Fernández Moyano A, Machín Lázaro J M, Martín Escalante M D, Aller Hernandez M B, Vallejo Maroto I
Servicio de Medicina Interna, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, España.
Unidad de Continuidad Asistencial Primaria-Interna (UCAPI), Servicio de Medicina Interna, Hospital Universitario de Guadalajara, Guadalajara, España.
Rev Clin Esp (Barc). 2017 Aug-Sep;217(6):351-358. doi: 10.1016/j.rce.2017.03.003. Epub 2017 May 4.
Polypathological patients have specific clinical, functional, psychoaffective, social, family and spiritual characteristics. These patients are generally elderly and frail and have frequent decompensations. They frequently use healthcare resources, have significant functional impairment and have a high index of dependence. This results in a significant social impact, high mortality and a high consumption of resources. The current healthcare models have not answered these needs, which causes problems with accessibility to healthcare services, a lack of coordination among these services, a higher probability of adverse events related to polypharmacy and a high consumption of resources. In the past decade, the healthcare models have changed and are characterized by work in multidisciplinary and interlevel teams, patient self-care, the availability of tools for decision making, information and communication systems and prevention. The goal is to have prepared and proactive health teams and an informed and active patient population. The assessment of health results, processes and the costs for these programs is still based on moderate to low evidence. It is therefore not an easy task to determine the type and intensity of interventions or to determine the patient groups that could gain more benefits.
患有多种疾病的患者具有特定的临床、功能、心理情感、社会、家庭和精神特征。这些患者通常年事已高且身体虚弱，病情经常出现失代偿。他们频繁使用医疗资源，存在显著的功能障碍，依赖程度高。这导致了重大的社会影响、高死亡率和高资源消耗。当前的医疗模式未能满足这些需求，从而引发了医疗服务可及性问题、这些服务之间缺乏协调、与多药联用相关的不良事件发生概率较高以及资源高消耗等问题。在过去十年中，医疗模式发生了变化，其特点是多学科和跨层级团队协作、患者自我护理、具备决策工具、信息和通信系统以及预防措施。目标是打造有准备且积极主动的医疗团队以及有见识且积极参与的患者群体。对这些项目的健康结果、流程和成本的评估仍基于中低水平的证据。因此，确定干预的类型和强度或确定能获得更多益处的患者群体并非易事。
