Study finds multimorbidity in nearly half of hospital patients in Malawi and Tanzania

The Multilink Consortium, a NIHR-funded partnership between the Liverpool School of Tropical Medicine, the Malawi-Liverpool-Wellcome Programme, Muhimbili University of Health and Allied Sciences and Kilimanjaro Christian Medical University College, has published the first-of-its-kind research in sub-Saharan Africa to examine the scale and impact of 'multimorbidity' in patients admitted acutely to hospital. Multimorbidity refers to the presence of two or more chronic diseases.

Researchers discovered that of 1007 patients admitted to four hospitals in Malawi and Tanzania, 47% had multimorbidity, most commonly hypertension, diabetes or HIV. Such conditions increase the risk of end-organ diseases such as heart failure, stroke and chronic kidney disease, and premature death.

Patients with multimorbidity were significantly more likely to die within 90 days of entering hospital (41.7%), compared to those with one long-term condition (28.3%) or no long-term conditions (13.5%).

The study, published in Lancet Global Health, also showed the economic cost of multimorbidity, with patients with acute illness reporting income loss, poorer quality of life, and higher medical bills, especially in Tanzania where healthcare is not free at the point of use.

The findings demonstrate the significant burden of multimorbidity in healthcare systems that do not typically screen for long-term conditions. This unfortunately often means that the initial diagnosis is made after complications have occurred.

Researchers argue that their findings demonstrate how multimorbidity is an urgent public health threat that requires changes to healthcare delivery to address population needs. Further research is now required to test context-sensitive health systems models to identify and control chronic disease, prevent complications, reduce disability and mortality, and ensure financial protection for patients.

Dr. Stephen Spencer, Wellcome Trust Clinical PhD Fellow at Liverpool School of Tropical Medicine and the Malawi-Liverpool-Wellcome Programme (MLW), and co-first author on the paper, said: "Multimorbidity is a growing problem in sub-Saharan Africa where there are very high rates of both infectious diseases (such as HIV and TB), but also an increasing burden from chronic, non-communicable diseases, like high blood pressure, diabetes, or heart disease, and we see multimorbidity in young adults as well as older adults.

"When someone with undiagnosed or uncontrolled multimorbidity comes to hospital, we have an opportunity to detect and treat all the conditions they may suffer from, but this is a challenge in resource limited hospitals that are already under strain. Hospital care pathways also traditionally focus on a single presenting disease, which risks overlooking multimorbidity. We now need to design, implement, and evaluate effective and efficient integrated models of care that meet the needs of people and the health system, to try to sustainably reduce the risk of preventable death and disability."

Professor Eve Worrall, Professor of Health Economics at LSTM and Multilink co-lead, said: "I'm proud of the Multilink team for the evidence presented in this paper. Not only does it highlight some of the critical challenges faced by people living with multimorbidity, and the health systems that are trying to deliver adequate care under severe resource constraints, but it represents a brilliant example of inter-disciplinary and international collaboration through a partnership which strives to be equitable.

"The paper shows how multimorbidity is underdiagnosed in Malawi and Tanzania, which likely impacts health system costs, patient costs, and health related quality of life, and leads to avoidable mortality. Given that many people living with multimorbidity are of working age, it likely has serious economic consequences beyond the health sector, and could profoundly affect Africa's economic growth potential over the coming decades. We are calling for action to improve prevention, diagnosis and management of multimorbidity in Africa and the next phase of the Multilink study will explore the feasibility of strategies to achieve this."

Malawi's health system, as is the case with most health systems in the sub-Saharan Africa, is currently overwhelmed with treating a duo burden of communicable and non-communicable diseases. The recent research findings that almost half of medical admissions have multiple long-term conditions, is an additional stressor to the system. Preparing our health system to identify and treat multimorbidity should be a priority."

Dr. Felix Limbani, Co-Principal Investigator, Multilink and Senior Research Associate at MLW

The paper also included authors from Queen Elizabeth Central Hospital, the Kamuzu University of Health Sciences and Achikondi Women Community Clinic in Malawi, Kilimanjaro Clinical Research Institute in Tanzania, the University of Manchester in the UK and Duke University School of Medicine in the USA.