The language of polypathology

last modified: 26/04/2013 11:50

This is a live interactive document that provides the first collaborative edition for the book chapter on "The language of polypathology" (Book Table of contents). To access the pdf version of the chapter, please click here. To access to the previous edition please click here.

Comments and contributions:

By clicking on the bubble that appears on the top right corner, you will be able to make comments on the corresponding section. Those individuals who make comments  will be invited to join the next edition of this chapter  as named contributors (if their comments make substantive additions) or will be named in acknowledgments (if not).

Follow section comments here!!

More information:

For any comments, questions, suggestions or technical support, please do not hesitate to contact us at info@opimec.org.

In order to edit this section in english the portal language needs to be changed to the original document language. After that you can change to your desired language using the language selector
First level chapter Second level chapter Third level chapter Fourth level chapter Fifth level chapter Sixth level chapter
You are editing one or more sections of this document, if you leave this page now any changes you made in the editors will be lost!

Use the "full screen" buttonpantallac to increase the size of the window and you can edit better.

In the upper left, choose the format of the text by selecting from the dropdown menu:

- Paragraph: for normal text

- Chapter of the first level, second or third: to highlight the titles of the sections and build the index. Those statements that highlight in this format will automatically appear in the document index (table of contents).

Use the options Ctrl V or CMD V to paste and CtrlC / CMD C to copy, Ctrl X / CMD X to cut (in some browsers buttons doesn´t work)

Once you finish editing do not forget to save your changes by clicking the bottom left button Save or Cancel if you don´t want to save the changes.

More information here

/media/css/tinybase.css,/media/css/tinycollab.css
Are you sure you want to delete this section?The language of polypathology: Vignette: How it could be
 
star star star three-quarter blank 14 votes
 

Vignette: How it could be

Paula, a 23-year-old medical student, is interviewing and examining Mr. Gupta, who has a long history of diabetes, arthritis and Parkinson's disease. As is now normal, she ensures that the 10 cameras in the consulting room capture every one of her actions, as well as the conversation with Mr. Gupta. It is still difficult for her to believe that her grandfather had to use pen and paper to take a patient's medical history, or that her father (another doctor; it seems to run in the family), had to type his impressions with a mouse on what was then called a computer.

She is very grateful to the unprecedented global effort that was made in the second decade of the 21st century to develop a taxonomy that now enables any health information system to record, code and classify each of her clinical and research activities, and report her outcomes, automatically, without any additional effort on her part. She is also very pleased to know that she is not part of a privileged minority. Every health professional, researcher, policy maker, manager, funder and member of the public interested in multiple chronic diseases uses this taxonomy, which is available anywhere in the world, free of charge, in over 100 languages and via multiple formats, technological platforms and media. She is also proud of the fact that, in keeping with the openness that inspired its creation, the taxonomy can be modified by her or by anyone else, from anywhere on the planet, at any time. She knows that her suggestions will be taken seriously by those elected to ensure that the taxonomy reflects the needs of its users and contributes to a people-centered sustainable health system.

Are you sure you want to delete this section?The language of polypathology: Summary
 
star star star star blank 18 votes
 

Summary

  • There is no accepted or acceptable terminology to identify, characterize, describe, code and classify what happens to people who live with multiple chronic diseases.

  • Such terminology could play a valuable role in efforts seeking to transform management and research efforts in these complex cases.

  • Existing coding and classification resources could be complemented to capture the
    nuanced nature of multiple chronic diseases.

  • Co-morbidity is a term that appears in most terminologies, but it does appear to refer, mostly, to multiple conditions that are associated with or secondary to a main disease.

  • Newer terms, such as pluri-pathology or polypathology, may be more appropriate as they tend to focus more on cases in which there is no primary or dominant
    disease.

  • Any terminology or taxonomy must take into account terms of great relevance to multiple chronic diseases, such as frailty, disability, and complexity.

  • The Internet, and particularly Web 2.0-powered resources, such as OPIMEC, could promote global collaborative efforts that could accelerate the development of a
    robust and widely supported taxonomy for multiple chronic diseases.

Are you sure you want to delete this section?The language of polypathology: Why is this topic important?
 
star star star star blank 16 votes
 

Why is this topic important?

Without valid, easy-to-use and widely acceptable tools to capture and communicate what happens to people who live with multiple chronic diseases, it would be very difficult for policy makers, clinicians, researchers, managers, patients, caregivers and any other interested group to pursue the unprecedented efforts that are required to enable the health system to meet the needs of this underserved population.

Are you sure you want to delete this section?The language of polypathology: What do we know?
 
star star star three-quarter blank 13 votes
 

What do we know?

The terms that have traditionally been used in relation to patients with chronic disease usually reflect the silos of the health system, emphasizing the needs of either individual diseases or organs.

