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[JAMA Intern Med发表述评]:日益增加的临床复杂性:对于医疗照护提供、费用支付模型以及人力资源的提示
2024年02月25日 研究点评, 进展交流 [JAMA Intern Med发表述评]:日益增加的临床复杂性:对于医疗照护提供、费用支付模型以及人力资源的提示已关闭评论

Invited Commentary 

January 8, 2024

Increasing Clinical Complexity—Implications for Care Delivery, Payment Models, and the Health Care Workforce

Daniel M. Blumenthal

JAMA Intern Med. Published online January 8, 2024. doi:10.1001/jamainternmed.2023.7407

In JAMA Internal Medicine, Naik et al1 present the results of a population-based serial, cross-sectional evaluation of trends in the complexity of hospitalized inpatients in British Columbia, Canada, between 2002 and 2017. The question that the authors pose—how has the complexity of hospitalized inpatients changed over time—is an important one and has implications for how we design, deliver, and pay for care as well as how we train and support our increasingly strained health care workforce.

The authors performed their analysis using population-based administrative health data, which they obtained by linking together data sets with patient-level medical claims, hospital discharges, community pharmacy prescriptions, demographic characteristics, and income bands with data on physician and hospital characteristics, from nearly 3.4 million nonelective acute care hospitalizations among more than 1.27 million unique individuals at 101 different acute care hospitals. They found that, by most measures of complexity, including age, number of clinical comorbidities, likelihood of being admitted via the emergency department, number of medications used, and the need for treatment of multiple acute medical problems, hospitalized patients in British Columbia grew consistently more complex over the duration of this 15-year study (Figure 3 in the study by Naik et al1). Indeed, compared with a hospitalized British Columbia resident in 2002, an inpatient in 2017 was, on average, 3 years older, taking 1 more medication, at 2.7 greater odds of being admitted via the emergency department, at 1.8 greater odds of taking 10 or more medications prior to admission, and at 2 greater odds of having 5 or more acute medical problems.

Major strengths of the study include its temporal breadth (evaluating nonelective hospitalizations over a 15-year time period), the size of the patient population, hospital cohort, and pool of unique treating physicians (more than 15 000 across this time period); the stability of payment models during the study (entirely fee-for-service reimbursement); and the completeness of the data sets. The lack of patient-level data on social determinants of health, which can dramatically compound the already difficult task of managing patients with multiple complex chronic conditions, is an important limitation.

Why are patients becoming increasingly complex? For one thing, and as the authors note, North America’s population is aging. Between 1977 and 2017, the number of Canadians older than 65 years grew from 2 million to 6.2 million.2 The United States is experiencing similar trends.3 As people age, they are more likely to develop chronic illnesses, including hypertension, diabetes, cardiovascular disease, cancer, lung disease, kidney disease, gastrointestinal disease, and mental illness. Many of these conditions require chronic pharmacotherapy, and acute exacerbations may necessitate urgent or emergent hospital-based care. As the authors correctly point out, greater adherence and access to preventive care and evidence-based chronic disease management, and, in particular, reductions in rates of smoking and increases in exercise as well as treatment advances for highly morbid illnesses have all contributed to our ability to manage this increasing medical complexity. Despite these improvements, continued growth in the prevalence of several of these chronic illnesses, including diabetes, obesity, heart failure, and cancer, is likely to drive further increases in patient complexity. These trends will continue to challenge our ability to deliver efficient, coordinated, patient-centered care across the care continuum.4-6

Importantly, the authors identified modest, but nonetheless important, shifts in the composition of clinical comorbidities affecting inpatients over time. Most notably, the prevalence of psychiatric illness and substance use disorders (both alcohol and drug use), diabetes, and kidney disease all increased over the course of the study, while rates of ischemic heart disease, both as a comorbidity and a cause of hospitalization, declined.

Their comparisons of hard clinical outcomes across the study period provide reason for optimism and highlight opportunities for improvement. Indeed, odds of intensive care unit stay and in-hospital death declined—findings that suggest more efficient resource utilization, better care despite increasing patient complexity, and possibly also greater ability to help terminally ill patients to die at home. However, odds of in-hospital adverse events, unplanned 30-day readmission rates, and death within 30 days of discharge all increased between 2002 and 2017.

All told, these findings reinforce the need for care models that enable seamless, longitudinal coordinated care for high-need patients with a combination of physical and mental health comorbidities. These care models must enable the delivery of care by multidisciplinary care teams composed of generalists, medical specialists, behavioral health specialists, experts in navigating and addressing social determinants of health, and those skilled in advanced-care planning and end-of-life care. Frequent communication between inpatient and outpatient care teams, supported by electronic data capture via electronic health records, which Canada adopted during this study period,7 is equally important, as is thoughtful incorporation of technologies that extend the bounds of the clinic into patients’ homes and communities. Deliberate, evidence-based segmentation of complex patients into cohorts with common and actionable drivers of avoidable morbidity and mortality and health policies that promote adoption of evidence-based approaches to managing complex patients, including payment models that incent their uptake, may ultimately help to speed successful implementation.8,9

As the authors astutely point out, to effectively care for an increasingly complex patient population, we must also prepare our clinician workforce with the requisite skills to manage this complexity—skills that span not just medicine and science, but also multidisciplinary team management, leadership, remote care delivery, care transitions, and complex care management.10 Effectively managing complex patients also requires more time and resources. In the aftermath of the COVID-19 pandemic, health care delivery systems face tremendous workforce challenges, including unprecedented rates of clinician burnout and attrition. In this moment, policymakers and health system leaders—all of us—must stop asking frontline clinicians to do more with less. Instead, we must continue to invest in our workforce and in the systems and care models necessary to effectively manage an aging, and evermore medically complex, populace. If we do so, we, along with patients, will be rewarded.

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