Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice

Shippee, Nathan D.; Shah, Nilay D.; May, Carl; Mair, Frances S; Montori, Víctor M.

doi:10.1016/j.jclinepi.2012.05.005

Cited by 540 publications

(691 citation statements)

References 154 publications

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“…This activity requires 'work' on behalf of the patient, and levels of literacy and numeracy influence patients' self-assessments of their needs and capacity to respond appropriately to this growing workload. (Shippee et al, 2012) As we have noted, previous research has shown that literacy skills are important; our research goes further, indicating that numeracy is equally and independently important, and different from literacy. Service delivery needs to recognise this distinctiveness and measures to address shortfalls in literacy and numeracy need to be aware of their implications for self-assessments of health.…”

Section: Discussionsupporting

confidence: 65%

“…We view health status both as a likely consequence of shortcomings in health service uptake and also as a construct deeply structured in its own right by social inequality at both the individual and area level. Within this context, following the cumulative complexity model of Shippee et al (2012), we see health status as relating to the burden of disease, and literacy and numeracy as elements of patient capacity to deal with that burden and the associated treatment regimes.…”

Section: Study Aimsmentioning

confidence: 99%

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Towards an understanding of the relationship of functional literacy and numeracy to geographical health inequalities

Moon

Aitken

Roderick

et al. 2015

Social Science & Medicine

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The relative contributions of functional literacy and functional numeracy to health disparities remain poorly understood in developed world contexts. We seek to unpack their distinctive contributions and to examine how these contributions are framed by place-based deprivation and rurality. We present a multilevel logistic analysis of the 2011 Skills for Life Survey (SfLS), a representative governmental survey of adults aged 16-65 in England. Outcome measures were self-assessed health status and the presence of self-reported long-term health conditions. Exposure variables were functional literacy (FL) and functional numeracy (FN).Age, sex, individual socio-economic status, ethnicity, whether English was a first language, non-UK birthplaces, housing tenure and geography were included as potential confounders and mediators. Geography was measured as area-based deprivation and urban/rural status. FL and FN were both independently associated with self-assessed health status, though the association attenuated after taking account of confounders and mediators. For long-term conditions, the association with FN remained significant following inclusion of confounders and mediators whilst FL attenuated to non-significance. Rurality did not influence these associations. Area deprivation was a significant factor in attenuating the association between FL and self-assessed health status. Policy makers and health professionals will need to be aware of the distinctive impact of FN as well as FL when combating health inequalities, promoting health and managing long-term conditions.

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Section: Discussionsupporting

confidence: 65%

Section: Study Aimsmentioning

confidence: 99%

Towards an understanding of the relationship of functional literacy and numeracy to geographical health inequalities

Moon

Aitken

Roderick

et al. 2015

Social Science & Medicine

View full text Add to dashboard Cite

show abstract

“…27 This includes understanding the potential negative impact of developing a clinical plan which, in order to operationalize, requires resources in excess of the patient's capacity at that time. 27 Minimally disruptive medicine, a promising theoretical approach for improving the care of complex clients, embodies the awareness of capacity in achieving patient-centered care while "imposing the smallest possible treatment burden on patients' lives." 28 This study, although not without its limitations, provides an in-depth exploration of the experiences of a small number of patients living with HIV, recruited from a single facility in Toronto, Canada after relatively long hospital stays.…”

Section: Discussionmentioning

confidence: 99%

The Lived Experience of the Hospital Discharge “Plan”: A Longitudinal Qualitative Study of Complex Patients

Carusone

O’Leary

McWatt

et al. 2017

Journal of Hospital Medicine

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BACKGROUND Transitions in care are a high‐risk time for patients. Complex patients account for the largest proportion of healthcare costs but experience lower quality and discontinuity of care. The experiences of complex patients can be used to identify gaps in hospital discharge practices and design interventions to improve outcomes. METHODS We used a case study approach with serial interviews and chart abstraction to explore the hospital discharge and transition experience over 6 weeks. Participants were recruited from a small hospital in Toronto that provides care to complex patients living with human immunodeficiency virus (HIV). Framework analysis was used to compare data across time‐points and sources. RESULTS Data were collected from 9 cases. Participants presented with complex medical and psychosocial challenges, including substance use (n = 9), mental health diagnoses (n = 8) and a mean of 5 medical comorbidities in addition to HIV. Data were analyzed and reported in 4 key themes: 1) social support; 2) discharge process and transition experience; 3) post‐discharge follow‐up; and 4) patient priorities. After hospital discharge, the complexity of participants' lives resulted in a change in priorities and subsequent divergence from the discharge plan. Despite the comprehensive discharge plans, with referrals designed to support their health and activities of daily living, participants experienced challenges with social support and referral uptake, resulting in a loss of stability achieved while in hospital. CONCLUSION Further investigation and changes in practice are necessary to ensure that discharge plans for complex patients are realistic within the context of their lives outside of the hospital.

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“…[12][13][14]16,17 Holzhausen and colleagues developed a conceptual framework, standardized instruments, and indicators for continuous monitoring of multimorbidity and associated healthcare needs in the population 65 years and older for a longitudinal epidemiological study. 15 Their model includes concepts of multimorbidity and its consequences, quality of life, healthcare services utilization, personal and social resources that modify the association between multimorbidity and outcomes measures, and sociodemographic variables.…”

Section: Purpose and Application Of Existing Modelsmentioning

confidence: 99%

“…13 Safford's Vector Model of Complexity was developed to inform clinical management of complex patients. 10,16 This model defines patient complexity at a given time-point along socioeconomic, cultural, biological/genetic, environmental/ ecological and behavioral axes that interact as health determinants; multimorbidity is one aspect. 10 In this model, patients can have greater vulnerability in one or more axes and axes contributing to complexity can change over time to reflect complexity's dynamic nature.…”

Section: Purpose and Application Of Existing Modelsmentioning

confidence: 99%

A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development

Zullig¹,

Whitson²,

Hastings³

et al. 2016

Journal of Patient-Centered Research and Reviews

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BACKGROUND: Patient complexity is often operationalized by counting multiple chronic conditions (MCC) without considering contextual factors that can affect patient risk for adverse outcomes. OBJECTIVE: Our objective was to develop a conceptual model of complexity addressing gaps identified in a review of published conceptual models. DATA SOURCES: We searched for English-language MEDLINE papers published between 1 January 2004 and 16 January 2014. Two reviewers independently evaluated abstracts and all authors contributed to the development of the conceptual model in an iterative process. RESULTS: From 1606 identified abstracts, six conceptual models were selected. One additional model was identified through reference review. Each model had strengths, but several constructs were not fully considered: 1) contextual factors; 2) dynamics of complexity; 3) patients' preferences; 4) acute health shocks; and 5) resilience. Our Cycle of Complexity model illustrates relationships between acute shocks and medical events, healthcare access and utilization, workload and capacity, and patient preferences in the context of interpersonal, organizational, and community factors. CONCLUSIONS/IMPLICATIONS: This model may inform studies on the etiology of and changes in complexity, the relationship between complexity and patient outcomes, and intervention development to improve modifiable elements of complex patients.

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Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice

Abstract: With its components largely supported by existing literature, the model has implications for analytic design, clinical epidemiology, and clinical practice.

Cited by 540 publications

References 154 publications

Towards an understanding of the relationship of functional literacy and numeracy to geographical health inequalities

Towards an understanding of the relationship of functional literacy and numeracy to geographical health inequalities

The Lived Experience of the Hospital Discharge “Plan”: A Longitudinal Qualitative Study of Complex Patients

A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development

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