Do we know the social complexity of the complex chronic patients?

Iglesias, Francisco Hernansanz; Celada, Clara Alavedra; Morales, Lidia Palau; Visús, Núria Albi; Navarro, Carme Berbel; Valverde, Cristina Cobo; Dorado, Vanessa Matias; Simó, Josep M.; Jordana, N. Montellà

doi:10.5334/ijic.3909

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“…GPs are used to giving code numbers to biological issues. When compared with clinical diagnoses, social diagnoses (people with potential health hazards related to socioeconomic and psychosocial circumstances, Z55-Z65, ICD-10) are scarce in electronic health records [34]. At least one third of the patients who are served in general practices suffer from psychosocial problems that they perceive as influencing their present health status; general practitioners only identified between a fifth and a half of these problems, but continuity of care increased the likelihood of the care provider becoming aware of them [35].…”

Section: Psychosocial Knowledge a Pending Subjectmentioning

confidence: 99%

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

Iglesias

Martori

Ramírez

et al. 2021

International Journal of Integrated Care

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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.

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Section: Psychosocial Knowledge a Pending Subjectmentioning

confidence: 99%