Chitalu, Petronella Natasha; (2024) Evaluating services for older adults with multimorbidity across health and social care. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background: Increasing life expectancy is associated with a higher prevalence of living with multiple chronic conditions (multimorbidity). Multimorbidity and age-related functional decline are components of frailty, an independent predictor of adverse health outcomes. While chronic disease management increasingly accounts for multimorbidity, such strategies do not always also consider frailty. This thesis explores the consequences of multimorbidity on health, frailty and functional outcomes, including quality of life, service use and costs. It uses cohort data and linked datasets to assess the impact of multimorbidity on chronic disease management for complex older adults. Methods and Results: I conducted a systematic review evaluating the literature on the efficacy and cost-effectiveness of multimorbidity interventions for older adults. I found that the effectiveness of multimorbidity interventions was generally inconsistent, with many studies giving varied results. However, one theme suggested that comprehensive assessments from an interdisciplinary team were beneficial. A more striking descriptive finding was that most multimorbidity interventions were often designed or evaluated without considering frailty. I then used cohort data to understand the simultaneous impact of multimorbidity and frailty on (arguably) the highest-order function: quality of life. I undertook a cross-sectional analysis of a population-representative cohort, using linear regression models to estimate quality of life scores using multimorbidity measures, life-space assessment, and a frailty index. Frailty measures were much more informative than multimorbidity, with quality of life being associated with both frailty and life space scores. Interactions suggested the strongest associations between functional mobility and quality of life was evident in those with higher frailty. Overall, this indicated that over and above multimorbidity, mobility interventions could have the biggest impact on quality of life in individuals living with frailty. Using datasets linked across primary, secondary, community, mental health and social care, I examined the longitudinal relationship between multimorbidity, unscheduled (acute) inpatient admission and long-term service use. I found that acute admissions were associated with increased service use across primary, secondary and social care settings. Though this attenuated over time, there was evidence of increased service utilisation well beyond the acute illness period. This was worse where there was more multimorbidity. Costs were greater across all settings, but particularly for social care after an acute admission. Conclusion: For older adults, services for multimorbidity could be more effective if frailty is simultaneously evaluated and managed. This is apparent in cohort data describing relationships between variables not usually available in routine health and social care records. However, using linked datasets provides opportunities to understand service use patterns in a more complete ecosystem. Together, these findings may help with integrated and coordinated service design, both in whole populations, and in subgroups.

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