Knowledge resources to help doctors help patients with multiple conditions

Dr Manan Pareek, Fellow in Cardiology, Copenhagen University Hospital, Gentofte, Denmark
Dr Kieran Walsh, Clinical Director, BMJ

Managing patients with multiple conditions who are admitted to hospital is not straightforward. First of all, there is the need to treat the acute condition that caused the admission in the first place. In general internal medicine, this is usually a common disorder such as pneumonia, infective exacerbation of COPD, heart failure, an acute ischemic event, or non-specific dehydration. However, an additional problem is the other background illness or illnesses that the patient might have, e.g., hypertension, diabetes, atrial fibrillation, cancer, depression, and anxiety. Patients are also commonly on multiple medications that may display interactions with any new medications required to treat the acute condition.

The COVID pandemic has made this phenomenon of patients with multiple illnesses even more obvious. Most patients who are hospitalized with severe COVID have comorbidities. One example is hypertension, the treatment for which was associated with a great deal of controversy during the initial stages of the pandemic. However, many of these concerns have now been debunked. Chronic kidney disease is another such comorbidity. Patients with chronic kidney disease and acute respiratory distress syndrome need tailored care so that their COVID infection can be treated without significantly worsening kidney function.

BMJ Best Practice Comorbidities helps with these dilemmas. The aim of this resource is to modify how doctors and other healthcare professionals think about patients. It gives advice on the extra things that doctors should think about when managing patients with multiple conditions. It also attempts to be honest about the underlying evidence base – sometimes there is a clear evidence-based answer to a clinical question, sometimes there is not. It is aimed particularly at junior doctors and may help them understand that not all patients should necessarily be treated in the same way. BMJ Best Practice offers clinical decision support but stops short of telling the doctor exactly what to do. For example, in the case of COVID, it might advise the use of steroids and state the preferred drug, but still leaves the exact choice of steroid somewhat open. This is sensible as different hospitals sometimes have different drugs available or different treatment protocols.

Importantly, the resource also accounts for mental health conditions. These comorbidities are commonly neglected, but any serious illness can exacerbate pre-existing illnesses. In the specific case of COVID, the use of steroids may cause destabilization of mood or sleep disturbances. Importantly, depression is not a contraindication to the administration of corticosteroids, but these patients need careful monitoring. This is especially important as mental health conditions are often seen as lower down the hierarchy than somatic conditions.

Sometimes the advice from a clinical decision support tool simply needs to state that the patient needs to continue with their usual medication – this in itself can be very helpful.

Finally, a clinical decision support tool needs to be readily accessible and easy and intuitive to use. In countries with socialized medicine focused on efficiency where doctors are extremely busy and supervision is often scarce, a tool like BMJ Best Practice has great potential to both aid the clinician and to serve as a learning tool.

Competing interests
KW works for the BMJ.