1:00pm - 2:00pm (Light lunch will be served at 12:45pm)
KCTCRC, 1/F, School of Public Health Building, Prince of Wales Hospital, Shatin
Professor Edouard Battegay
MD, FACP, ESH Specialist Hypertension, Fellow SSPH+
Professor of Medicine, Head Department of Internal Medicine, University Hospital Zurich, Switzerland
Between 20–30% of the population and about 90% of inpatients hospitalized in General Internal Medicine have multiple concurrent acute or chronic diseases, i.e., they are multimorbid (MM). Complexity increases overproportionally with the number of concurrent diseases, probably partially due to disease-disease interactions (DDIs)
Very typical MM clusters include vascular risk factors, heart - and pulmonary disease. Another cluster includes major mental disorders in conjunction with somatic diseases, and in the elderly frailty, falls and depression. Conditions occur sometimes in characteristic dyadic, triadic or higher combinations (pain and depression, non-adherence and depression, hypertension and pain, diabetes and high dose steroids, acutely exacerbated COPD and depression). Some of these conditions and combinations of interactions interact to worsen length of stay, morbidity and mortality as well as resource use. Thus, a newer and more restricted definition of MM emphasizes the complex interactions of several concurrent diseases.
There are only limited evidence-based guidelines for MM, even for most prevalent forms of MM and frequent interacting combinations (e.g. pain and hypertension). This leaves MM care heavily reliant upon clinical guidelines intended for the treatment of single diseases. However, these guidelines do not adequately address the combined risk to multimorbid patients and tend to ignore adverse DDI’s (disease-disease, drug-disease and drug-drug interactions, due to multiple drug regimens, i.e., polypharmacy), especially if a condition is outside the usual realm of those specialists from the same field of expertise that wrote the guidelines.
Decision-making concerning therapeutic conflicts typically demands prioritizing and reconciling adverse DDI’s with the most suitable, best acceptable and sometimes surprising therapeutic strategy. Decision-making in dilemma situations can induce psychological stress upon patients and especially on very conscientious medical doctors that they need to consciously deal with. For that matter we are setting up a virtual reality lab to train medical doctors in medically challenging situations of ambiguity.
Overall, neither health care systems, nor hospitals or medical doctors or patients are fully prepared and set up to deal with these forms of complexity yet.