Multiple chronic conditions

INTRODUCTION — Multimorbidity, also known as multiple comorbidities or multiple chronic conditions, is common and greatly increases the complexity of managing disease in patients. Worldwide, people are living longer with disability and multiple comorbidities, with important implications for global health care needs [1].

This topic will discuss the challenges posed by managing patients with multiple chronic conditions and will present strategies to maximize effective care for such patients.

TERMINOLOGY — Multimorbidity refers to the cooccurrence of two or more chronic medical or psychiatric conditions, which may or may not directly interact with each other [2-4]. The term "multimorbidity" is sometimes used interchangeably with comorbidity [5], but comorbidity technically indicates a condition or conditions that coexist in the context of an index disease [6]. As an example, an oncologist may be concerned with the effect of comorbidity on the management of lung cancer, whereas multimorbidity captures the general complexity of patients without focusing on any single disease [7,8].

"Multiple chronic conditions" is a term closely related to multimorbidity. Several initiatives in the United States use this term in targeting a population for improving outcomes and care quality. The National Quality Forum defines multiple chronic conditions as "two or more chronic conditions that collectively have an adverse effect on health status, function, or quality of life and that require complex healthcare management, decision-making, or coordination" [9]. This concept recognizes the marked heterogeneity within the large population of individuals with two or more chronic conditions. Hypertension and hypothyroidism, for example, do not generally encompass the same complexity or health needs as heart failure and dementia. Therefore, it can be beneficial to identify a subset of people with multiple chronic conditions that is in particular need of a different paradigm for care. Hereafter, we refer to the more basic definition of multimorbidity as two or more conditions, but we recognize that more nuanced definitions may better target interventions towards specific populations that need them.

EPIDEMIOLOGY — Although exact prevalence estimates depend on the type and number of conditions considered in the definition of multimorbidity [10,11], the presence of multiple chronic conditions is common [12-14], and the number and proportion of patients with multiple chronic conditions is growing [2,15]. A study of adults over age 65 in Alberta, Canada found that the prevalence of at least three morbidities was 34 percent, which rose to 50 percent over nine years [16]. Although the prevalence of multimorbidity is highest among adults age 65 or older, younger persons also represent a large proportion of those with multimorbidity [17-19]. In addition to age, lower socioeconomic status may be associated with a higher prevalence of multimorbidity, although data are scarce [20].

Because certain conditions heighten the risk of developing other conditions, people with multimorbidity are likely to accumulate more diagnoses and experience escalating clinical complexity [7,21]. In one study that analyzed data from over 60,000 adults in the Netherlands and adjusted for age and insurance status, individuals with multimorbidity at baseline were 40 percent more likely than those without multimorbidity to be diagnosed with two or more new conditions during the next year [22].

Data from the United States National Health and Nutrition Examination Survey (NHANES) found that among 1259 individuals with coronary heart disease, coexisting noncardiac morbidities included arthritis (57 percent), chronic lung disease (25 percent), diabetes (25 percent), renal insufficiency (24 percent), and stroke (14 percent) [23]. Functional issues included urinary incontinence (49 percent), mobility difficulty (40 percent), falls or dizziness (35 percent), and cognitive impairment (30 percent).

IMPACT — Multimorbidity is associated with high health care utilization and costs, especially among those with functional limitations [21,24,25]. The two-thirds of Medicare beneficiaries with multimorbidity account for 96 percent of Medicare expenditures [26].

Individuals with multiple chronic conditions are at heightened risk of significant adverse health outcomes, often beyond the effects of the individual conditions [16,21,27-36]. These include:

●Death

●Functional limitations and disability

●Frailty (see "Frailty")

●Nursing home placement

●Diminished quality of life

●Treatment complications

●Emergency department visits

●Adverse drug reactions

●Hospitalizations, including avoidable admissions

PATIENT CARE CHALLENGES — Clinicians and patients face many challenges in quality health care delivery. In focus group interviews, primary care clinicians in the United States identified multiple issues in providing care for patients with multimorbidity, including insufficient data about best practices, inadequate support and collaboration with specialists, conflicts between clinician and patient priorities, and reimbursement policies that don't adequately compensate for the effort involved in the management of complex patients [37]. In a systematic review of 10 studies involving general practitioners in seven different countries, specific issues identified in managing patients with multimorbidity were: fragmentation of health care, inadequate guidelines and evidence-based medicine, and challenges delivering person-centered care and incorporating shared-decision making [38].

