Clustering Complex Chronic Patients: A Cross-Sectional Community Study From the General Practitioner's Perspective.

OBJECTIVE: Characterize subgroups of Complex Chronic Patients (CCPs) with cluster analysis from the general practitioner's perspective. STUDY DESIGN: Cross-sectional population-based study. SETTING: Three Primary Care urban centres for a reference population of 43,647 inhabitants over 14 years old in Sabadell, Catalonia, Spain. METHODS: Complexity is defined by the independent clinical judgment of general practitioners with the aid of complexity domains (both clinical and social). We used a Two-Step Cluster method to identify relevant subgroups of CCPs. RESULTS: Three relevant subgroups were identified. The first one was mainly managed by primary care professionals, and 63% of its CCPs belonged to the high-risk stratum of the Adjusted Morbidity Groups (GMA). The second subgroup included younger patients than the other two clusters, and showed the highest ratios of social deprivation and severe mental disease; 48% of its CCPs belonged to the high-risk stratum of the GMA. A third cluster included patients who belonged to the high-risk stratum of the GMA. Their age was similar to that of the patients in the first cluster, but they showed the highest values in the following areas: (i) risk of admission; (ii) proportion of advanced chronic disease and limited-life prognosis; (iii) functional loss and (iv) geriatric syndromes, along with special uncertainty in decision-making and clinical management. CONCLUSIONS: Characterization of CCPs shows clearly distinct profiles of needs, which provides an improved epidemiological picture by identifying clusters of patients who are likely to benefit from targeted interventions.

Perfil y evolución de pacientes crónicos complejos en una unidad de subagudos / Profile and evolution of chronic complex patients in a subacute unit

Objetivo: Para mejorar el manejo de pacientes pluripatológicos, en Cataluña se ha promovido la identificación como paciente crónico complejo (PCC) o con enfermedad crónica avanzada (MACA). Ante descompensaciones se promueve el ingreso de estos pacientes en unidades de subagudos (SG) ubicadas en hospitales de atención intermedia y especializadas en geriatría, como alternativa al hospital de agudos. Queremos evaluar los resultados del ingreso de PCC/MACA en SG. Diseño: Estudio cuantitativo descriptivo-comparativo, transversal. Emplazamiento: Unidad de subagudos de un hospital de atención intermedia. Participantes: Pacientes ingresados consecutivamente en SG durante 6 meses. Mediciones principales: Comparamos características basales (datos demográficos, clínicos y de valoración geriátrica integral), resultados al alta y a 30días post-alta entre pacientes identificados como PCC/MACA vs otros pacientes. Resultados: De 244 pacientes (promedio edad ± DE = 85,6 ± 7,5; 65,6% mujeres), 91 (37,3%) eran PCC/MACA (PCC = 79,1%, MACA = 20,9%). Estos, comparado con los no identificados, presentaban mayor comorbilidad (Charlson = 3,2 ± 1,8 vs 2,0; p = 0,001) y polifarmacia (9,5 ± 3,7 fármacos vs 8,1 ± 3,8, p = 0,009). Al alta, el retorno al domicilio habitual y la mortalidad fueron comparables. PCC/MACA tuvieron mayor mortalidad sumando los 30 días post-alta (15,4% vs 8%; p = 0,010); en un análisis multivariable, la identificación PCC/MACA (p = 0,006) y demencia (p = 0,004) se asociaba a mayor mortalidad. A pesar de que PCC/MACA reingresaban más a 30días (18,7% vs 10,5%; p = 0,014), en el análisis multivariable las únicas variables asociadas independientemente a reingresos fueron sexo masculino, polifarmacia e insuficiencia cardiaca. Conclusiones: A pesar de mayor comorbilidad y polifarmacia, los resultados de PCC/MACA al alta de SG fueron comparables con los otros pacientes, aunque experimentaron más reingresos a 30días, posiblemente por su comorbilidad y polimedicación (AU)

