety of projects, including multicentre randomised controlled trials of remote home telemetric blood pressure monitoring; and studies on automated AI-enhanced interpretation of CT brain imaging
3 – We will develop new interventions to direct clinical behaviour in managing multi-morbidity.
- Continue enhancing OpenPrescribing dashboards with new features and greater flexibility for analyses. Project underway to detect and understand unusual patterns of prescribing.
- Create new, more powerful dashboards using Royal College of General Practitioners Research and Surveillance Centres. Following BRC funding, we attracted new income to develop a similar project creating new dashboards on pathology testing.
- Wide range of additional research planned: new RCTs and new data science approaches to describing and improving the diffusion of innovation in NHS.
- Continue to promote and facilitate better use of data across NHS through our policy work.
Lionel Tarassenko, Professor of Electrical Engineering, Director, Institute of Biomedical Engineering, University of Oxford, talks about how mobile phones are being used by patients to monitor their conditions and send information to their doctor or nurse. Current trials are underway for the self-management of diabetes and chemotherapy side effects.
What is available in Oxford to deliver this theme:
- World class and unique intensively phenotyped disease cohorts (Rothwell, Hobbs, Myerson, McManus), contributing to changes in international disease guidelines in heart failure, blood pressure variability and outcomes, stroke prevention, and acute vascular event recognition.
- Oxford University Hospitals NHS Foundation Trust (OUH) and the University of Oxford are in the leading group of partnerships for Highly Cited Publications (HCPs) in primary health care (RAND Europe, 2002-13).
- Internationally competitive clinical (Hobbs, McManus, Farmer) and methodology scientists (Perera, Altman, Gray, Stevens, Bankhead) in diagnostic and monitoring research. We developed novel integration of routine clinical data to produce the world’s first centile charts for routine measures in children, predicted interval frequency for common test follow up (lipids and blood pressure), and modelled impact of treatment effects on common risk scores
- Largest and most highly regarded centre for generalist community-based medicine in Europe, UK top ranked in successive RAEs/REF since 1996.
- The George Institute for Global Medicine, with global expertise in distributed technologies and leads of the Blood Pressure Trialists Collaboration (MacMahon, Rahimi, Woodward)
- Oxford Centre for Evidence Based Medicine, one of the most successful secondary research and evidence synthesis centres globally (inc Cochrane groups) (Heneghan)
- Unrivalled research infrastructure, including NIHR-accredited specialist PC trials unit (Butler), Leadership of the NIHR School for PC Research, NIHR Applied Research Collaboration (ARC) Oxford and Thames Valley (formerly CLAHRC), and Oxford DEC.
- World leading expertise in real-time clinical system integration, analysis and application development, and retrospective big-clinical data linkage and analyses (Goldacre)