The limited work that has been done in relation to multiple chronic diseases has focused mostly on comorbidity, understood chiefly in terms of a primary disease and its associated conditions (see below). Other terms, more related to health services or overall health status, such as frequent flyers, hyper-attenders, polymedicated, frailty and disability, are also frequently used. However, there is a lack of standardization in the terminology employed both by clinicians and investigators in this field. We lack a poly-pathologic disease thesaurus, an unambiguous taxonomy with widely accepted, easy-to-follow and valid definitions of terms, and a clear framework designed to promote the exploration of the relationship among them.

The US National Library of Medicines Medical Subject Headings (MeSH) provides the broadest coverage of concepts for health, but it lacks many terms related to the issues confronted by patients living with multiple chronic diseases. The World Health Organization (WHO) International Classification of Diseases (known as ICD), is widely used within many health systems around the world, but it is little more than an unidimensional ordering of terms describing medical concepts, with little relevance for chronic complex patients. Even SNOMED CT (Systematized Nomenclature of Medicine- Clinical Terms), the most comprehensive clinical vocabulary available in any language, lacks specific terms to enable a clear and reproducible description of the conditions, the interventions for the outcomes achieved in any case in which two or more chronic diseases co-exist (1). The only significant attempt to classify disease management interventions through a comprehensive taxonomy was proposed in 2006 in relation to cardiovascular diseases (see section The importance of a common taxonomy for chronic disease interventions) (2).

The following is a brief description of the most widely used terms:

Are you sure you want to delete this section?The language of polypathology: Comorbidity
 
star star star star blank 11 votes
 

 Comorbidity

In 1990, the US National Library of Medicine introduced the MeSH term comorbidity defining it as the presence of coexistent diseases, or diseases which have a compounding effect, dating from an initial diagnosis or referring to a primary condition which is the subject of study. This approach, which emphasizes the existence of a primary or core disease and a constellation of associated conditions (only sometimes secondary to the primary disease) makes comorbidity a vertical concept. Because of its verticality, patients can be labeled differently depending on the clinician's point of view. For instance, a patient with advanced diabetes who presents congestive heart failure, peripheral neuropathy and incipient nephropathy could be assigned different primary diseases depending on whether she is being managed by an endocrinologist, a cardiologist, a neurologist or a nephrologist.

Seasoned clinicians who devote most of their time to the management of patients with multiple diseases suggest that comordibity be classified in three groups depending on the relationship between the index disease and the accompanying conditions (Bob Bernstein, personal communication):

- Random: These are the diseases that occur together with a frequency no different from that of the individual conditions separately in the population. An example is the co-existence of hand warts and osteoarthritis.

- Consequential: This is the usual type of co-morbidity included in most classification systems, and refers to conditions that are patho-physiologically part of the same process, such as diabetes and hypertension, occurring together with a frequency that is much greater than what could be explained by chance. These co-morbidities, though interesting, are predictable.

- Cluster co-morbidity: This is what happens when there is non-random clustering of health conditions without an evident underlying patho-physiological cause, as occurs with obesity and cancer, for instance. This provides an opportunity for new discoveries-either new understandings of patho-physiology, or a new appreciation of the nature of complexity. This term could be considered equivalent to polypathology, as described below.

Terms that would translate as multimorbidity, polypathology or pluripathology are often used interchangeably with comorbidity in German, French and Spanish (3-12). Polypathology, however, may offer some advantages in its own right, as a distinct term.

 

Are you sure you want to delete this section?The language of polypathology: Polypathology
 
star star star star quarter 16 votes
 

Polypathology

Polypathology (also described as pluripathology) is widely used in Spain as a concept that is complementary (not antagonistic) to comorbidity. This concept has emerged out of the need to address the population of people who live with two or more chronic symptomatic diseases more holistically. In these patients it is difficult to establish a predominant disease, as all those that co-exist are similar in terms of their potential to destabilize the person, while generating significant management challenges.

Consequently, it is a more transversal concept that focuses on the patient as a whole and not on a disease or the professional who cares for the patient.

In 2002 a set of criteria for polypathology was proposed in Andalusia, and this has since then been adopted by several regional health authorities (13) serving a population of over 8 million people. Its prognostic value has been validated through prospective cohorts (14) of people with polypathology in a hospital setting.

According to these criteria, patients are defined as pluripathological or polypathological when they have chronic diseases which belong to TWO or MORE of the 8 categories outlined in Table 1.

Table 1: Criteria which define the Polypathological Patient (the patient must present chronic diseases defined in TWO or MORE of the following categories)

tab1_cap2

Tab1b_cap2

1 Slight limitation of physical activity. Usual physical activity produces breathlessness, angina, tiredness or palpitations.

2 Albumin/Creatinine Index > 300 mg/g,  microalbuminuria  > 3mg/dl in urine sample or Albumin > 300 mg/day in 24-hour urine sample or > 200 microg/min

3 Inability to keep pace with another person of the same age, walking on level ground, owing to breathing difficulties or the need to stop and rest when walking on the flat at one’s own pace.

4 Defined on the basis of clinical, analytical, echographical or endoscopic data.

 The concept of polypathology covers a broad clinical spectrum, ranging from patients who, as a result of their disease, are subject to a high risk of disability, to patients who suffer from various chronic diseases with continual symptoms and frequent exacerbations that create a demand for care which, in many cases, do not match traditional services within the healthcare system.

