Building a Risk Model for the Patient-centred Care of Multiple Chronic Diseases

With the increase of multimorbidity due to population ageing, managing multiple chronic health conditions is a rising challenge. Machine-learning can contribute to a better understanding of persons with multimorbidity (PwMs) and how to design an effective framework of care and support for them. We present a risk model of older PwMs that was derived from the TILDA dataset, a longitudinal study of the ageing Irish population. This model is based on a 26-nodes Bayesian network that represents patients possibly having one or more chronic conditions among diabetes, chronic obstructive pulmonary disease and arthritis, through a joint probability distribution of demographic, symptomatic and behavioral dimensions. We describe our method, give an exploratory analysis of the risk model, and assess its prediction accuracy in a cross-validation experiment. Finally we discuss its use in supporting management of care for PwMs, drawing on comments from health practitioners on the model.