An AI-enabled multimorbidity care service

为患有多种长期疾病（多病）的患者提供预防性和前瞻性初级保健是NHS面临的主要挑战。《主要疾病战略》确定，25%的人口被诊断出六种慢性和长期疾病中的两种或两种以上，这些疾病占英格兰健康不佳和过早死亡的60%以上（卫生和社会保障部，2023年）。随着人口老龄化和生存率的提高，患有多种疾病的患者数量正在迅速增加，给有限的NHS资源带来了巨大的压力。全科医生实践和初级保健网络（pcn）习惯于根据个人健康状况来规划护理服务。护理的黄金标准包括“护理协调员”管理复杂的病例，但由于劳动力压力和繁重的工作量，他们很难管理多个单独的患者名单，并让患者参与预防性自我护理。一些混杂的系统因素使提供高质量的多病护理变得困难：*市场失灵-问责不清和搭便车效应*双边问题-公众接受必须与卫生服务能力相匹配*激励机制失效-奖励单一条件产出而不是结果*紧急偏差-优先考虑紧急任务而不是重要任务。他们在系统中感到不知所措，收到相互矛盾的建议和难以遵循的治疗方案，对动机、参与度和结果产生负面影响。有效的多病症护理需要采取以患者为中心的方法，注重预防和患者赋权。Appt是一家医疗技术中小企业，它与伦敦东部一家具有前瞻性的PCN Network 6合作，开发了一种全新的、支持人工智能的多疾病护理服务。这种方法侧重于使用先进的机器学习技术来了解每个患者的整体需求，并将需求映射到最合适的护理计划（与不同临床医生的一系列预约），这将确保早期诊断、自我管理和高质量的治疗，以管理其多重疾病的复杂性。

Providing preventive and proactive primary care for patients with multiple long-term conditions (multimorbidity) is a major challenge facing the NHS. The Major Conditions Strategy identified that 25% of the population are diagnosed two-or-more of the six chronic and long-term conditions that account for over 60% of ill-health and early death in England (Department for Health and Social Care, 2023). With an ageing population and improving survival rates, the number of patients living with multimorbidity is rapidly increasing, putting significant pressure on limited NHS resources.GP practices and Primary Care Networks (PCNs) are accustomed to planning care delivery around treating a person based on an individual health condition. The gold-standard of care involves 'Care Coordinators' managing complex cases, but due to workforce pressures and heavy workloads, they struggle to manage multiple, separate patient lists and engage patients in preventive self-care. Several confounding systemic factors make it difficult to deliver high-quality multimorbidity care :* Market failure - unclear accountability and free-rider effects* Two-sided problems - public uptake must match health service capacity* Broken incentives -rewarding single-condition outputs not outcomes* Urgency bias - prioritising urgent task over important onesThis paradigm isdisastrous for patients, who feel overwhelmed navigating the system and receive conflicting advice and hard-to-follow treatment regimens, negatively impacting motivation, engagement, and outcomes.Effective multimorbidity care requires a patient-centred approach, focused on prevention and patient empowerment.Appt is a health technology SME thathas partnered with Network 6, a forward-thinking PCN in East London, to develop a radical new, AI-enabled multimorbidity care service. This approach focuses on using advanced machine learning techniques to understand the holistic need of each patient and map that need to the most suitable care plan (a sequence of appointments with different clinicians) which will ensure early diagnosis, self-management, and high-quality treatment that manages the complexity of their multimorbidity.