Consequently, the polypathological patient group is not defined solely by the presence of two or more diseases, but rather by a special clinical susceptibility and frailty which entails a frequent demand for care at different levels which is difficult to plan and coordinate, as a result of exacerbations and the appearance of subsequent conditions that set the patient along a path of progressive physical and emotional decline, with gradual loss of autonomy and functional capacity. They constitute a group which is particularly predisposed to suffer the deleterious effects of the fragmentation and super-specialization of traditional health systems. We can therefore regard them as sentinels or gauges of the general health of the health system, as well as of its level of internal inter-level coherence.

Polypathology then, as a new syndrome, may define a population of patients who are highly prevalent in society and demonstrate considerable clinical complexity, significant vulnerability, frailty and consumption of resources and high mortality at the level of both primary and hospital care, underscoring the need for integrated and coordinated interlevel care.

In accordance with its Quality and Efficiency Plan, the Andalusian Ministry of Health in Spain designed an organizational process to optimize the care of polypathologies following strategies of total quality management (Chapter 6). This process, which was developed by a team of internal medicine specialists, family physicians and nurses, focuses on roles, workflows and best clinical practices, all supported by an integrated information system, with the fundamental aim of achieving continuity of care (15, 16).

Recently the incidence of polypathologies in internal medicine wards of a tertiary-level hospital was estimated at 39% of admissions each month (17). Moreover, this study demonstrated prospectively that the criteria outlined above correctly identified patients with significant clinical complexity and frailty (35% met 3 or more criteria and had a greater need for urgent care and hospital admissions); high mortality (19% during the index admission) and progressive disability (significant impairment and functional deterioration during the care process).

The importance of standardized definitions and processes for the management of polypathological patients has begun to be reflected in publications about comorbidity at the national level, when referring to both hospitalized patients (17-21) and the general population (22-24).

Recently it has been demonstrated that mortality rates amongst hospitalized polypathological patients are  significantly higher during hospitalization than in patients who are not hospitalized, irrespective of the cause of hospitalization. The factors independently associated with a poorer vital prognosis were more advanced age and a poor functional situation.

Moreover, these patients usually deteriorate more while in hospital than non-polypathological patients. Figure 1 shows the results of a recent comparative study on functional deterioration in the presence of polypathology and general patients during conventional hospitalization (24).

  

Figure 1. Baseline Functional Impairment (measured on the Barthel scale) at Admission and Discharge of General and Pluripathological Patient Cohorts

Fig1_cap2

 Complex chronic disease

Used at institutions that specialize in multiple chronic diseases, such as Bridgepoint Health in Canada, this is another emerging term used in relation to people living with two or more chronic diseases [http://www.lifechanges.ca/complex_chroni...]. The main limitation of this term, however, is that pluripathology is only one aspect of the complexity in these cases. People living with polypathology may be complex or not, depending on many other related factors. In fact, polypathology may be neither a necessary nor sufficient condition. Some patients might be complex with a single «classical» disease, while others with multiple conditions might be easy to manage with few resources. For instance, a person living on the street with just schizophrenia is complex, while a stable well-controlled person with diabetes with managed hypertension and hyperlipidemia is not.

Therefore, in complex patients the disease burden is not only dependent on the health problems, but also on social, cultural, environmental circumstances and lifestyle. It cannot be denied that these circumstances will frequently exacerbate or alleviate the disease burden, and they may explain the different consequences of identical clinical situations for different people (25).

   Confluent morbidity

Multiple coexistent diseases can be given diagnostic labels that are easily counted and aggregated, for epidemiologic purposes or for the creation of clinical practice guidelines. However, as the number of diseases increases in a person, the clinical value of this approach decreases. An increasing number of diseases is often accompanied by an increasing number of medications. At some point the confluence of the effects of the conditions and the prescribed medications is so complex that it prevents any clearcut effort to attribute signs or symptoms to a specific cause (26). In these cases, the term confluent morbidity could enable clinicians and patients to focus on the relief of symptoms and not on futile diagnostic exercises.

Are you sure you want to delete this section?The language of polypathology: Assessment tools
 
star star star three-quarter blank 15 votes
 

Assessment tools

A systematic review of methods to measure comorbidity revealed one that was a simple disease count and 12 indexes (27). The following were regarded as valid and reliable:

The Charlson Index

This is the most extensively used instrument for prognostic evaluation in patients with comorbidity. It was published initially in 1987 and subsequently modified in 1994. The creation of the Charlson index (28) was initially based on a prospective study of 559 patients that correlated one-year mortality with comorbidity (Table 2). Depending on the cause of mortality, a score was given to each chronic disease present and, when these were added up, the result was an index which correlated well with mortality.

The success of the Charlson index is largely due a the modification introduced by Deyo (29), who adapted to the diagnostic codes stored in administrative databases with information about more than 27,000 patients subjected to lumbar spine interventions in 1985. Deyo's adaptation of the Charlson index has become the most widely used index of comorbidity. It is important to emphasize that the study was based on a hospital cohort and on one-year mortality. The mortality for each study patient quartile was: score 0: 12%; score 1-2: 26%; score 3-4: 52% and score 5: 85%.

