Multimorbidity - Diabetes, Hypertension and Hyperlipidaemia

Background

Multimorbidity is commonly seen in primary care. Multimorbidity refers to the presence of several co-occurring long-term conditions, being related or not, in each patient¹. In the polyclinic setting, 50% of the patients had two chronic conditions in their early 50s, three chronic conditions in their early 60s and four chronic conditions in their late 70s². Multimorbidity is associated with higher healthcare cost in the primary care setting³. The commonest pattern of multimorbidity seen in primary care is the combination of the three chronic conditions – diabetes, hypertension and hyperlipidaemia⁴.

Clinical Approach

Minimally disruptive medicine (MDM)⁵ can be a framework to use for managing patients with multimorbidity. The aim is to reduce treatment burden and increase patient capacity .
Combining the individual treatment targets would be based on shared decision-making.

Management

Aims of management:

Prevent cardiovascular disease (CVD)
Prevent or delay progression of Target Organ Damage

Principles of Management

Screen for 10-year risk of Coronary Artery Disease .
Aim for disease management targets based on multimorbidity and macrovascular (other organ) complications (refer to Table 1).
Medication management for those with polypharmacy or transition of care⁷.

Table 1: Type 2 Diabetes Mellitus co-occurring with other organ complications

	Diabetes⁸ & Hypertension & Hyperlipidaemia⁹	Atherosclerosis/ Cardiovascular Disease⁶	Chronic Kidney Disease	Stroke⁶
Lifestyle	↓Weight ↑Exercise ↓Sedentary behaviour ↓Alcohol ↓Sodium Healthy Plate, DASH diet, ↓fat, avoid sugary drinks & food. ↓Stress Smoking cessation Manage sleep apnoea	Medical clearance may be recommended for exercise Assess fitness to drive annually	Medical clearance may be recommended for exercise Low protein diet (Limit to 2 servings of protein daily or < 0.8g/kg/day) For later CKD stages, ↓potassium, ↓phosphate & fluid restriction	Medical clearance may be recommended for exercise Assess fitness to drive annually
BP	< 140/80 mmHg		< 130/80 mmHg
LDL	LDL-cholesterol < 2.6 mmol/L or <100mg/dL	LDL-cholesterol < 2.1 mmol/L or <80mg/dL
HbA1c	General HbA1c target of ≤ 7.0%, but target of treatment should be personalised (e.g. for elderly)
Medication adjustment	Avoid diuretics Avoid β-blockers ACEI or ARB are preferred for BP control or albuminuria Fenofibrate for raised TG Metformin, SGLT2-inhibitor preferred for obese patients Whilst statins are generally the preferred choice for lipid disorders, the addition of fenofibrate to a statin may benefit certain patients with T2DM with both high TG and low HDL-cholesterol dyslipidaemia pattern, particularly those with microvascular complications⁹	ACEI or ARB preferred Consider to start and continue β-blockers indefinitely Beware of postural hypotension from HT and BP-lowering CVD drugs (e.g., ISDN) Start anti-platelets (Beware of low Hb with anti-platelets)	Maximise ACEI or ARB dosage Titrate hypoglycaemics as patients more susceptible to hypoglycaemia Use metformin, diuretics & fenofibrate with caution Fibrates can be used in patients in stage 1 to 3 CKD but the dosages should be reduced, with appropriate monitoring for side effects, especially myopathy. Fibrates are contraindicated for stage 4 or 5 CKD⁹.	Beware of postural hypotension from HT and BP-lowering CVD drugs e.g. ISDN Beware of low Hb with anti-platelets Antithrombotic therapy, including anti-platelet or anticoagulant agents, is recommended for nearly all patients without contra-indications High dose statin +/- ezetimibe
Others			For stage 3-5 CKD, consider checking calcium, phosphate, vitamin D, Hb and Ferritin levels

ACEI – Angiotensin converting enzyme inhibitors; ARB – Angiotensin receptor blockers; BP – Blood pressure; CVD – Cardiovascular disease; CKD – Chronic kidney disease; DASH - Dietary Approaches to Stop Hypertension; Hb- Haemoglobin; HbA1c – Glycated haemoglobin; HDL-cholesterol – High-density lipoprotein cholesterol; HT – Hypertension; ISDN - Isosorbide dinitrate; LDL-cholesterol – Low-density lipoprotein cholesterol; PARP – Physical activity recommendation process; SGLT2 – Sodium-glucose cotransporter-2 Inhibitors; T2DM – Type 2 Diabetes Mellitus; TG - Triglyceride

Data Submission

The following data fields should be documented in your case notes as part of good clinical practice for all patients enrolled to your practice.

Submission of data fields marked with asterisks* is required for subsidy claims and Healthier SG payments.

