In keeping with the challenge presented by our Editor, of how to translate evidence into policy and practice,1 this article will focus on a fundamental barrier: ‘multimorbidity’.

Multimorbidity refers to the co-occurrence of two or more chronic conditions in one patient.2 Management targeting one condition in a patient may cause undesirable sequelae with regard to their other conditions. Some examples include non-steroidal anti-inflammatory medications for pain relief from arthritis, which aggravate hypertension and renal disease, diuretic medications for heart failure causing exacerbation of renal failure, aspirin for heart disease with the potential of causing bleeding in patients with gastric ulcers and steroids for inflammatory and autoimmune conditions causing high glucose levels in diabetics. Yet patients with multiple chronic diseases are often excluded from clinical trials that constitute the bulk of the evidence supporting treatment for specific conditions.3 This exclusion might not be a substantial concern if multimorbidity was rare, but it is not.

In primary care, 45% of patients have multimorbidity. In older adults this increases to 50% of those older than 65 years having three or more co-morbid conditions and 20% having five or more conditions. The prevalence is increasing, with more than 50% of the US population expected to have a chronic disease by the year 2020. [4, 5 as cited in 6] These patients tend to have increased disability, depression, anxiety and rapid declines in health status.6 Currently, 75% of …