Multimorbidity – The AFFIRMO Project

AFFIRMO is a recently funded Horizon 2020 five-year research project.

Multimorbidity is a common condition in older age, and can substantially influence individuals’ health and quality of life, making management more difficult. A single-disease approach with fragmented care is still prevalent in current healthcare systems despite multimorbidity representing a heterogeneous spectrum of disease combination(s). On this background, the novel approach underpinning the AFFIRMO project is to focus on clusters of multimorbidity where atrial fibrillation(AF) represents one of the chronic conditions. Improving the management of AF in the context of multimorbidity may benefit individuals on a larger scale, with a holistic approach to optimize clinical management of older AF patients taking into
account the multifaceted aspects of individuals’ health, including multimorbidity, polypharmacy, personal preferences, and social context.

First, the project aims to identify different clusters of multimorbidity in older patients with AF. Second, AFFIRMO aims to assess the needs of patients, caregivers, and health professionals for the comprehensive management of multimorbidity including AF, and to examine ways of optimizing care and self-management. Third, AFFIRMO will develop, implement and test the effectiveness of a patient-centered approach on older multimorbid AF patients in the clinical practice. We aim to adapt, implement and promote a care pathway, in older patients with multimorbidity. A specific objective will be to develop an interoperable care framework that can facilitate the application of this personalized care pathway, that bridges the continuum between primary and secondary care, with the active involvement of patients with shared decision-making. A further aim will be to model the impact of multimorbidity including AF on healthcare costs and the health economic benefits by the proposed integrated care pathway. Finally, subgroup analyses would assess differences on outcomes of in relation to gender and social inequalities.

The main approach underpinning AFFIRMO is to identify older patients with multimorbidity (including AF), ascertain their distinctive needs, and deliver a holistic integrated approach that includes assessment of general health, multimorbidity and polypharmacy, as well as personal preferences for treatment and considers the social context.

An idea of the complexity of multimorbidity is reflected in an example of the Multimorbidity Complexity Map depicted below.

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia worldwide. In 2014 the AF prevalence in Europe was estimated at 2%. This means that at the present time in the European community there are approximately 10 million of patients affected by AF. This figure is forecast to reach 14-17 million by the end of 2030; this is expected to determine 280.000-340.000 further new ischemic stroke, 3.5-4 million hospitalization for AF, and 100-120 million outpatient visits. The magnitude of this data raised a concern for an “atrial fibrillation epidemic”.

Both incidence and prevalence of AF increases with age, especially over 65 years, affecting up to 9% of octogenarians. Of note AF doubles the risk of mortality and is associated with risk of stroke approximately five-folds higher than in the general population. Finally, there is great morbidity associated with AF, such as higher risk of hospitalizations, impaired quality of life, development of left ventricular dysfunction and heart failure, and cognitive decline. AF is frequently associated with other cardiac and non-cardiac chronic conditions; in particular, one third of patients with AF have at least three-associated chronic disease including also cancer, hematologic and immunologic disorders.

The specific aim of the AFFIRMO project is to implement and test the effectiveness of an integrated patient-centered holistic care pathway for the management of older patients with AF and multimorbidity, which will facilitate cooperation among different health disciplines and promote a shared decision-making process. The final result will be to provide comprehensive management of AF, which being tailored in the context of coexisting disease and patient preferences can potentially lead to a reduction in physical and mental impairment allowing the older patient to cope better with multimorbidity.