Clinical Scorecard: Co-designing Integrated Care Approaches for Patients with Multimorbidity in Elective Surgical Pathways: A Mixed-Methods Study
At a Glance
Category
Detail
Condition
Multiple long-term conditions (MLTC) in patients undergoing elective surgery
Key Mechanisms
Early identification at surgical listing, integrated care pathways, optimization during surgical waiting interval, structured communication
Target Population
Patients with multimorbidity scheduled for elective surgery in the UK
Care Setting
National Health Service (NHS) elective surgical pathways
Key Highlights
Current elective surgical pathways inadequately address the complex needs of patients with MLTC, with late preassessment limiting optimization opportunities.
Only 10% of UK hospitals have MLTC-specific care pathways for elective surgery, mainly focusing on diabetes or anaemia.
A co-designed intervention includes surgeon-led checklist at listing, automated referrals, patient activation materials, optimization during waiting time, and structured discharge communication.
Guideline-Based Recommendations
Diagnosis
Implement early identification of MLTC at the point of surgical listing using a checklist.
Management
Use the surgical waiting interval to optimize chronic disease management (diabetes, hypertension, weight, smoking cessation).
Facilitate automated referrals to primary care and specialist services for MLTC management.
Provide patient activation materials to support self-management.
Monitoring & Follow-up
Ensure structured discharge communication to maintain continuity of care across organizational boundaries.
Risks
Delayed preassessment reduces the window for effective optimization of chronic conditions, increasing postoperative complications and functional decline.
Patient & Prescribing Data
Patients with multiple long-term conditions undergoing elective surgery in NHS hospitals
Early, integrated interventions during the surgical waiting period may improve short- and long-term health outcomes by addressing MLTC proactively.
Clinical Best Practices
Shift MLTC care upstream to the point of surgical listing to maximize optimization time.
Use multidisciplinary co-design approaches involving patients and healthcare professionals to develop feasible interventions.
Leverage existing NHS policies such as 'Making Every Contact Count' and the 'NHS Long Term Plan' to integrate chronic disease management into surgical pathways.
by Sivesh K Kamarajah, Jugdeep Dhesi, Kamlesh Khunti, Krishnarajah Nirantharakumar, Paul Cockwell, Clare Hughes, Paul Stern, Joyce Yeung, Dion G Morton, Aneel A Bhangu, Shalini Ahuja
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