The index has subsequently been validated for different geographic areas and different groups of patients with specific pathologies, and it has also been correlated with many variables such as health-related quality of life, readmissions and health costs, among
others.

Table 2. Modified Charlson Index

Tab2_cap2

 

Are you sure you want to delete this section?The language of polypathology: The CIRS Scale (Chronic Illness Resources Survey)
 
star star star blank blank 10 votes
 

The CIRS Scale (Chronic Illness Resources Survey)

 

This tool has been validated in different regions of the world and in very diverse patient populations (30). Its principal advantage is that its scoring scale defines the extent to which organs and systems are affected, without referring to specific diseases (Table 3). Despite its validity and reliability, however, there are few references to its use in research studies.

Table 3: Cumulative Illness Rating Score

Tab3_cap2

Are you sure you want to delete this section?The language of polypathology: The ICED (Index of Coexisting Disease)
 
star star star blank blank 8 votes
 

The ICED (Index of Coexisting Disease)

This was developed (31) as a tool to assess the prognosis of cancer survivors. It has subsequently been validated for other patient populations with different comorbidites. The main advantage of this prognostic tool is that it combines two dimensions: the severity of the disease, and the level of disability or functional compromise as experienced by the patient.

The first dimension (IDS or individual disease severity) includes a total of 19 possible comorbidities, each of which is scored on a scale that spans from 0 (absence of the disease in question) to 3 (severe disease).

The second dimension assesses the impact of comorbidities on the physical state of the patient (IPI or individual physical impairment). It evaluates 11 physical functions, grading them from 0 (normal function) to 2 (severe disability, dependence in order to perform a particular physical function).

This tool is rarely used, probably because it is too complex to apply in busy clinical settings.

Are you sure you want to delete this section?The language of polypathology: The Kaplan or Kaplan-Feinstein Index
 
star star star blank blank 10 votes
 

The Kaplan or Kaplan-Feinstein Index

This was developed to facilitate the prognostic assessment of patients with diabetes in relation to their comorbidity (32). Subsequent attempts have been made to export this instrument to other patient populations, but the results have been highly divergent and its use is therefore now only recommended for health research in diabetic populations (Table 4).

Table 4: Kaplan-Feinstein Comorbidity Index

Tab4_cap2

Are you sure you want to delete this section?The language of polypathology: Other instruments
 
star star star quarter blank 10 votes
 

Other instruments 

There has been a flurry of activity since the beginning of the new century, with new tools developed and validated with the intention of predicting mortality among pluripathological patients over the age of 70 years, mostly following hospital discharge (33-36). The Spanish Society of Internal Medicine is also supporting a multi-centre project, known as PROFUND, which is aimed at developing a new tool for the assessment of the prognosis of polypathological patients (37).

Other tools have been designed to enable patients to self-report multiple chronic diseases (38-40). Their clinical utility is still unclear.

Are you sure you want to delete this section?The language of polypathology: What do we need to know?
 
star star star half blank 15 votes
 

What do we need to know?

The following questions aim to encapsulate some of the most important knowledge gaps
in relation to the language of polypathology:

  • Is it possible to develop a valid, user-friendly and widely acceptable patient-centered tool that could provide a holistic assessment of the experience of people living with multiple chronic diseases? Such a tool (or toolkit) should ideally integrate issues related to symptom burden, functional status, psychosocial support needs and selfrated health. It should also be sensitive to changes over time and equally valuable to clinicians (especially in busy clinical settings), researchers, policy makers, managers and patients.
  • Is it feasible to create a globally accepted common language for polypathology, a taxonomy? Such an initiative would be invaluable in facilitating the codification and benchmarking of clinical activities, and in the evaluation of interventions and policies across institutional and geographic boundaries.
Are you sure you want to delete this section?The language of polypathology: What innovative strategies could fill the gaps?
 
star star star three-quarter blank 13 votes
 

What innovative strategies could fill the gaps?

The development and validation of usable and widely acceptable tools to identify, assess and guide the management and study of polypathologies will only be possible through meaningful global collaboration among leading academic, political, corporate and community organizations. The OPIMEC platform has been equipped with powerful resources to make this possible. It includes a workspace exclusively dedicated to the cocreation of terms related to polypathology, which has been populated with content from what may still be the only taxonomy designed with management issues in mind (41). The space also includes social media resources that enable anyone, anywhere in the world, to make a contribution and to join forces with like-minded people, free of charge (42). The challenge now is to use these resources with the enthusiasm and commitment required to meet the challenge.

Are you sure you want to delete this section?The language of polypathology: Contributors
 
star star star star blank 5 votes
 

Contributors

Manuel Ollero, Máximo Bernabeu and Manuel Rincón wrote the first draft of this chapter in Spanish.

