Almost unnoticed by medical schools and health systems the nature of health care has changed radically. The traditional medical model is “patient admitted, diagnosed, treated, cured, sent home,” and the special role of doctors, said one chief medical officer recently, is “diagnosis, diagnosis, diagnosis.” In reality there is little diagnosis and even less curing. Most of health care is now concerned with frail patients, often elderly, with multiple chronic conditions. Indeed, patients with five or more chronic conditions account for two thirds of the costs of Medicare.
Spain, which currently holds the presidency of the European Union, has recognised this change, and on Tuesday at a conference in Granada it launched a book entitled When people live with multiple chronic diseases: a collaborative approach to an emerging global problem. (1) The book brings together for the first time what we know—and still more importantly what we don’t know—about how best to manage these patients and organise health services to improve their care and independence.
A paper copy in English was made available in Granada, but the book is actually a living document, a wiki, available in Spanish and English to which anybody can contribute. Indeed, 55 people from 18 countries made 235 contributions. I’ve urged people before to contribute to the book, and you can do so at: http://www.opimec.org/equipos/when-people-live-with-multiple-chronic-diseases/
One of the tricky things in addressing this issue is to know what language to use.
Researchers have often used the word “comorbidity,” but the problem with this is that it assumes a dominant condition. Patients with several unrelated conditions—for example, diabetes, chronic obstructive pulmonary disease, and depression—might thus be labeled in three different ways.
Another term, the one we started out with, is “complex chronic disease,” but this is confusing as people may have a single condition—perhaps schizophrenia—that presents in a highly complex form that is difficult to manage.
The book thus comes down in favour of “polypathology” (also sometimes called “pluripathology”) that puts the emphasis squarely on patients having more than one disease. An advantage of this term is that doctors in Andalucia have been using it since 2002. They have defined nine distinct chronic conditions (http://www.opimec.org/equipos/Definicion_Fragilidad_pluripatologia_complejidad/documentos/877/#ante-section-4174 ), and for patients to qualify as having polypathology they must have two or more of the conditions.
Using this definition the Andalucian doctors have found that some 40% of admissions are patients with polypathology and that the taxonomy predicts prognosis—that is, the more the conditions the poorer the outcome. Some 19% die while in hospital, and disturbingly—but not perhaps surprisingly—patients with polypathology who are admitted to hospital are more likely to die than those not admitted. That’s one reason why Andalucia is redesigning its health system to better serve these patients and has put the major emphasis on primary care.
Clearly we won’t make much progress with this global issue if we can’t agree on language. That’s why the editors of the book are particularly keen on comments on the language we should use. Why don’t you tell us what you think? Perhaps you even have a duty to do so.
Competing interest: I am one of the editors of the book. Like everybody else, I was not paid, but the Andalucian government did kindly pay for my wife and me to travel to Andalucia for the launch. It also paid for a trip round the Alhambra and a particularly delicious meal in a restaurant across from the Alhambra that was once the home of the last Moorish queen.
1. Jadad AR, Cabrera A, Martos F, Smith R, Lyons RF. When people live with multiple chronic diseases: a collaborative approach to an emerging global challenge. Seville: Andalusian Government; 2010. Available at: http://www.opimec.org/equipos/when-people-live-with-multiple-chronic-diseases/