Limitations of disease focused approach — Most treatments and practice guidelines target a single index condition, but patients with multimorbidity are complex and heterogeneous. The traditional disease-focused approach to clinical medicine may render care that is fragmented and poorly coordinated, and produce treatment plans that are inefficient, ineffective, or even harmful for patients with multimorbidity [7,23,27,37,39-41]. Clinicians have limited guidance or evidence on which to base care decisions for such patients.

Overlapping treatments can cause clinically relevant challenges. For example, a patient with early dementia may be prescribed donepezil, a cholinesterase inhibitor, which boosts levels of acetylcholine to improve their cognitive trajectory. However, if the same patient experiences urinary incontinence from overactive bladder, a different provider may prescribe oxybutynin or other anticholinergic. Now, this patient is taking a procholinergic medication for one problem (dementia) and an anticholinergic medication for another problem (overactive bladder). Another common problem is "therapeutic competition," which means that a medication prescribed for one condition is harmful or exacerbating for another condition. A common example of therapeutic competition is rosiglitazone prescribed for diabetes resulting in worsening heart failure symptoms [42].

Adherence to multiple clinical practice guidelines — Most clinical practice guidelines are developed with the intent to address the diagnosis or management of a single clinical entity. The challenges and potential harm brought about by rigid adherence to clinical practice guidelines in patients with multimorbidity is illustrated in a paper that examined the hypothetical case of a 79-year-old woman with hypertension, diabetes mellitus, osteoporosis, osteoarthritis, and chronic obstructive pulmonary disease (COPD) [41]. In following the most inexpensive and simple treatment plan that would satisfy all guidelines, the hypothetical patient would need to take 12 medications and, each year, follow 14 recommendations related to self-care or education, diagnostic testing, or referrals to other specialists or services (table 1 and table 2). Furthermore, different guidelines may offer conflicting recommendations (eg, weightbearing exercise recommended by the osteoporosis guideline conflicts with cautions in weightbearing for neuropathic patients in the diabetes guideline) [41].

Although the applicability of most clinical practice guidelines to patients with multimorbidity is limited [43,44], there are some that do recognize the need to adapt recommendations for patients with increased complexity. Specific steps have been described that may be considered to increase the relevance of guidelines to people with multiple comorbidities [45-52]. As an example, the American Geriatrics Society (AGS) and American Diabetes Association's recommendations for the management of older patients with diabetes advocate for prioritization of goals of care among multiple conditions and recommend more permissive targets for glycemic control and blood pressure among patients with frailty or limited life expectancy [53,54].

The key to prioritizing among recommendations from multiple guidelines is in understanding what matters most to the patient, and what outcomes are most important or bothersome to the patient. Another important concept is time horizon to benefit, meaning how long it will take until benefits of interventions are achieved, and the net benefit across all benefit and harm outcomes relevant to the clinical question [55,56].

Competing demands and shifting priorities — Issues related to competing demands are common when caring for patients with multiple conditions. Patients with multimorbidity typically experience a fluctuating health status, with particular ailments rotating into and out of the forefront in terms of their influence on the patient's overall well-being [57,58].

To maximize quality of life, patients with multimorbidity must strike a daily balance between attending to their health problems, thereby controlling symptoms and reducing flares and complications while avoiding the potential for their lives to be ruled by the demands of chronic disease management [57]. Clinicians' well-meaning attempts to aggressively treat all conditions all the time, without sufficient attention to the whole person and their shifting priorities, may result in treatment recommendations that the patient finds overwhelming, unaffordable, or otherwise unrealistic [41].

Clinicians themselves must balance competing demands for their time in attempting to address multiple health issues within the confines of a 15- to 20-minute office visit. By time constraints alone, a primary care provider in the United States with a standard patient panel may be unable to deliver the services recommended for chronic disease management and prevention [59,60]. The situation is compounded when a treatment beneficial for one condition (eg, anticoagulation for atrial fibrillation) may lead to harm due to a concurrent condition (eg, bleeding from diverticulosis), forcing a prioritization of competing health objectives. Similarly, patients with multimorbidity and the clinicians who provide their care must prioritize conditions that require the most active management and balance treatment strategies consistent with the patient's preferences, tolerance, and needs.