Alejandro Jadad approved the first draft before it was made available online through the OPIMEC platform. This draft received important contributions from Ross Upshur and Bob Berstein (in English). Francisco Martos incorporated such contributions into the revised version of the chapter, which was edited extensively and approved by Alejandro Jadad.

Responsibility for the content rests with the main contributors and does not necessarily represent the views of Junta de Andalucia or any other organization participating in this effort.

Acknowledgments

Antonia Herraiz Mallebrera, Jose Murcia Zaragoza, Isabel Fernández y Barbara Paterson made comments to the chapter (in Spanish) that did not lead to changes in its contents.

How to reference


Ollero M*, Bernabeu M*, Rincón M*, Upshur R, Bernstein B. [*Main contributors] The language of polypathology. In: Jadad AR, Cabrera A, Martos F, Smith R, Lyons RF. When people live with multiple chronic diseases: a collaborative approach to an emerging global challenge.
Granada: Andalusian School of Public Health; 2010. Available at: http://www.opimec.org/equipos/when-people-live-with-multiple-chronic-diseases

Are you sure you want to delete this section?The language of polypathology: References (click here to access)
 
star star star star quarter 8 votes
 
Are you sure you want to delete this section?The language of polypathology: Creative Commons License
 
blank blank blank blank blank 0 votes
 
 

Comments to the whole document Comments feed

Anthony Papagiannis · 06/06/2010 06:32

In my specialist-centred opinion, the term “comorbidity” came into use because the patient would be seen by a specialist with a narrow focus on one primary problem related to this specialist’s field, to which everything else would be peripheral, or even an annoyance. In a patient-cented model of course we would care for a patient with problems A, B, C etc., which would have to be listed as active or inactive and given the relevant priority. So the choice of terms may reflect the healthcare environment and/or the specific doctor. Thus general (family) practice may consider "polypathology" more appropriate, and specialist medicine may find "comorbidity" more convenient. However, we all should agree that patients are not single-disease entities, and recognize the limits of our professional capacity. I am qualified in both general and respiratory medicine but practice almost exclusively the latter, so I am quite happy to refer patients for control of their blood pressures or sugars.

conchi
Conchi Candela
19/03/2012 09:25

Es obvio que necesitamos hablar en los mismos términos para entender que estamos diciendo. La polipatología actual debe estar por encima de las especialidades médicas como cajones sin comunicación.

Es necesario que se trate a la persona de manera holística, no sólo como alguien con problemas cardiacos, renales o hepáticos. La existencia en la misma persona con varias enfemedades obliga a valorar algo mas que lo específico de la enfermedad, tal como la discapacidad, la vulnerabilidad, la dependencia, la necesidad de otras personas para la adhesión terapeutica...

Herramientas que prevean o ayuden a preveer la evolución de estas personas en su discapacidad o afectación a órganos para evitar interacciones farmacológicas,... mejoran a corto y a largo plazo la vivencia de quienes padecen esta pluripatología

anpeutra
Antonio Miguel Perez Utrabo
04/04/2012 19:24

Estoy totalmente de acuerdo con los planteamientos descritos en este capítulo, es necesario unificar o clarificar el lenguaje, yo personalmente estoy más familiarizado con el de pluripatológico, creo que hace más referencia a la persona, que el de multicronicidad o comorbilidad, resultan más de tipo estadístico y centrado principalmente en la patología en sí más que en la persona.

El otro día trasladabamos a un señor del domicilio al hospital y nos pedian el CIE motivo del traslado, ¿cual le damos, diabetes descompensada, retencion urinaria por ca. de prostata, o sufrimiento espiritual?. es complicado habilitar una taxonomia, pero realizar un enfoque más centrado en la persona que en la enfermedad sí es posible, valorando más el entorno, la realidad social del paciente y sus hábitos de vida.

 

Raimundo
Raimundo Tirado Miranda
07/04/2012 02:43

Yo estoy más identificado con pluripatología y pluripatológico. Me parece que polipatología ha podido confundir algo el significado. Lo más importante sería establecer una terminología que nos permitiera visualizar "la carga de pluripatología" que tiene el paciente.

antoniopinto
Antonio Gonzalez Pinto
20/05/2012 18:49

estoy de acuerdo con la idea de que todos utilicemos las mismas palabras para definir los mismos terminos, y que esas mismas palabras sirvan para todo el mundo.

es frecuente enfocar el tratamiento y cuidados de los pacientes ""pluripatologicos" dependiendo de cuales son sus "polipatologias", sin embargo, creo que este enfoque deberia ser, como dice el articulo, "holistico". creo que lo que nos interesa es centrarnos en el bienestar del paciente y de ahi que todos nuestras acciones deban ser dirigidas a que el paciente este en las mejores condiciones posibles que posibiliten realizar la mayor parte de las actividades de la vida diaria.

mfernandez

Es sumamente interesante ponernos de acuerdo en la terminología y algo que lo demuestra es un pequeño ejercicio que he hecho tras esta lectura.

