The path to improving healthcare quality for individuals with complex health conditions is complicated by a lack of common understanding of complexity. Modern medicine, together with social and environmental factors, has extended life, leading to a growing population of patients with chronic conditions. In many cases, there are social and psychological factors that impact treatment, health outcomes, and quality of life. This is the face of complexity. Care challenges, burden, and cost have positioned complexity as an important health issue. Complex chronic conditions are now being discussed by clinicians, researchers, and policy-makers around such issues as quantification, payment schemes, transitions, management models, clinical practice, and improved patient experience. We conducted a scoping review of the literature for definitions and descriptions of complexity. We provide an overview of complex chronic conditions, and what is known about complexity, and describe variations in how it is understood. We developed a Complexity Framework from these findings to guide our approach to understanding patient complexity. It is critical to use common vernacular and conceptualization of complexity to improve service and outcomes for patients with complex chronic conditions. Many questions still persist about how to develop this work with a health and social care lens; our framework offers a foundation to structure thinking about complex patients. Further insight into patient complexity can inform treatment models and goals of care, and identify required services and barriers to the management of complexity.Journal of Comorbidity 2012;2:1–9

ObjectiveThis study investigated what is important in care delivery from the perspective of hospital inpatients with complex chronic disease, a currently understudied population.Participants and SettingOne‐on‐one semi‐structured interviews were conducted with inpatients at a continuing care/rehabilitation hospital (n = 116) in Canada between February and July 2011.DesignThe study design was mixed methods and reports on patient characteristics and care delivery experiences. Basic descriptive statistics were run using SPSS version 17, and thematic analysis on the transcripts was conducted using NVivo9 software.ResultsPatients had an average of 5 morbidities and several illness symptoms including activity of daily living impairments, physical pain and emotional disturbance. Three broad themes (each with one or more subthemes) were generated from the data representing important components of care delivery: components of the care plan (a comprehensive assessment, supported transitions and a bio‐psycho‐social care package); care capacity and quality (optimal staff to patient ratios, quicker response times, better patient–provider communication and consistency between providers) and the patient–provider relationships (characterized by respect and dignity).ConclusionsAs health systems throughout the industrialized world move to sustain health budgets while optimizing quality of care, it is critical to better understand this population, so that appropriate metrics, services and policies can be developed. The study has generated a body of evidence on the important components of care delivery from the perspectives of a diverse group of chronically ill individuals who have spent a considerable amount of time in the health‐care system. Moving forward, exploration around the appropriate funding models and skill mix is needed to move the evidence into changed practice.

Although intravenous thrombolysis increases the probability of a good functional outcome in carefully selected patients with acute ischemic stroke, a substantial proportion of patients who receive thrombolysis do not have a good outcome. Several recent trials of mechanical thrombectomy appear to indicate that this treatment may be superior to thrombolysis. We therefore conducted a systematic review and meta-analysis to evaluate the clinical effectiveness and safety of new-generation mechanical thrombectomy devices with intravenous thrombolysis (if eligible) compared with intravenous thrombolysis (if eligible) in patients with acute ischemic stroke caused by a proximal intracranial occlusion. We systematically searched seven databases for randomized controlled trials published between January 2005 and March 2015 comparing stent retrievers or thromboaspiration devices with best medical therapy (with or without intravenous thrombolysis) in adults with acute ischemic stroke. We assessed risk of bias and overall quality of the included trials. We combined the data using a fixed or random effects meta-analysis, where appropriate. We identified 1579 studies; of these, we evaluated 122 full-text papers and included five randomized control trials (n=1287). Compared with patients treated medically, patients who received mechanical thrombectomy were more likely to be functionally independent as measured by a modified Rankin score of 0-2 (odds ratio, 2.39; 95% confidence interval, 1.88-3.04; I2=0%). This finding was robust to subgroup analysis. Mortality and symptomatic intracerebral hemorrhage were not significantly different between the two groups. Mechanical thrombectomy significantly improves functional independence in appropriately selected patients with acute ischemic stroke.

Background Radiofrequency thalamotomy and deep brain stimulation are current treatments for moderate to severe medication‐refractory essential tremor. However, they are invasive and thus carry risks. Magnetic resonance‐guided focused ultrasound is a new, less invasive surgical option. The objective of the present study was to determine the cost‐effectiveness of magnetic resonance‐guided focused ultrasound compared with standard treatments in Canada. Methods We conducted a cost‐utility analysis using a Markov cohort model. We compared magnetic resonance‐guided focused ultrasound with no surgery in people ineligible for invasive neurosurgery and with radiofrequency thalamotomy and deep brain stimulation in people eligible for invasive neurosurgery. In the reference case analysis, we used a 5‐year time horizon and a public payer perspective and discounted costs and benefits at 1.5% per year. Results Compared with no surgery in people ineligible for invasive neurosurgery, magnetic resonance‐guided focused ultrasound cost $21,438 more but yielded 0.47 additional quality‐adjusted life years, producing an incremental cost‐effectiveness ratio of $45,817 per quality‐adjusted life year gained. In people eligible for invasive neurosurgery, magnetic resonance‐guided focused ultrasound was slightly less effective but much less expensive compared with the current standard of care, deep brain stimulation. The results were sensitive to assumptions regarding the time horizon, cost of magnetic resonance‐guided focused ultrasound, and probability of recurrence. Conclusions In people ineligible for invasive neurosurgery, the incremental cost‐effectiveness ratio of magnetic resonance‐guided focused ultrasound versus no surgery is comparable to many other tests and treatments that are widely adopted in high‐income countries. In people eligible for invasive neurosurgery, magnetic resonance‐guided focused ultrasound is also a reasonable option. © 2018 International Parkinson and Movement Disorder Society

A growing number of individuals require health services to manage multiple chronic conditions (i.e., complex chronic disease), yet little is known about their experience. The purpose of this study was to investigate the impact of *The authors thank the Bridgepoint Health Hospital Foundation for funding the study and to Great-West Life, London Life, Canada Life New Scientist Fund for providing salary support for the lead author.