DM Control

HbA1c (%)*
Date*

Lipid Profile

LDL-C (mg/dL or mmol/L)*
HDL-C (mg/dL or mmol/L)
Triglycerides (mg/dL or mmol/L)
Total Cholesterol (g/dL or mmol/L)
Date*

Blood Pressure

Systolic BP (mmHg)*
Diastolic BP (mmHg)*
Date*

Weight

BMI (kg/m²), calculated from height*, weight*
Waist Circumference (in cm; optional field to fill)
Date*

Kidney Assessment

Serum creatinine (μmol/L)* or eGFR (ml/min/1.73m²)*
Urine ACR (mg/mmol)* or Urine PCR (mg/mmol)*
Date*

Diabetic Retinal Photography

Conducted?*

Yes
No
NA: patient on active follow up with ophthalmologist^#

Date*^#
Results*

No abnormality detected
Non-proliferative retinopathy
Proliferative retinopathy
Diabetic maculopathy
Other abnormalities (e.g. cataract, ungradable)
Result unknown^#

Follow up actions
Other findings
Detailed report & image

^#Notes:

If “NA” is selected under “DRP Conducted”, GP will be eligible for variable component payment provided date of visit and results are submitted.]
For “Date of Visit”, fill date of last diabetic retinal photography or eye assessment at the SOC.
For “Outcome”, select “Result Unknown” if GP is unable to obtain DRP/eye assessment results. This does not include ungradable DRP results (GP should select ‘other abnormalities’ for ungradable DRPs). GP will not be eligible for payment if this is selected as decisions on further clinical care may not be conclusive.

Diabetic Foot Screening

Conducted*?

Yes
No#
NA: patient on active follow up with orthopaedics, vascular surgery or podiatry#

Date of visit*^#
Outcome*^# (refer to ACG 2019 DFS guideline)

Low risk for diabetic foot ulcers
Moderate risk for diabetic foot ulcers
High Risk for diabetic foot ulcers
Result unknown^#

^#Notes:

If an enrolee has bilateral lower limb amputations, select “No” for “DFS Conducted” as they do not require DFS. GPs should note down in clinical notes that patient is a bilateral amputee and does not require DFS.
If the enrolee is on specialist management for foot-related issues and does not require DFS, select “NA” for “DFS Conducted”. GPs will be eligible for variable component payment provided date of visit and outcomes are provided.
For “Date of Visit”, fill date of last DFS or foot assessment by podiatry or SOC.
For “Outcome”, if both feet have different risk outcomes, the higher risk tier should be selected
For “Outcome”, select “Result Unknown” if GP is unable to obtain results of foot screening performed elsewhere. GPs will not be eligible for payment this is selected as decisions on further clinical care may not be conclusive.

Vaccination

Influenza Vaccination* (Yes/No), Date of Vaccination*
Pneumococcal Vaccination* (Yes/No), Date of Vaccination*

Smoking History

Smoking Status* (Never Smoker, Ex-Smoker, Current Smoker)
Year started smoking (if smoker)
No. of sticks smoked/day* (if smoker)
State of change: (i) Pre-contemplation, (ii) Contemplation, (iii) Preparation (iv) Action, OR (v) Maintenance.

Financing

CHAS/PG/MG cardholders who are Healthier SG enrolees would be eligible for the new Healthier SG Chronic Tier, which provides percentage-based subsidies for a whitelist of drug products (see [placeholder] for the full list) at capped selling prices. For subsidy claims, GPs should document the quantities and selling prices for each whitelisted drug product prescribed.

Click here for additional clinical guidance on subsidised drugs for DM management under MAF (placeholder hyperlink).

References

Mercer S, Salisbury C, Fortin M. ABC of Multimorbidity. BMJ Books. 2014.
Lee ES, Lee PSS, Xie Y, Ryan BL, Fortin M, Stewart M. The prevalence of multimorbidity in primary care: a comparison of two definitions of multimorbidity with two different lists of chronic conditions in Singapore. BMC Public Health. 2021;21(1).
Tan SY, Lew KJ, Xie Y, Lee PSS, Koh HL, Ding YY, et al. Healthcare cost of patients with multiple chronic diseases in Singapore public primary care setting. Annals of the Academy of Medicine, Singapore. 2021;50(11):809-17.
Tan SY, Lew KJ, Xie Y, et al. Healthcare cost of patients with multiple chronic diseases in Singapore public primary care setting. Annals of the Academy of Medicine, Singapore 2021;50(11):809-17. doi: 10.47102/annals-acadmedsg.2021246
Abu Dabrh AM, Gallacher K, Boehmer KR, et al. Minimally disruptive medicine: the evidence and conceptual progress supporting a new era of healthcare. J R Coll Physicians Edinb 2015;45(2):114-7. doi: 10.4997/JRCPE.2015.205
Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021;52(7):e364-e467. doi: 10.1161/STR.0000000000000375 [published Online First: 2021/05/25]
Penm J, Vaillancourt R, Pouliot A. Defining and identifying concepts of medication reconciliation: An international pharmacy perspective. Res Social Adm Pharm. 2019 Jun;15(6):632-640. doi:10.1016/j.sapharm.2018.07.020. Epub 2018 Aug 1. PMID: 30100200.
Health Promotion Board. National. Diabetes Reference Materials. (Cited 27 May 2022)
MOH Clinical Practice Guidelines – Lipids 2016. (Cited 27 May 2022)
ACE Clinical Guidance. Chronic Kidney Disease – Early Detection [Internet]. 2022 [cited 2022 September 10].