Polypharmacy — Medication use among older adults in the United States is high and continues to rise [61]. Patients with more chronic conditions and more frequent clinical encounters take more medicines and are at the greatest risk of being prescribed potentially inappropriate medications [62].

Even when each medication has an appropriate indication, polypharmacy is associated with burden, cost, and risk of drug-drug or drug-condition interactions [63,64]. The important issue of polypharmacy is discussed in detail separately. (See "Drug prescribing for older adults", section on 'Polypharmacy' and "Deprescribing".)

Limited evidence — A major challenge in delivering appropriate care to patients with multimorbidity stems from the fact that these complex patients are underrepresented in clinical research populations [40,65]. Comorbidities are typically an exclusion factor for patient recruitment into studies addressing a given clinical condition. When investigators do attempt to include representative numbers of patients with multimorbidity in a clinical trial, they often face challenges in terms of recruitment and retention that lead to selection bias and large amounts of missing data [66].

As a result, the evidence base to guide medical decision-making for these patients is lacking [41]. In the absence of trial data, providers cannot be certain how the presence of coexisting conditions may alter the tolerance or treatment effect of an intervention for a particular disease [67]. Many pivotal trials lack generalizability to "real-world" patient populations who have significant complexity and morbidity burden. Despite strong evidence of efficacy in a trial population, clinicians at the bedside are left uncertain of the benefit (or harm) that an intervention offers to their patient [68].

A 2021 systematic review of 17 trials to improve outpatient management of patients with multimorbidities found little or no difference in clinical outcomes with small improvement in patient-reported outcomes among trials evaluating a variety of interventions focused either on care delivery (eg, through case management or enhanced multidisciplinary team work) or patient-oriented interventions (eg, education or self-management support) [69].

Finally, the heterogeneous nature of multimorbidity makes it difficult to control for confounding or to draw inferences about how a broad array of coexisting conditions may have impacted treatment effect [70,71].

APPROACH TO THE PATIENT WITH MULTIMORBIDITY

Overall approach from expert group guidelines — A panel convened by the American Geriatrics Society (AGS) has identified five guiding principles for management of multimorbidity (algorithm 1) [72]:

●Elicit and incorporate patient preferences into medical decision-making

●Recognize the limitations of the evidence base in interpreting and applying the medical literature to persons with multimorbidity

●Frame clinical management decisions within the context of risks, burdens, benefits, and prognosis (remaining life expectancy, functional status, quality of life)

●Consider treatment complexity and feasibility when making clinical management decisions

●Choose therapies that optimize benefit, minimize harm, and enhance the quality of life

In 2019, the AGS convened a second workgroup to translate these guiding principles into action [73]. The multiple chronic condition action steps are summarized as follows:

●Identify and communicate patients' health priorities and health trajectory

●Stop, start, or continue care based on health priorities, potential benefit versus harm and burden, and health trajectory

●Align decisions and care among patients, caregivers, and other clinicians with patients' health priorities and health trajectory

When considering disease-specific guidelines, these action steps are useful in the context of overall health status, considering the patient's life expectancy, degree of functional impairment, and chronic disease burden. The AGS advises the following approach:

•For patients with >10 years life expectancy, few chronic conditions, and none or few functional limitations, disease-specific guidelines should be utilized in accordance with patient preferences.

•For patients with <1 to 2 years life expectancy and advanced illness, guideline-specific care to aggressively treat and manage disease is often not best aligned with patient goals and preferences. Rather, care should focus on aggressive palliation of symptoms and a care plan that prioritizes quality over quantity of life.

•For patients with 2 to 10 years life expectancy, an increasing number or severity of chronic conditions and functional impairment, the multiple chronic condition action steps should be utilized.

Guidelines for management of multimorbidity have also been developed by the National Institute for Health and Care Excellence (NICE) in the United Kingdom [74]. The guidelines advise:

●Tailor care to meet personal goals and priorities

●Identify people who may benefit from care that takes into account multimorbidity by considering factors such as presence of frailty, falls, difficulty with daily activities or medication management, or need for multiple services or frequent use of emergency care

●Establish what is important to the patient

●Identify the impact of disease and treatment burden on quality of life

●Review medications: consider stopping nonessential treatment, consider nonpharmacologic approaches

●Develop an individualized management plan

We have attempted to highlight key aspects of care delivery for those with multimorbidity that promote coordinated, safe, high-quality care in keeping with patient preferences and feasible within the current health care system, consistent with the AGS guiding principles.