Objective: To improve the management of geriatric pluripathologic patients in Catalonia, the identification of chronic complex patient (PCC) or patients with advanced chronic disease (MACA) has been promoted. Patients with exacerbated chronic diseases are promoted to be admitted in subacute units (SG) located in intermediate hospitals and specialized in geriatric care, as an alternative to acute hospital. The results of the care process in patients identified as PCC/MACA in SG have not been evaluated. Design: Descriptive-comparative, cross-sectional, and quantitative study. Location: SG located in intermediate care hospital. Participants: Consecutive patients admitted in the SG during 6 months. Main measurements: We compared baseline characteristics (demographic, clinical and geriatric assessment data), results at discharge and 30days post-discharge between PCC/MACA patients versus other patients. Results: Of 244 patients (mean age ± SD = 85,6 ± 7,5; 65.6%women), 91 (37,3%) were PCC/MACA (PCC=79,1%, MACA = 20,9%). These, compared with unidentified patients, had greater comorbidity (Charlson index = 3,2 ± 1,8 vs 2,0; p = 0,001) and polypharmacy (9,5 ± 3,7 drugs vs 8,1 ± 3,8; p = 0,009). At discharge, the return to usual residence and mortality were comparable. PCC/MACA had higher mortality adding the mortality at 30 day post-discharge (15,4% vs 8%; p = 0,010). In a multi-variable analysis, PCC/MACA identification (p = 0,006), as well as a history of dementia (p = 0,004), was associated with mortality. Although PCC/MACA patients had higher readmission rate at 30 day (18,7% vs 10,5%; p = 0,014), in the multivariable analyses, only male, polypharmacy, and heart failure were independently associated to readmission. Conclusions: Despite having more comorbidity and polypharmacy, the outcomes of patients identified as PCC/MACA at discharge of SG, were comparable with other patients, although they experienced more readmissions within 30 days, possibly due to comorbidity and polypharmacy (AU)

Is the integration of nutritional care in the different assistance levels possible? Refl ections from the perspective of chronicity and clinical complexity / ¿Podemos integrar la atención nutricional en los distintos niveles asistenciales? Reflexiones desde la cronicidad y la complejidad clínica.

Nowadays, chronicity is the leitmotiv in all healthcare systems. Consequently, multimorbidity and the management of complex care needs become a critical challenge in modern welfare societies. Professionals and other agents' difficulties to identify and satisfy healthcare related needs of these patients is especially signifi cant in a 5% of the population. This has an enormous impact not only from a clinical perspective, but also in terms of the resilience of public health care systems. In this context, nutritional status plays an outstanding role as a health indicator and also as a determinant vector of morbidity and mortality. However, improvement possibilities regarding the evolution of epidemiological knowledge and the implementation of person-centered attention models are still vast. The management of malnutrition related to complex chronic conditions is not limited to the profi le of the patient's conditions, since the explanatory role of social factors, which become key to clinical management, is crucial. As a result of the above, integrated and person-centered approaches, where nutritional factors often play an important role, are required to provide care to the most vulnerable patients within our settings. Therefore, collaborative work appears as one of the keys to success.

[Profile and evolution of chronic complex patients in a subacute unit]. / Perfil y evolución de pacientes crónicos complejos en una unidad de subagudos.

OBJECTIVE: To improve the management of geriatric pluripathologic patients in Catalonia, the identification of chronic complex patient (PCC) or patients with advanced chronic disease (MACA) has been promoted. Patients with exacerbated chronic diseases are promoted to be admitted in subacute units (SG) located in intermediate hospitals and specialized in geriatric care, as an alternative to acute hospital. The results of the care process in patients identified as PCC/MACA in SG have not been evaluated. DESIGN: Descriptive-comparative, cross-sectional, and quantitative study. LOCATION: SG located in intermediate care hospital. PARTICIPANTS: Consecutive patients admitted in the SG during 6months. MAIN MEASUREMENTS: We compared baseline characteristics (demographic, clinical and geriatric assessment data), results at discharge and 30days post-discharge between PCC/MACA patients versus other patients. RESULTS: Of 244 patients (mean age±SD=85,6±7,5; 65.6%women), 91 (37,3%) were PCC/MACA (PCC=79,1%, MACA=20,9%). These, compared with unidentified patients, had greater comorbidity (Charlson index=3,2±1,8 vs 2,0; p=0,001) and polypharmacy (9,5±3,7 drugs vs 8,1±3,8; p=0,009). At discharge, the return to usual residence and mortality were comparable. PCC/MACA had higher mortality adding the mortality at 30day post-discharge (15,4% vs 8%; p=0,010). In a multi-variable analysis, PCC/MACA identification (p=0,006), as well as a history of dementia (p=0,004), was associated with mortality. Although PCC/MACA patients had higher readmission rate at 30day (18,7% vs 10,5%; p=0,014), in the multivariable analyses, only male, polypharmacy, and heart failure were independently associated to readmission. CONCLUSIONS: Despite having more comorbidity and polypharmacy, the outcomes of patients identified as PCC/MACA at discharge of SG, were comparable with other patients, although they experienced more readmissions within 30days, possibly due to comorbidity and polypharmacy.

