Multimorbidity associated with emergency hospital admissions. A screen and link strategy to improve outcomes for high risk patients in Sub-Saharan Afica
Abstract
Type and place of study: This is a prospective longitudinal cohort study of adult acute medical
hospital admissions with nested situation analysis and health economic measures, to screen and
link for multimorbidity in Africa. It will be based at:
1. Queen Elizabeth Central Hospital, Blantyre, Malawi
2. Chiradzulu District Hospital, Southern Region, Malawi
3. Hai District Hospital, Moshi, Tanzania
4. Muhimbili National Hospital, Dar-es-Salaam, Tanzania
Problem: Sub-Saharan Africa suffers from an interplay of high rates of infectious disease and
rising prevalence of non-communicable diseases, resulting in multimorbidity. Importantly, HIV
(and anti-retroviral treatment) can accelerate non-communicable disease. Patients frequently
delay seeking treatment until they are severely ill and require emergency management. Hospital
care then predominantly focusses on the primary presenting problem, overlooking
multimorbidity. This oversight precipitates frequent hospital admissions, increases health system
and out-of-pocket expenses, and leads to disability and death.
Main objective: Determine prevalence of multimorbid disease in acute adult medical admissions,
clustering of diseases as part of multimorbidity, and their effect on patient outcomes including
quality of life and incurred costs..
Secondary objectives:
1. Determine Hhospital readmission free survival 90 days after admission; markers of
disease control 90 days after admission; rate of end-organ damage (e.g. CVA, MI, ESRF)
90 days after admission;
2. Obtain a qualitative description of healthcare pathways through ; situation analysis of
healthcare pathways forof acute medical admissions, and; qualitative exploration of
health literacy and experience of care for patients with multimorbidity.
3. Estimate direct and indirect healthcare costs (from provider and patient perspectives) of
care for patients with multimorbidity.
Methodology: We will recruit adults (≥18 years) admitted to hospital as a medical emergency
(n=1548 participants) into a longitudinal cohort study with nested situation analysis & health
economic evaluation. Follow-up duration will be 90 days from hospital admission. The study is
planned for 18 months; estimated end April 2023. We will use deferred emergency recruitment
with retrospective consenting procedures, consecutive recruitment within 24 hours of emergency
presentation and stratified recruitment across four sites to ensure balance and mitigate against
recruitment bias. In parallel with quantitative data collection from tablet based structured09-May-2022
Multilink cohort study REC submission v1v2.0 – COMREC28/10/202128/03/2022 Page 8 of
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questionnaire using standardised tools, we will use point of care blood and urine tests to refine
estimates of disease pathology, making these available to the medical teams (see Table 1) . We
will use qualitative interviews with healthcare workers in a portion of treating providers after
patient discharge. Qualitative interviews will also take place with a proportion of patients after
follow up visit at 90 days.
Expected findings: The main outcome measure is the individual and multimorbid prevalence of
hypertension, diabetes mellitus, HIV-infection and chronic kidney disease in adults admitted with
acute medical condition. Secondary outcome measures includeare: 90-day survival and
readmission after acute admission; Interim hospital readmission within 90 days of admission;
diagnosis and control of hypertension (WHO criteria); diagnosis and control of, diabetes mellitus,
(WHO criteria); diagnosis and control, including ARV complianceHIV and viral load) of HIV
infection (WHO definitions);, and diagnosis and control of chronic kidney disease (KDOQI).
The data will allow a clear estimate of the prevalence and constitution of multimorbidity
according to a standard definition of “two or more concurrent chronic medical pathologies”. The
size of the cohort will allow us to estimate prevalence look for intersections of
diseasemultimorbidity, including those which occur more commonly in association i.e.
“clustering”. This will be for first formal description of multimorbidity amongst inpatients in sub-
Saharan Africa. It will allow the researcher network, which is closely tied to policymaking and
community representatives, to understand what an intervention to identify multimorbidity might
look like. After presentation of these data, and consultation, we will co-design such an
intervention and design a protocol to test it using a cluster-randomised controlled trial.
Dissemination: Will be done through policy and stakeholder networks, international conferences
and presentation, and direct feedback to COMREC
Description
Keywords
Multimorbidity-associated emergency hospital admissions: a “screen and link” strategy to improve outcomes for high-risk patients in sub-Saharan Africa (cohort study) by Jamie Rylance