Elicit patient goals and priorities — The Institute of Medicine's report, "Crossing the Quality Chasm," emphasized that the "true north" of quality in health care is the patient experience [75]. This becomes all the more relevant for patients with multimorbidity, given the challenges of conflicting recommendations, competing demands, and limited evidence.

To optimize care for the individual patient, a provider must understand the patient's goals and preferences and how their health relates to perceived roles within a family or community [76]. The dialogue about patient goals and priorities includes a discussion of end-of-life preferences, as well as medical decision-making to include drug initiation and discontinuation, hospitalizations and procedures, receipt of preventive services, and recommendations for behavioral changes such dietary restrictions and frequency of blood pressure monitoring [76]. For example, an older adult may prioritize the ability to live at home, walk their dog, eat what they want, or get down the steps in order to be able to go visit family. These priorities can and should inform decision-making. (See "Discussing goals of care".)

Successful elicitation of patient preference requires that the patient and provider communicate effectively and that the patient has an adequate understanding of relevant choices and their expected outcomes. It is important to recognize that patients with multimorbidity frequently have impairments in hearing, vision, or cognition that may restrict communication or their capacity to process information. Special measures may be necessary to overcome the barriers associated with these impairments (table 3).

Even in patients without known communication barriers, there is considerable variability in individual's comfort level and desire to engage in the medical decision-making process [77]. Approaches to enhancing patient involvement need to be flexible. Factors implicated in successful patient engagement include communication skills of the provider, trust in the relationship, and adequate time [77]. When available, a referral for Comprehensive Geriatric Assessment may be a useful means of clarifying goals and priorities for patients with multimorbidity. (See "Comprehensive geriatric assessment".)

Coordination of care — Patients with multimorbidity experience frequent clinical encounters, often with multiple providers representing different disciplines across many health care settings (including outpatient, inpatient, emergency department, long-term or rehabilitation facilities, and in-home care) [75,78]. Transitions of care have been identified as a high-risk opportunity for medical errors, particularly for complex patients [79-81]. (See "Hospital discharge and readmission", section on 'Failed handoffs'.)

Inconsistent recommendations or duplicative care from various providers can result in patient confusion, unnecessary cost, and treatment burden resulting in poor quality of care [82,83]. An essential component of high-quality care for patients with multimorbidity is coordination of a uniform care plan that is communicated across settings, providers, and caregivers.

Electronic health records are helpful in coordinating care because they facilitate access to and sharing of information between various providers [84,85]. For particularly complex medical decisions, direct communication among providers, patients, and caregivers is often the best means of filling in knowledge gaps or arriving at a consensus. Multidisciplinary forums, such as tumor boards or stroke teams, may provide regular opportunities for discussion of patients by multiple providers involved in a certain aspect of patient care.

The time constraints of most clinical practices and the fragmented, disease-focused nature of service provision make it challenging to coordinate an overall care plan effectively in the current health care system. Case managers and extended care providers may play an essential role in coordinating care for the most complicated and vulnerable patients within a practice [86,87].

In addition, the value of informal, unpaid caregivers (family and friends) is increasingly recognized, particularly in the care of patients with multimorbidity [88]. Nonprofessional caregivers influence adherence and decision-making, supplement self-care, and frequently accompany patients to office visits [88-90]. Although questions remain about how to optimally engage and integrate this support network, such caregivers are often instrumental in managing "the big picture" for patients with multimorbidity [91,92].

Innovative models show promise in their ability to promote more seamless, efficient, and holistic care for older adults with multimorbidity. These programs often incorporate many aspects of the Wagner Chronic Care model, which emphasizes system elements that promote coordinated care by creating partnerships among patients, their families and informal caregivers, and providers [93-95]. Examples of these models of care include Guided Care [96-98], the Program of All-Inclusive Care of the Elderly (PACE) [99], Geriatric Resources for Assessment and Care of Elders (GRACE) [100], and the Patient-Centered Medical Home [101].

Integrated care, involving both psychiatric and medical specialty providers, to address the medical conditions and depression that frequently coexist in older patients with chronic medical problems can improve quality of life and disability outcomes [102].

Less may be best — Every intervention, hospitalization, or medication prescribed creates the potential for harm. These risks are magnified in patients with multimorbidity.