Una herramienta que usamos habitualmente para buscar la mejor evidencia es el Tripdatabase si introducimos el termino polipatología encontramos 3 estudios realizados en AP, si introducimos el termino pluripatologia encontramos 64 evidencias entre ellas 3 revisiones sistemáticas y si introducimos el término comorbilidad encontramos 13115 evidencias con 638 revisiones sistemáticas, una unificación de los terminos facilitaría el acceso de los profesionales a la mejor evidencia existente para un adecuado abordaje de nuestro pacientes con polipatología.

RICARDO
María Lopez Cano
25/05/2012 01:05

Si el término Polipatologia ha surgido para dar un enfoque holistico a aquellas personas que viven con dos o mas enfermedades cronicas, se exige ante las necesidades existentes una formacion transdisciplinar, una visión común hacia el manejo de conceptos que permitan un abordaje efectivo.

blopez
Begoña Lopez Hernandez
26/05/2012 20:19

Me ha resultado interesante y esclarecedor.

Entiendo que existe falta de consenso en los conceptos enfermo pluripatologico o polipatologico. Gracias a lo que he leído sobre el tema me gustaría expresar la conclusiones que saco sobre el tema:

El problema de salud se define como el motivo que mueve al usuario a realizar una consulta o demandar una atención de índole medico-sanitaria. Este problema no siempre exige el diagnóstico de una enfermedad. Una alteración familiar, o una situación de índole social pueden provocar un  problema de salud que se deriva de una enfermedad.

La enfermedad es una alteración del estado fisiológico del organismo que se manifiesta a través de síntomas y signos. Los síntomas son procesos subjetivos y los signos son procesos objetivables.  Cuando se posean síntomas pero se desconozca a qué afección responde, no se puede hablar de enfermedad.

Según estos conceptos, el enfermo pluripatologico o polipatologico se puede definir cuando concurran dos procesos crónicos o más en el mismo sujeto, no pudiendo definirse en el caso de que no existan estos diagnósticos nosológicos. Así, el concepto de hiperfrecuentador, o polimedicado, no podrían ser utilizados como equivalentes del paciente pluripatológico.

El concepto de comorbilidad creo que está bien definido, dos enfermedades pueden ser dependientes una de otra, o ambas pueden estar derivadas de una etiopatogenia común.

Para que el concepto de pluripatología responda a la necesidad específica de atención que tienen estos pacientes, estas enfermedades deben tener gravedad, además del componente de cronicidad. Es cierto que personas con una mayor capacidad para afrontar su polipatología, pero creo que este aspecto no debe incluirse en el concepto de enfermo pluripatologico ya que este equilibrio es frágil e inestable y llevaría a errores de clasificación cuando queramos medir aspectos concretos: necesidad de recursos, nivel de cuidados, pronóstico, etc.

Ya que el paciente pluripatologico es un paciente principalmente ambulatorio, verá adecuado utilizar la taxonomía de la Clasificación Internacional de Atención Primaria (CIAP-2),  para seleccionar las enfermedades crónicas que lo definirían, que además proporciona la equivalencia con la clasificación Internacional de Enfermedades (CIE-10).

Como sugerencia, creo que la clasificación de criterios definitorios del paciente pluripatologico que se incluye en el artículo podría traducirse al español.

mari5
Carmen Ratia Anguita
01/06/2012 19:28

Es evidente que debemos unificar terminos para una mejor comunicacion entre los profesionales medicos, enfermeros , gestores , legisladores . etc.

En Andalucia se implanto el Proceso Asistencial de Atencion al Enfermo Pluripatologico, que procura el abordaje de estos pacientes desde una vision centrada en el paciente, en los profesionales que prestan los servicios y en el proceso asistencial en si mismo.

baldomero
Baldomero Gonzalez Sabin
11/06/2012 11:23

Creo que es evidente que  la base para una investigación y asistencia  adecuadas,  esta en que todos hablemos de lo mismo y en los mismos términos, la disparidad en el uso de términos lleva  a la confusión y a la dispersión de los esfuerzos. Cuando tratamos  a estos pacientes se debe realizar una visión global de sus problemas, pero para ello necesitamos no solo de una taxonomía valida, si no, de una serie de herramientas consensuadas y validadas a nivel general para su aplicación . A mi criterio el termino “polipatologia” sería el mas a adecuado para todos los estamentos implicados, en relación al comentario anterior, y que el esfuerzo debería estar orientado en estos pacientes, a que no cada especialidad los trate por separado, si no que con el empleo de una historia clínica universal, se pudiese integrar toda la actuación en un paciente en concreto en un acto “único “, creando una herramienta colaborativa, estilo “ sesiones clínicas”, con periodicidad, donde intervengan distintas especialidades que discutan y aporten su visión sobre cada paciente.   

soniasc
Sonia Sancho Cabrera
22/06/2012 15:22

Un tema que resulta realmente interesante, es evidente que al tratar cualquier tema cotidiano, debamos utilizar siempre los mismos términos y además que sean conocidos por todos, cuanto más si se trata de un tema médico. Es totalmente necesaria la estandarización y en cuanto a la terminología utilizada, y una taxonomía que no sea ambigua.

