Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
Ann Intern Med. 2011 Dec 20;155(12):797-804. doi: 10.7326/0003-4819-155-12-201112200-00001.
Patients with complex health needs are increasingly the focus of health system redesign.
To characterize complex patients, as defined by their primary care physicians (PCPs), and to compare this definition with other commonly used algorithms.
Cohort study.
1 hospital-based practice, 4 community health centers, and 7 private practices in a primary care network in the United States.
40 physicians who reviewed a random sample of 120 of their own patients.
After excluding patients for whom they were not directly responsible, PCPs indicated which of their patients they considered complex. These patients were characterized, independent predictors of complexity were identified, and PCP-defined complexity was compared with 3 comorbidity-based methods (Charlson score, Higashi score, and a proprietary Centers for Medicare & Medicaid Services algorithm).
Physicians identified 1126 of their 4302 eligible patients (26.2%) as complex and assigned a mean of 2.2 domains of complexity per patient (median, 2.0 [interquartile range, 1 to 3]). Mental health and substance use were identified as major issues in younger complex patients, whereas medical decision making and care coordination predominated in older patients (P<0.001 for trends by decade). Major independent predictors of PCP-defined complexity (P<0.001) included age (probability of complexity increased from 14.8% to 19.8% with age increasing from 55 to 65 years), poorly controlled diabetes (from 12.7% to 47.6% if hemoglobin A1c level≥9%), use of antipsychotics (from 12.7% to 31.8%), alcohol-related diagnoses (from 12.9% to 27.4%), and inadequate insurance (from 12.5% to 19.2%). Classification agreement for complex patients ranged from 26.2% to 56.0% when PCP assignment was compared with each of the other methods.
Results may not be generalizable to other primary care settings.
Primary care physicians identified approximately one quarter of their patients as complex. Medical, social, and behavioral factors all contributed to PCP-defined complexity. Physician-defined complexity had only modest agreement with 3 comorbidity-based algorithms.
Partners Community Healthcare, Inc.
患有复杂健康需求的患者日益成为医疗体系重新设计的重点。
描述初级保健医生（PCP）定义的复杂患者，并将其与其他常用算法进行比较。
队列研究。
美国一家初级保健网络中的一家医院、四家社区健康中心和七家私人诊所。
40 名审查了他们自己的 120 名随机患者样本的医生。
在排除他们未直接负责的患者后，PCP 表示他们认为哪些患者是复杂的。对这些患者进行了特征描述，确定了复杂性的独立预测因素，并将 PCP 定义的复杂性与三种基于合并症的方法（Charlson 评分、Higashi 评分和医疗保险和医疗补助服务公司的专有算法）进行了比较。
医生确定了他们 4302 名符合条件的患者中的 1126 名（26.2%）为复杂患者，并为每位患者分配了 2.2 个复杂性领域（中位数为 2.0[四分位距，1 至 3]）。精神健康和物质使用问题在年轻的复杂患者中更为突出，而在老年患者中则以医疗决策和护理协调为主（按十年趋势，P<0.001）。PCP 定义的复杂性的主要独立预测因素（P<0.001）包括年龄（年龄从 55 岁增加到 65 岁，复杂性的概率从 14.8%增加到 19.8%）、未得到良好控制的糖尿病（糖化血红蛋白水平≥9%时，从 12.7%增加到 47.6%）、使用抗精神病药物（从 12.7%增加到 31.8%）、酒精相关诊断（从 12.9%增加到 27.4%）和保险不足（从 12.5%增加到 19.2%）。当将 PCP 分配与其他方法进行比较时，复杂患者的分类一致性范围为 26.2%至 56.0%。
结果可能不适用于其他初级保健环境。
初级保健医生确定了大约四分之一的患者为复杂患者。医疗、社会和行为因素都促成了 PCP 定义的复杂性。医生定义的复杂性与三种基于合并症的算法仅有适度的一致性。
合作伙伴社区医疗保健公司。