Treatment goals — Careful consideration should be given to each treatment decision and how it figures into the patient's preferences and overall equation of potential benefit versus burden and risk. The specific examples of diabetes and hypertension are discussed below. (See 'Common disease-specific considerations' below.)

Cancer screening — Preventive practices such as cancer screening should remain relevant and appropriate for patients with multiple chronic conditions [103,104]. Cancer screening in patients with limited life expectancy is associated with unfavorable risk to benefit ratios, especially in patients with less than a five-year life expectancy or in those who would decline treatment if disease is identified [105-107]. The types and severity of comorbid conditions present can help guide estimates of life expectancy and inform personalized decisions about when to cease routine cancer screening (table 4) [105]. Tools are available to estimate life expectancy (eg, ePrognosis). Overall, the patient's preferences, as well as the patient's overall health, should inform decision-making.

Medication considerations — A concept of "time to benefit" (TTB) has been considered in relation to drug prescribing for patients who have multiple morbidities and also may have limited life expectancies [108]. This concept has also been identified as "time horizon to benefit" [72]. TTB, defined as the time to significant benefit observed in trials of people treated with a drug compared with controls, can be estimated from data from randomized controlled trials. Such information may help guide decision-making for drug prescribing in individual patients, although it should be recognized that patients with multimorbidity are often excluded from randomized trials.

To minimize inappropriate prescribing and adverse drug reactions in patients with multimorbidity, we recommend the following general strategies:

●Start low, go slow with any medication initiation or dose change.

●Always ask, "Can this problem or symptom be addressed without my prescription pad?" For example:

•Can sleep disturbance be addressed with sleep hygiene and behavioral changes?

•Could incontinence be addressed with scheduled voiding and referral to urogynecological rehabilitation specialist?

•Could reflux be addressed with dietary changes and elevation of the head of the bed?

•Can ankle edema be addressed with leg elevation and compression stockings?

●Frequent review of medication list for appropriateness in the context of patient's current goals and preferences, with consideration of deprescribing as necessary. (See "Deprescribing".)

●Consolidate drug dosing schedules to minimize complexity and chance of error. The Institute of Medicine has proposed a standardized schedule for specifying medication dosing (morning, noon, evening, bedtime), recognizing that 90 percent of prescriptions are taken four or fewer times daily [109].

●Consolidate treatments when possible (ie, angiotensin-converting enzyme [ACE] inhibitor for blood pressure, renal protection, and heart failure).

Identify and address issues that impact multiple conditions — One efficient way to promote better outcomes for patients with multimorbidity is to identify issues that affect a patient's well-being or quality of life in ways that cut across many diseases. Examples of these issues include:

●Nutrition

●Physical activity/exercise

●Function/independence

●Sleep disturbance

●Mental health

●Safety of environment and adequacy of support in current level of care

●Caregiver stress [110]

Common disease-specific considerations — Even in patients with multimorbidity, it is sometimes appropriate to apply typical management strategies to individual chronic conditions. For example, aggressive management of heart failure may be necessary to prevent exacerbations and frequent hospitalizations. Patients with a history of myocardial infarction (MI) should receive a trial of beta blockers, even in the setting of comorbid chronic obstructive pulmonary disease (COPD), because many patients with COPD tolerate beta blockers and the treatment benefit of beta blockers post-MI is clear. (See "Acute myocardial infarction: Role of beta blocker therapy".)

However, the presence of comorbidity frequently dictates the need to adjust the treatment plans for individual conditions. Due to the heterogeneity of comorbidities that may coexist with any condition, it is not feasible to provide a uniform set of guidelines for the management of a specific disease in patients with multimorbidity. The guiding principle in patients with multimorbidity should be individualization of treatment. We have highlighted frequent considerations that arise in the setting of two common comorbidities, which may justify departure from rigid adherence to disease-specific guidelines.

Diabetes

●The appropriate target for glycated hemoglobin (A1C) should be individualized based on life expectancy and comorbidity burden (table 5). A target of 8 percent is appropriate in persons with limited life expectancy or persons in whom the risks of hypoglycemia outweigh the benefit of more aggressive targets (eg, persons who have difficulty maintaining consistent caloric intake due to gastrointestinal comorbidities or conditions that cause frequent nausea or anorexia) [53,54] (see "Treatment of type 2 diabetes mellitus in the older patient"). Further, the American College of Physicians recommends avoiding a target HbA1c level altogether in patients with a life expectancy less than 10 years, and treating only to minimize symptoms [111].