En mi opinión es más acertado utilizar el término "pluripatología" que el de  "comorbilidad", aún teniendo en cuenta la distinción que existe entre los tres grupos, ya que engloba un amplio espectro clínico que abarca a pacientes con dos o mas enfermedades crónicas, con una enfermedad compleja y personas con una gran discapacidad, y que todas ellas necesitan y frecuentemente una atención médica compleja, independientemente si una enfermedad es consecuencia de la otra o no. Y sobre todo porque al paciente se debe tratar de una forma "holística".

Me ha llamado mucho la atención el término morbilidad confluente, en el que nos dice que podría permitir a los médicos centrarse en aliviar los síntomas o signos que aparecen sin una causa específica concreta, cuando confluyen los efectos de las enfermedades y de los medicamentos prescritos, "en lugar de perder el tiempo en inútiles ejercicios de diagnóstico". En mi opinión no creo que se esté perdiendo el tiempo, al contrario, muchos de esos signos o síntomas se producen por la utilización de esos medicamentos, por lo cual, la suspensión del medicamento es suficiente para que desaparezcan los síntomas, y no sería necesario por tanto la utilización de otro medicamento para esos síntomas nuevos que aparecen.

evalvarezp
Eva Alvarez Perez
29/04/2014 17:55

Para una comunicación eficaz es fundamental el acuerdo semántico. Me parece más adecuado en nuestro idioma el término pluripatológico y veo que es con el que estamos más familiarizados.

roampa_jerez
Amparo Fernandez Rodriguez
01/05/2014 23:50

En nuestro ambiente sanitario lo habitual es la denominacion de pluripatologia, para determinar a pacientes complejos, la carga de la enfermedad no solo depende de los problemas de salud, sino también de circunstancias sociales, culturales y medioambientales y de su estilo de vida por tanto el abordaje debe ser multidisciplinar.

mmc3866
Carmen Morcillo Molina
02/05/2014 17:11

Creo que el término pluripatológico , al que estamos familiarizados, define bien la situación de confluencia de varias enfermedades crónicas o invalidantes.

Lo importante es que nuestros cuidados estén dirigidos a solventar situaciones que afecten negativamente en el día a día del paciente y familia, con profesionalidad  y procedimientos  consensuados por los profesionales, de forma holística.

dmateoluque

Naturalmente que es necesario una buena comunicación y que para ello es necesario ponernos de acuerdo en la terminología. Pero semántica a parte el enfermo esta ahí con su pluripatologia y es mas que un corazón, un cerebro, unos riñones.....nos hemos subespecializado tanto que hemos olvidado a la persona que se encuentra detras

buendia

Es fundamental manejar los mismos términos, en el  campo de la atención y de la investigación.

esterita_07
Esther Martin Aurioles
25/05/2014 20:00

Me ha parecido fantástico este documento¡¡¡¡. me ha aclarado mucho, es fundamental conocer toda la terminología

No sé porque en el curso no forma parte del contenido obligatorio. Creo que al menos debería estar reseñado de alguna manera para que los compañeros que vayan cortos de tiempo se animen a echarle un vistazo


esterita_07
Esther Martin Aurioles
15/09/2014 13:25

Os animo a echar un vistazo a un articulo publicado  en Atención Primaria en junio de este año. Es muy clarificador de todo lo tratado en este tema

Desarrollo de guías de práctica clínica en pacientes

con comorbilidad y pluripatología

M. Bernabeu-Wittela,, P. Alonso-Coellob, M. Rico-Blázquezc,d,

R. Rotaeche del Campoe, S. Sánchez Gómezf y E. Casariego Valesg

http://dx.doi.org/10.1016/j.aprim.2013.11.013

cargoblaz
Carlos Gomez Blazquez
16/09/2014 10:40

Una terminologia comun me parece imprescindible, pero debe ser asequible al paciente para que sea participe en su salud y sus enfermedades.

Por otro lado Creo que existe una sobremedicacion, la cual termina por ser otra enfermedad, tambien una sobrediagnostizacion, en la cual una tristeza se convierte en depresion y la vejez en una enfermedad.

Espanyer
Andrés España Rebollo
03/12/2014 19:00

EL LENGUAJE DE LA POLIPATOLOGÍA

     Debido al aumento del envejecimiento de la población y  la esperanza de vida cada vez es más frecuente en nuestra sociedad  la pluripatología.  Esta tiene importantes repercusiones en la salud de una población, ya que supone una atención sanitaria más frecuente, aumenta la probabilidad de requerir ingreso hospitalario y de consumir fármacos, altera la calidad de vida, genera discapacidad y aumenta el riesgo de muerte.

     Aunque no hay una definición universalmente aceptada para definir al PACIENTE PLURIPATOLÓGICO, el término que manejamos nos facilita un perfil de paciente dada la prevalencia creciente de enfermedades crónicas en la población y el aumento de la esperanza de vida.

     El concepto de pluripatología, no sólo incluyen la suma de problemas crónicos  en dos o más sistemas (cardíaco, respiratorio, etc) sino también la gravedad de las patologías.

