With older age, greater functional impairment, greater dependency, and higher risk prognostic stratification. These are the characteristics that the profile of the complex chronic patient and multiple pathologies hospitalized in the Internal Medicine services of the hospitals of the National Health System (SNS). This has been revealed in the round table “The chronic or polypathological patient at the center of health care”.
This workshop has been organized by the Working Group for Pluripathological Patients and the Elderly (PPyEA) of the Spanish Society of Internal Medicine (SEMI) and was held within the framework of the 43rd National Congress of Internal Medicine of the SEMI-8th Congress of the Asturian Society of Internal Medicine (SAMIN)-8th Iberian Congress of Internal Medicine that is being held these days in Gijón, Asturias.
According to the CRONICOM study, prepared by the aforementioned SEMI working group, it reveals that 61% of patients admitted to Internal Medicine they are already complex chronicles and that 40% are multipathological.
Among the pathologies that most affect these patients are ischemic heart disease, stroke and chronic kidney disease. They are diseases that produce limitations to carry out normal activities of daily living or deterioration in mental capacityas well as tumors that do not have curative treatment, among others.
During the round table, the need to commit to strengthening the basic principles of medicine by making the doctor-patient relationship the main bulwark for quality care. The importance of knowing the patient and her needs to help him in all its extension and fullness and training from her perspective has also been pointed out.
In this sense, it should be considered that “knowing the disease itself, the drugs that are taken (their indications and their correct dosage), undoubtedly contributes to improving symptom control and reduces the risks of exacerbations”, as reported by SEMI.
Juana Mateos, from the Madrid School of Health, stressed that “Health for Citizenship schools are community participation and shared learning initiatives aimed at citizens/patients to promote the adoption of healthy habits and lifestyles and encourage co-responsibility of people in their health care and in the self-management of their illness”. In addition, “they favor the exchange of knowledge and experiences and offer the population quality information and training related to health”, he says.
Complex chronic patient profile
The most prevalent pathologies of complex chronic patients with multiple pathologies admitted to Internal Medicine Services are heart disease (68%)followed by chronic kidney disease (49%), neurological diseases (43%) and respiratory (32%). 60% have a high degree of dependence for activities of daily living. This population, according to Dr. Pilar Cubo Romano, coordinator of the PPyEA Working Group and head of the Internal Medicine Service at the Infanta Cristina de Parla University Hospital (Madrid).
This patient has a high mortality during admissions and, in clinical follow-up, a low quality of life related to perceived health and a high prevalence of dependency on the caregiver. Also, present a special susceptibility and clinical fragility which entails a frequent demand for attention. Other chronic diseases, much less prevalent individually but of significant relevance and individual and family affectation, would also become a part, such as minority diseases, indicates the specialist.
Coordination between care levels
Another aspect that has been highlighted at the table is the need for shared decision-making and abandoning medical paternalism. The relationship and decision-making should be based on the conviction and knowledge of the patient of his pathologyto freely guide the evolution of his illness.
Professionals must seek an agreement with their patients, in a conversation that aims to bring scientific evidence closer to the preferences and values of the person. Polypathological patients benefit, through a global multidimensional assessment, of a strategy in which they are truly the center of the system. “It is the health system, and not the patient, who must adapt to offer the best care and avoid harm to the patient himself,” the round table said.
Each patient must have an individualized plan shared between the different levels of care that promotes the empowerment of the patient or their caregiver and specifies the actions to be taken in the event of an alarm due to possible decompensation. For it, It is necessary to improve coordination and continuity of care between different levels of care, Primary Care and socio-health centers or residences. In this way, the quality of care for these patients will be improved, especially in care transitions.
The role of internists
Internal Medicine, as a holistic specialty that cares for people as a whole and not by parts or systems, has the mechanisms to carry out this global and individualized assessment and experience on most of the pathologies of polypathological patients, is capable of globally assessing the situation, both physical and mental and social, and of adapting the medication avoiding polypharmacy and the unwanted effects of the drugs, as they have put highlight the participants at the table.
“Chronicity is a pandemic that requires general specialists with seasoned clinical, human and organizational skills to give an appropriate response to the people who suffer from it”. Numerous experts advocate for a hospital of the future based mainly on these professionals.
In Internal Medicine, they have spent years dedicating themselves to complex, multi-pathological and elderly chronic patients, understanding that through a collaborative process with other specialtiesespecially with Primary Care, must offer a paradigm shift.
The table concluded with the idea that there are different profiles of complex chronic patients and multipathological, with very different needs. The comprehensive approach must be adjusted to the different types (age, digital culture, decision-making capacity, family support, etc.) and continuity and inter- and intra-level coordination is essential.
The round table was moderated by doctors Juan Igor Molina, from the Internal Medicine Service of the Complejo Asistencial de Ávila; and Jesús Díez Manglano, president of SEMI. The following have participated in it: Juana Mateos, from the Madrid School of Health; Dr. Ignacio Vallejo, deputy medical director of the Hospital de Valme (Seville); Dr. José Manuel Casas, from the Internal Medicine Service of the Infanta Cristina de Parla University Hospital (Madrid); and with Alfredo de Pablos, president of the Association of Patients with Chronic Pluripathologies.