The challenge of treating a patient with various pathologies

The demographics have changed, the habits of the population have also changed and with them the profile of the patients, but the health system He has barely done it. Continues to focus on the acute processes of patients with a single disease, when the dominant pattern is that of a chronic patient afflicted with several pathologies at once. They are elderly patients with long-term diseases and slow progression, who need permanent control and who enter and leave the hospital whenever any of their pathologies is decompensated.

The demographic transition has not been accompanied by a sanitary. In all Western countries, as the Organization for Economic Cooperation and Development (OECD), it evolves towards a pattern of healthcare demand that has chronicity as a common denominator. It is fruit of both a great success and a great failure. Of the success of medicine and social progress, which means that now we can live many more years and overcome pathologies that previously shortened life. But also of failure, in many cases, in the prevention of habits that cause disease. Many of the chronic diseases that fill hospitals are caused by avoidable causes. This is the case, for example, of chronic obstructive pulmonary disease (COPD) caused by smoking, cirrhosis derived from alcoholism or diabetes or heart disease associated with obesity, inadequate nutrition and a sedentary lifestyle.

In all Western countries, a pattern of care demand is evolving, with chronicity as a common denominator.

The health managers are aware of the need to change the structures of the system to adapt it to this new profile of patients. Since 2012, there has been a National Strategy in Spain to address Chronicity in the National Health System, but its deployment is extremely slow and uneven. "The problem is that the system has a great inertia and it is difficult to introduce the necessary changes," says Jesús Díez Manglano, head of the Internal Medicine Service of the Royo Villanova Hospital in Zaragoza.

The 2009 European Health Survey indicated that 45.6% of the population over 16 suffers from at least one chronic process and 22% two or more processes. Not all chronic patients are older. We must also count 11% of children under 16 who suffer from chronic allergy or 7% who have asthma. But the determining factor is that as age advances, ailments are added. It is estimated that 5% of those over 65 suffer several diseases at the same time. And it is increasing. 42% of the multi-pathological patients attended suffer three or more pathologies.

"In internal medicine services we used to see patients with two or three associated pathologies, but now it can be six, eight or more," adds Professor Manglano. The first consequence is polypharmacy. 94% of these patients take between five and ten medications on an ongoing basis. Family doctors have to make great efforts to monitor the interactions that occur in the prescriptions of different specialists. "Often falls into an impertinent medicine, that is, that offers inappropriate solutions. It is not always better", Concludes Díaz Manglano.

As the age advances, ailments are added. It is estimated that 5% of those over 65 suffer several diseases at the same time

This change in the profile of the patients puts to the test, in the opinion of Joan Bautista Soriano, of the Hospital la Princesa and professor of the Autonomous University of Madrid, the sustainability of the system. "The increase in chronicity requires more nurses, more time for patient care in Primary Care, and to educate the patient and their families. Personalized medicine, with increasingly costly therapies and drugs, causes years of good management to falter. The solutions are not easy or fast, but probably require a combination of three elements: reinforce primary care, move from a specialized medicine to a more generalist profile, and greater effort in the promotion of health ".

The current health structure is far from that model. Focused on the episodic and discontinuous care of acute pathologies, with a strong reactive component and a more curative than preventive approach, when in the case of the chronically ill, the cure is ruled out, the priority is to avoid decompensation, relapse. and, above all, to prevent the risk of premature death.

Being complex patients, often when decompensated, they are referred to the hospital. But it is not efficient to kill flies with cannon fire. If a person with respiratory failure suffers a crisis, if it can be resolved in the health center, a day center or even at home, it is always better than admitting him to a hospital, where to obtain the same result they will be employed much more expensive resources. But the most important thing is often not taken into account: for an elderly and vulnerable patientHospital admission is already a risk, since hospital infections can have fatal consequences.

And this is not, at all, a minor problem. In 2017, 7.74% of hospitalized patients suffered an acquired infection during their stay at the center. The most affected group were men over 65 years old according to the EPINE study, which since 1990 measures the prevalence of nosocomial infections in Spain. In 2016, 337,572 potentially preventable hospitalizations were produced in Spain, according to data from the Ministry of Health. The affected patients had an average of 75.9 years and were an average of 8 days admitted.

It must be anticipated that chronicity will continue to increase. In its Projection of the Population of Spain to Long Term, the INE estimates that within 20 years the percentage of people over 65 will reach 31.9% of the population. And if the current obesity epidemic is not corrected, pluripathology will also increase. A study coordinated by the Hospital del Mar Institute of Medical Research of Barcelona shows that 70% of men and 50% of women are overweight. If the current trend is not corrected, in 2030 these percentages will be 80% and 55%. Almost 10% of the population will have morbid obesity. All this will mean a surcharge of 3,000 million euros per year for the health system. Apart from an increase in cases of diabetes and cancer, "improvements in cardiovascular risk factors achieved in the last 20 years will be dramatically neutralized by the obesity epidemic, "the study authors conclude.

It is therefore necessary to take preventive measures and accelerate reforms to adapt the health system to the new reality. Based on the national strategy, the different autonomies are applying attention programs to chronicity, but with different intensity and very uneven results. There are successful initiatives that could be generalized, such as the day hospital device enabled in Lugo, which serves more than 100 Chronically ill newspapers. Or the GesEPOC comprehensive care program for patients with respiratory failure, which has substantially improved the care of these patients.

Telemedicine can also be very helpful, but it requires investments. The Promete II program coordinated by Julio Ancochea, chief of the Pneumology Department at the La Princesa Hospital in Madrid, has shown that monitoring patients with COPD at home can detect symptoms of aggravation and avoid hospitalization in time. The patients themselves measure oxygen saturation and other parameters, and the data is sent via a 3G modem to the medical center.

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A complex patient
with many backpacks

Medicine has worked for many years compartmentalized by specialties that cut the body and serve in a compartmentalized way the different pathologies associated with each organ. The hospitals have devoted great efforts to the training of specialists and to guarantee an increasing level of super-specialization in very specific areas.

This specialization will continue to be necessary in order to efficiently apply medical advances, but its weight in the healthcare setting must decrease. Changing the profile of patients will require a more generalist medicine capable of attending a growing number of patients in a comprehensive manner. chronic patients, many of them with several associated pathologies. They are more complex patients, more vulnerable and with greater care needs, just when sociological changes are diminishing the available family supports.

Many more family doctors, geriatricians and specialists in Internal Medicine will be needed to ensure good attention to chronicity. This type of patients requires a tutor who takes them through the health system and coordinates the assistance responses they need at all times. That tutor must be, in the opinion of Jesús Díez Manglano, the family doctor and when the patient enters a hospital, who can better assume that tutorial function is the internist.

The lack of coordination and continuity of care are indicated by the national chronicity program as the two most serious deficiencies. The result is the pilgrimage of chronic patients and their families for the different specialties, each with their therapeutic guides and their waiting lists.