Giorgio VESCOVO MD PhD London

Transcription

1 Sorrento, 13/5/2017 MISURARE LA COMPLESSITA DEL PAZIENTE: I DATI PRELIMINARI DELLO STUDIO COMPLIMED Giorgio VESCOVO MD PhD London FESC

2 Il sottoscritto GIORGIO VESCOVO. ai sensi dell art. 3.3 sul Conflitto di Interessi, pag. 17 del Reg. Applicativo dell Accordo Stato-Regione del 5 novembre 2009, dichiara che negli ultimi due anni NON ha avuto rapporti diretti di finanziamento con soggetti portatori di interessi commerciali in campo sanitario

3 Definition and mission statement of Internal Medicine Internal medicine is the core medical discipline that is responsible for the care of adults with one or more complex, acute, or chronic illnesses, both in the hospital and in the community It is patient-centred, scientifically based and committed to ethical, scientific and holistic principles of care. EFIM working group on professional issues in internal medicine in Europe

4 Definition and mission statement of Internal Medicine Specific fields of interests include: - problems caused by polymorbidity - patients with difficult and complex diagnoses - preventive, acute, chronic and palliative care Internists are able to translate their knowledge into patient care Internists cope with the challenge of developing standards, decision-making, quality improvement and patient safety tools, and integrated health care delivery systems EFIM working group on professional issues in internal medicine in Europe

5 Complexity Stacey and Zimmerman model Stacey, Ralph D. Strategic management and organisational dynamics: the challenge of complexity. 3rd ed. London: Financial Times, 1999.

6 Disfunzione COGNITIVE cognitiva DYSFUNCTION/CLINICAL - Fragilità clinica e/o FRAGILITY sociale LOW Bassa Alta HIGH THE THREE AXIS I DEFINING 4 assi che COMPLEXITY definiscono IN INTERNAL Instabile la complessità assistenziale MEDICINE in Medicina InternaUNSTABLE INTERMEDIATE Complessità COMPLEXITY intermedia Bassa LOW complessità INTENSITY Grado di instabilità/criticità clinica HIGH alta COMPLEXITY complessità alta HIGH intensità INTENSITY (high care) Basso LOW COMORBIDITIES Indice di comorbilità INDEX HIGH Alto critico CRITICAL STABLE Stabile Non NON critico CRITICAL HIGH Alto PossibilitàFUNCTIONAL di recupero dell autonomia RECOVERY funzionale Basso LOW

7 THE CONCEPT OF COMPLEXITY - COMORBIDITIES - DEPENDENCY FINALIZED TO PROGNOSTIC STRATIFICATION

8 INDICES OF COMPLEXITY WITH PROGNOSTIC SIGNIFICACE 1 MPI 2 COMPLIMED

9 Multidimensional Prognostic Index 1 ACTIVITIES DAILY LIVING 2 INSTRUMENTAL ACTIVITIES DAILY LIVING 3 SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE 4 MINI NUTRITIONAL ASSESSEMENT 5 EXTON SMITH SCALE 6 COMORBIDITY INDEX RATING SCALE 7 NUMBER OF DRUGS 8 HOUSING

10 Risultati questionari somministrati DOMINIO Dipendenza funzionale QUESTIONARI AMISSIONE in M.I. (Media± D.S.) DIMISSIONE (Media± D.S.) ADL 2.4 ± ± 2.5 IADL 4.0 ± 3.0 BARTHEL 53.9 ± ± 37.5 Comorbidità Charlson 4.0 ± ± 2.6 CIRS 3.4 ± ± 1.8 Stabilità clinica MEWS 1.3 ± ± 1.3 Fragilità Sociale Flugelman 12.1 ± ± 3.8 Disfunzione cognitiva SPMSQ 3.1 ± ± 3.4 Depressione GDS (5-items) 2.0 ± ± 1.7 Nutrizione MNA 18.6 ± ± 6.0 Lesioni da decubito Exton Smith 14.8 ± ± 4.1 Aderenza alla tp. Morisky 3.2 ± 1.2 Dolore NRPS 2.2 ± ± 1.9

11 PCA Principal Component Analysis Analisi dei Cluster Componente 2 COMORBIDITA Componente 1 DIPENDENZA La Componente 1 intercetta il 55% dell informazione totale La Componente 2 intercetta il 14% dell informazione totale Componente 1 + Componente 2 70% dell informazione totale

12 COSTRUZIONE COMPLIMED SCORE CS2 = scs x 100 COMORBIDITIES CS1 = (BI + ES)/2 DEPENDENCY

13 Predictive Value of COMPLIMED Score vs. MPI score One year mortality

14 BMI ETA ANDAMENTO CLINICO CAPACITA PREDITTIVA DI MORTALITA AD UN ANNO

15 1 year

16 Polytherapy Comorbidities Clinical Stability Age Pressure lesions COMPLEXITY Social Fragility Cognitive Dysfunction Depression pain Functional Dependency Caregiver Nutrition COMPLIMED Score VS. MPI Score

17 Possiamo semplificare la complessità? MPI Score Activities of Daily Living (ADL) 6 items Instrumental Activities of Daily Living (IADL) 8 items Short Portable Mental Status Questionnaire (SPMSQ) 10 items Mini-Nutritional Assessment (MNA) 18 items Exton-Smith Scale 5 items Cumulative Illness Rating Scale (CIRS) 14 items Number of drugs 1 Social index 1 TOTAL 63 items COMPLIMED SCORE Barthel Index 10 items Exton-Smith Scale 5 items Charlson index 19 items TOTAL 34 items

18 THE INTERNIST: A PHYSICIAN ABLE TO COPE WITH COMPLEX SCENARIOS CHF as an example of applicability of complexity evaluation - PATIENT COMPLEXITY - DISEASE COMPLEXITY

19 NHS conception of a model for managing patients with long term conditions PERSONALIZED MEDICINE PRECISION MEDICINE Perhaps it is more important to know what kind of patient has the disease, than what kind of disease has the patient William Osler, 1894 Richard Smith, United Health Europe Formerly ed. BMJ

20 FIELDS OF APPLICATION HEART FAILURE

21 FRAILTY VS COMPLEXITY PROGNOSTIC VALUE?

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23 HEART FAILURE TREATMENT APPROPRIATENESS AGE

24 APPROPRIATENESS (IN HOSPITAL MANAGEMENT) INTENSITY OF CARE 1 CCU 2 ICU 3 Emergency Medicine 4 Ward 5 Hospice Rapid evaluation of Complexity, Comorbidities and Prognosis in ED

25 APPROPRIATENESS (COMPLEX PROCEDURES) 1 ICDs 2 TAVI 3 RESYNCHRONIZATION 4 LVAD HEART FAILURE TEAM FOR TAKING DECISIONS Integrated by specialist of complexity

26 APPROPRIATENESS (DISCHARGE STRATEGIES) 1 rehabiltation 2 HF outpatient 3 GPs 4 Telemedicine 5 Nursing Home 6 Hospice Complexity and comorbidities evaluation

27 CONCLUSIONS

28 END OF LIFE DESISTIVE MEDICINE PALLIATIVE CARE CHOOSING WISELY (SLOW MEDICINE)

29 THANK YOU FOR ATTENTION

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