Co-morbidity does not reflect complexity in internal medicine patients

Abstract

Internal medicine patients are mostly elderly; they have multiple co-morbidities, which are usually chronic, rather than self-limiting or acute diseases. Neither administrative indicators nor co-morbidity indexes, though validated in elderly patients, are able to completely define these "complex" patients or to allow physicians to correctly "cope" with them. For the complex patients found in internal medicine wards, internists need not only to find the best diagnosis and treatment, but also to apply a complex intervention (i.e., a comprehensive assessment and both continuous and multi-disciplinary care) in order to maintain their health and ability to function and to prevent or delay disability, frailty, and displacement from home and community. The aim of this review is to underscore the differences between the concepts of co-morbidity and complexity, to discuss instruments for their measurement, and to highlight related implications, areas of uncertainty, and the responsibilities of internists in the assessment and management of inpatients of their wards. The conclusion we come to is that it is mandatory to shift from a finance/administrative-based management system to a clinical process model (clinical governance) driven by the quality of the medical outcome and the cost of achieving that outcome. From a "complexity theory" standpoint, patient-centered care and collaboration can be seen as simple rules that guide desirable behaviors in a complex system. By exploring the real complexity of our patients, we exercise the holistic, anthropologic medicine of the person that is internal medicine.

Quality of Care for Patients with Multiple Chronic Conditions: The Role of Comorbidity Interrelatedness

“…9,26,27 While multimorbidity generally refers to the presence of multiple clinical conditions, there is also growing recognition that a multitude of patient-level factors independent of specific comorbid conditions may complicate care and affect outcomes for multimorbid patients. 10,28,29 For example, Safford et al proposed a conceptual approach to complex patients that involves interactions between biological, socioeconomic, cultural, environmental, and behavioral forces as health determinants. 10 Incorporating these dimensions into clinical assessments is likely to help ensure that care is aligned with patient's preferences, goals, and needs.…”

“…1). 10,12,29 These dimensions may moderate the relationship between comorbidity interrelatedness and quality of care, especially if certain characteristics play a dominant role in management decisions (e.g., if a patient prefers not to escalate treatment) or characteristics interact with conditions in ways that shape treatment decisions (e.g., if a patient's history of medication adherence or level of social support favors one treatment modality over another). These relationships highlight opportunities to enhance quality of care for complex patients with multiple chronic conditions; for example, by ensuring that they have ample time to discuss their health challenges and competing demands with their providers, and by offering services from social work, mental health providers, and other support staff.…”

Multimorbilidad: bases conceptuales, modelos epidemiológicos y retos de su medición

“…En el contexto de la multimorbilidad, si existe una interrelación entre las enfermedades que afecte el bienestar del paciente, incluso cuando no haya un vínculo etiológico ni patológico, se presentaría un perfil complejo de interés clínico y epidemiológico. Gran parte del problema reside, precisamente, en que la mayoría de los estudios epidemiológicos hace énfasis en las comorbilidades concordantes, lo cual se ha traducido, lamentablemente, en la ausencia en las guías basadas en la evidencia de estrategias de manejo y de una discusión sobre las diferencias en el pronóstico de los pacientes con comorbilidades no relacionadas (47).…”

Disability Impacts Length of Stay in General Internal Medicine Patients

“…20 Currently, it is the most frequently used scoring system by clinicians in evaluating comorbidity burden. 21 We charted the Functional Independence Measure (FIM) as our primary disability measure in this study. It is a common internationally used outcome measure in rehabilitation cohorts for prognostication and funding, especially in North America, Australia and Japan.…”