¿Podemos integrar la atención nutricional en los distintos niveles asistenciales? Reflexiones desde la cronicidad y la complejidad clínica / Is the integration of nutritional care in the different assistance levels possible? Reflections from the perspective of chronicity and clinical complexity

En los tiempos actuales, en los que la cronicidad es el argumento casi hegemónico de los sistemas de salud, la multimorbilidad y la gestión asistencial de las necesidades complejas aparecen como retos prioritarios de las sociedades del bienestar. En un 5% de la población la dificultad de los profesionales y de los agentes para identificar y responder a lo que estos pacientes necesitan -en términos de salud- es especialmente significativa. Ello conlleva un impacto muy relevante no solo desde el punto de vista clínico, sino también en cuanto a la resiliencia de los sistemas públicos de atención a las personas. En este contexto, las condiciones nutricionales tienen un papel destacado como marcador del estado de salud y como vector determinante de la morbimortalidad. A pesar de ello, los márgenes de mejora en la generación de conocimiento epidemiológico y en la aplicación de modelos de atención centrados en la persona son aún magníficos. La gestión de la desnutrición relacionada con las condiciones de cronicidad compleja va más allá del simple perfil de las enfermedades que la persona padece. Así, los condicionantes sociales tienen un rol explicativo central y constituyen una palanca prioritaria de la gestión clínica. Por todas estas consideraciones, los enfoques de atención integral, integrada y centrada en la persona, son los que mejor van a permitir atender a los pacientes más vulnerables de nuestro entorno en los que, con frecuencia, el argumento nutricional tendrá un papel destacado. El trabajo colaborativo parece ser, pues, una de las principales claves del éxito (AU)

Nowadays, chronicity is the leitmotiv in all healthcare systems. Consequently, multimorbidity and the management of complex care needs become a critical challenge in modern welfare societies. Professionals and other agents’ difficulties to identify and satisfy healthcare related needs of these patients is especially significant in a 5% of the population. This has an enormous impact not only from a clinical perspective, but also in terms of the resilience of public health care systems. In this context, nutritional status plays an outstanding role as a health indicator and also as a determinant vector of morbidity and mortality. However, improvement possibilities regarding the evolution of epidemiological knowledge and the implementation of person-centered attention models are still vast. The management of malnutrition related to complex chronic conditions is not limited to the profile of the patient’s conditions, since the explanatory role of social factors, which become key to clinical management, is crucial. As a result of the above, integrated and person-centered approaches, where nutritional factors often play an important role, are required to provide care to the most vulnerable patients within our settings. Therefore, collaborative work appears as one of the keys to success (AU)

Tópicos y reflexiones sobre la reducción de ingresos hospitalarios: de la evidencia a la práctica / Topics and considerations on reducing hospital admission: From evidence to practice

Los cambios demográficos y la realidad económica de los últimos años han condicionado una reorientación de las políticas sanitarias priorizando la atención a la cronicidad. Dada la concentración de costes en la atención hospitalaria de los pacientes con enfermedades crónicas, la reducción de las hospitalizaciones ha pasado a ser un objetivo preferente. Mientras tanto, constatamos que entre el objetivo paradigmático de abordaje eminentemente comunitario propuesto para estos pacientes y la realidad asistencial vigente, queda aún un largo recorrido que valdría la pena realizar paso a paso. Con la evidencia científica de la que disponemos en el momento actual: ¿Es razonable dar por sentado que hay un nivel adecuado de ingresos o que reducir el número de ingresos es necesariamente mejor para los pacientes? ¿Es posible definir operativamente y con la suficiente fiabilidad cuáles de los ingresos hospitalarios son evitables? ¿Es perjudicial para un paciente y para el sistema que una persona con enfermedades crónicas con altas necesidades de atención ingrese en un hospital? ¿No serán los ingresos hospitalarios evitables y los reingresos, indicadores de fragmentación de los sistemas de salud? Ante esta situación, un abordaje razonable requiere en primer lugar de un análisis crítico de las distintas realidades asistenciales (microsistemas) y de la revisión sistemática de la evidencia científica –rompiendo algunos tópicos si es preciso–. En segundo lugar es indispensable llevar este conocimiento a la práctica asistencial, con la necesidad absoluta de conciliar el «qué» y el «cómo», la visión individual con la visión poblacional, la enfermedad única con la multimorbilidad y, finalmente, el abordaje clínico con la planificación sanitaria (AU)

Demographic changes and the economic situation of the recent years have conditioned a turning point in health policies, which have decided to progressively prioritize chronicity care programs. Given that hospital costs were concentrated in attention to patients with chronic diseases, reduction on admissions is now a priority target.Meanwhile, we state that among the obviously community handling paradigmatic aim for those patients and the current care situation, there is a long way to do that should be done gradually. According to the current scientific evidence: Is it sensible to assume that there is a proper level of admissions or is it better for the patients to reduce the number of admissions? Is it possible to operationally and reliably define which hospital admissions are avoidable? Is it harmful to a patient and to the health care system to admit a patient with multiple chronic disease? Maybe are hospital admissions are avoidable and readmissions are indicators of a fragmented health care system?Given that situation, a reasonable approach requires firstly a critical analysis of the various realities of care (microsystems) and a systematic review of the scientific evidence-breaking, and rejecting some topics if necessary. Secondly, we should bring all this knowledge to clinical practice, conciliating «what» and the know-how, individual and population view, sole disease and multimorbidity, and finally clinical approach and health planning (AU)