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 (LTC), which account for half of GP appointments, 70% of inpatient bed days, and 70%of the acute care budget i.e over two-thirds of NHS expenditure for one-third of the population. Multi-morbidity is also rising – 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, common therapies) or discordant (high risk of interactions, worse prognosis), prompting NIHR to designate Multi-Morbidity a research priority in 2015.
Our research with well phenotyped prospective cohorts, has helped predict more extreme expressions of disease, such as degree of blood pressure variability predicting likelihood of major vascular events. Our analyses of big clinical datasets showed that increasing BMI was causally associated with the chronic kidney disease progression, independently of established risk factors. Novel technologies in monitoring MM patients have been explored in home-based care of patients with heart failure, patient management of high blood pressure, and initiatives in AF (atrial fibrillation, abnormal heart rhythm) detection.
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 NHS Foundation Trust (OUH) and the University of Oxford (UoO) 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 Centre 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 CLAHRC Oxford 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)
We will expand our BRC Theme to focus upon 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 in prospective well-phenotyped disease cohorts, and by testing the utility of new smart data platforms based upon real-time analyses of routine clinical databases.
Years 1-2 will focus mainly upon integrating and then analysing our routine EHR and bespoke well-phenotyped disease cohort databases and modelling the potential for promising clinical interventions.
Year 1 & 2 Objectives:
- Create new integrated database of well phenotyped patient cohorts with long-term conditions (LTCs) curated in Oxford.
- In new analyses of routine clinical and research cohort databases, improve our understanding of which multi-morbidities most matter and why.
- Research better methods for early detection and monitoring of discordant multimorbidities.
- Develop feasibility for wearable or diagnostic devices in a small number of major impact clinical disorders (planned early candidates in AF screening, heart failure monitoring).
Years 3-5 will focus mainly upon testing of working applications or technologies, and pull through with health providers as soon as effective models are identified. We will also identify in the first 2 years at least one tested discovery that is then rapidly evaluated with healthcare partners via the Oxford CLAHRC:
Years 3-5 Objectives:
- Develop and test novel interventions or technologies that mitigate the impact of LTCs, alter their prognosis, or and guide management.
- Develop and test interventions to positively direct clinical behaviour in managing mult-morbidity through the immediate real-time presentation of clinical performance.