●Insulin therapy may be inappropriate in patients with cognitive or visual impairments that increase the risk of medication error, unless the patient has a caregiver with the ability to assist with every insulin dose.

●The risk of hypoglycemia is increased in older adults, particularly those with comorbidities. Thus, when possible, therapeutic agents should be selected that have a lower risk for hypoglycemia (eg, metformin, shorter-acting sulfonylurea, or repaglinide).

●The value of self-monitoring blood glucose (SMBG) in patients with type 2 diabetes who are diet-treated or treated with oral agents that are not associated with hypoglycemia is not as clear as for other diabetic patients. Thus, advice regarding SMBG for older diabetic patients, and especially those with comorbidity, should be tailored to the patient, based upon medications and functional and cognitive abilities.

●Electrolytes and renal function should be assessed within one to two weeks of initiation or dose adjustments of ACE inhibitors, angiotensin II receptor blockers (ARBs), or diuretics, due to the increased likelihood of adverse effects in patients with multimorbidity [112].

Hypertension

●A less aggressive systolic goal blood pressure may be appropriate for patients with limited life expectancy. (See "Goal blood pressure in adults with hypertension" and "Treatment of hypertension in older adults, particularly isolated systolic hypertension".)

●All patients should receive nonpharmacologic therapy, particularly dietary salt restriction and weight loss in obese patients. Drug therapy should be started if lifestyle changes are not sufficient.

●Blood pressure should be reduced gradually. Tolerance to blood pressure reduction should be assessed at regular intervals with attention to orthostasis, postprandial hypotension, falls, and activity restriction due to dizziness. More permissive blood pressure targets are appropriate, if patient preferences favor quality of life over potential benefit of additional blood pressure reduction. (See "Treatment of hypertension in older adults, particularly isolated systolic hypertension", section on 'Goal blood pressure'.)

●Comorbidities should guide choice of agent. The goal is to avoid exacerbating comorbid conditions (eg, discontinue beta blockers if they worsen reactive airway disease or diuretics if they exacerbate urinary incontinence) and to minimize polypharmacy (eg, choose an alpha blocker to simultaneously address benign prostatic hypertrophy and hypertension, rather than prescribing a separate medication for each condition). (See "Choice of drug therapy in primary (essential) hypertension".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: When you have depression and another health problem (The Basics)" and "Patient education: Taking medicines when you're older (The Basics)" and "Patient education: When you have multiple health problems (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Terminology and impact – Multimorbidity, the cooccurrence of two or more medical or psychiatric conditions, occurs in patients of all ages and is increasingly prevalent with advancing age. Multiple chronic conditions is a closely related term. Patients with these conditions are more likely to have poor health outcomes and significant health care expenditures. (See 'Terminology' above and 'Impact' above.)

●Patient care challenges – The challenges of managing patients with multimorbidity are multiple. They include:

•Lack of guidelines that are applicable to these complex patients

•Conflicting recommendations that arise in trying to apply guidelines developed for single disease entities

•Competing and shifting patient priorities of conditions to be addressed

•Risks associated with polypharmacy

•Lack of evidence on how best to treat patients with multimorbidity (see 'Patient care challenges' above)

●Guidelines from expert groups – Expert groups have developed principles and guidelines for care of these patients centered around an understanding of patient preferences and shared decision-making. (See 'Overall approach from expert group guidelines' above.)

●Our approach – Key principles in caring for patients with multiple chronic conditions include (see 'Approach to the patient with multimorbidity' above):

•Attention to understanding a patient's goals of treatment and health care priorities. (See 'Elicit patient goals and priorities' above.)

•Communication between the multiple providers, health care facilities, and caregivers involved in a patient's treatment. (See 'Coordination of care' above.)

•Recognition of the potential harms associated with medical interventions. (See 'Less may be best' above.)

•Minimizing drug dosing and complexity. (See 'Medication considerations' above.)

•Identifying and addressing lifestyle and psychosocial issues that may affect the patient's quality of life and response to medical care. (See 'Identify and address issues that impact multiple conditions' above.)

●Patients with diabetes or hypertension – The presence of comorbidity frequently dictates the need to adjust the treatment plans for individual conditions, such as diabetes of hypertension. (See 'Common disease-specific considerations' above.)