     Para la planificación sanitaria disponemos de las encuestas de salud que permiten una aproximación a la frecuencia y características de la población con pluripatología.

     La polipatología viene acompañada de  determinadas características, como:

     . Paciente con más de una enfermedad crónica.

     . Tratamientos complejos.

     . Síntomas contínuos /o frecuentes agudizaciones y hospitalizaciones.

     . Disminución de autonomía y deterioro funcional.

     . Frecuente fragilidad psico-social.

     La enfermedad se suele presentar de forma única o aislada en los adultos y en los ancianos, sin embargo, en estos últimos lo mas habitual es encontrar varias enfermedades que se presenten conjuntamente y que afecten a varios órganos y sistemas, interrelacionados o no. En general, se puede decir que en el anciano la existencia de un proceso patológico facilita la aparición de otro. Los factores que predisponen la pluripatologia en las personas mayores son:

    - La alteración de la homeostasia.

    - La interacción de los sistemas orgánicos.

    - Los largos periodos de latencia de muchas enfermedades que afectan al anciano que hacen que se pueda.

      superponer cualquier otro proceso agudo.

 

olgagavin
Olga Gavín Blanco
09/12/2014 16:48

En los países desarrollados, las mejoras sanitarias y la modificación de estilos de vida han propiciado que actualmente exista un aumento de la esperanza de vida y una predominancia de enfermedades crónicas.

Como consecuencia de estos cambios los sanitarios debemos dar respuesta a otro tipo de necesidades de la población; sin embargo, el modelo de salud existente hasta el momento está más centrado en la curación que en el cuidado de los pacientes. Poco a poco estamos cambiando a un enfoque centrado en las personas y sus necesidades, teniendo para ello en consideración todas sus condiciones sanitarias, sus limitaciones y el contexto social. Por ello, en los últimos años, están entrando en boga una serie de conceptos y términos que todo profesional de la salud debe conocer. En algunas ocasiones utilizamos dichos términos de forma errónea.  

Llamamos enfermedades crónicas a los procesos patológicos de larga duración. Suelen presentar una progresión lenta, aunque a su vez pueden darse agudizaciones a lo largo de la enfermedad. 

La Biblioteca Nacional de Medicina de Estados Unidos en 1990 añadió el término MeSH comorbilidad, y lo definió como todas aquellas enfermedades que acompañan a una entidad nosológica central tanto aguda como crónica. La comorbilidad, por tanto es un concepto vertical. Cada una de las comorbilidades ejercerá diverso peso clínico evolutivo y el conjunto de ellas modificará el pronóstico, evolución, tipo de tratamiento necesario y respuesta al mismo.

Polipatología (también descrito como pluripatología) se utiliza habitualmente en España como un concepto complementario del de comorbilidad.Este concepto se aplica cuando el enfermo padece dos o más enfermedades crónicas, en las que todas “están al mismo nivel”.

El término multimorbilidad se reserva para denominar a aquellos pacientes que presentan dos o más patologías crónicas que potencialmente, en el momento actual, no tienen un riesgo incrementado de deterioro clínico; por ejemplo hipertensión arterial y asma controlado.

peperuin
José Luis Rodríguez Cubas
13/12/2014 22:57

Si existe un territorio donde los distintos actores estamos obligados a entendernos , más en términos de semántica y taxonomía, es en el de los pacientes crónicos, por lo que me parece más que pertinente este documento. En el marco de la Atención Primaria donde me desenvuelvo es más habitual el concepto de pluripatología como sumación de enfermedades no necesariamente interdependientes o derivadas, y que pueden mermar el grado de independencia de la persona. Creo que este es el subgrupo de pacientes crónicos donde debemos concentrar todos nuestros esfuerzos en los próximos años y decenios.

EliaP

La visión holística del paciente implica:

  • Factores físicos como la pluripatología, cronicidad, dependencia, envejecimiento.
  • Factores psicológicos (estados depresivos, ansiedad...)
  • Determinantes sociales como la soledad, aislamiento social, disponibilidad de recursos económicos,nivel educativo.

Tenemos que consensuar la terminología, para poder tener una integración de la información asistencial independientemente del punto donde se ha registrado.  

EliaP

Comorbilidad: asociación de cualquier patología con una entidad nosológica principal, tanto aguda como crónica, que modula el diagnóstico y tratamiento.

Pluripatología: coexistencia de dos o más enfermedades crónicas.

Enfermedad crónica, OMS: enfermedad que se prolonga en el tiempo (más de seis meses), cuya curación no puede preveerse o no ocurrirá nunca.

Quizás sería más completo tener unos sistemas de codificación comunes con unos mismos criterios, que aúnen todos éstos conceptos con los aspectos bio-psico-sociales del paciente estandarizados.

lolasalva69
Dolores Carmen Salva Martin
07/04/2019 09:53
Creo que es fundamental el desarrollo de una terminología común para una atención de los pacientes crónicos, donde ellos sean el centro y no las patologías como venía siendo habitual , este paso es obligatorio para conseguir una asistencia integral y eficaz .