Monday, 27 May 2019

Cumulative complexity and minimally disruptive medicine

The clinical model based exclusively on the diagnosis and treatment of chronic diseases is precipitating medicine to fail. Addressing complex realities from partial positions is, at least, unfortunate, and despite this evidence, health care systems continue to finance the fragmented provision of services. Mary Tinetti and Terri Fried warned us in 2004, in "The end of the disease era", that it should evolve towards a bio-psycho-social model, prioritizing the integral evaluation of each person, adjusting the therapeutic plans to each reality and offering integrated services. The analysis was timely except that the authors were wrong when they predicted that, the old model would end with the advent of the new century.

Cumulative complexity model

Going further, a group of researchers from the "Knowledge and Evaluation Research Unit" (KER Unit) led by Víctor Montori at Mayo Clinic, in order to offer a new conceptual framework for research and clinical work with complex patients, published in 2012 "Cumulative Complexity Model (CuCoM)". According to this model, if you want to obtain good results in health, it’s important that each patient’s natural capacity to manage their illnesses is not overwhelmed by the burden of treatment.
The ability of everyone to manage their illnesses

Everyone has their own way of dealing with diseases ("capacity" in the graph), which is determined by our cultural level, especially understanding of what affects us; the attitude that we have in life; the quality of our mental health, especially affected when depression or anxiety appears; the cognitive state; the presence of limiting symptoms such as insomnia, incontinence, fatigue or chronic pain; the functional level in the activities of daily life; family support; social roots and finances, taking into account that poverty is a disturbing element in many aspects of life and especially so with this.

The burden of treatment

Living with one or several complex diseases is usually a heavy burden that demands time and energy from patients and their families, as they have to follow recommendations that often clash with the established lifestyles: stop smoking, stop drinking alcohol, eat without salt, lose weight or have to exercise, to name but a few. On the other hand, there’s  a need to control parameters such as weight, blood glucose or blood pressure, in addition to having to follow treatments that are difficult to remember and often changing is a task that demands a lot of attention; in addition to having to cope with a full agenda of medical visits, nursing care, answers to evaluative scales and not forgetting  to have to go to different centres to undertake a lot of diagnostic tests, some of which require specific preparations.

The cycle of accumulation of complexity

Now imagine, following the graph, where the affected person doesn’t have enough capacity to face the burden of treatment. If this happens, the first thing that will suffer will be the follow-up of the recommendations (the adherence surveys warn that this is very frequent), and additionally the services will probably be used inappropriately. Therefore, the results will worsen and as a consequence increase the burden of the disease, which will reduce the functional capacity of the patient. Physicians, on the other hand, will redouble the treatment by inducing a cumulative escalation in complexity, without having instead assessed the root of the problem that is none other than the increasing imbalance between capacity and load.

The social extension of the cumulative complexity model

The same team of researchers in 2017 proposed an extension of the cumulative complexity model towards social aspects. It is, according to them, to reinforce the idea that both research and clinical practice, even those most adapted to complex patients, places too much emphasis on the individual capacity of people and ignores the great influence of the family and social environment. Let’s imagine that a patient with complex social and health needs that, despite everything, has a good balance between his capacity to handle the situation and the burdens imposed by the therapeutic plan, suddenly becomes widowed and also descend into poverty. it’s clear that if your care team doesn’t have the skills to adapt the action plan to the new scenario, the results will worsen and the complex accumulation cycle will be activated.

Minimally disruptive medicine, the challenge

The proposal byVictor Montori and collaborators to overcome the cumulative cycle of complexities is the practice of minimally disruptive medicine, a model of clinical work that, from the evaluation of the capacity of each patient, develops individually adjusted therapeutic plans. If you are interested in this I recommend reading "Assessing the burden of treatment", where the authors describe the two available scales to measure the loads of the treatments and encourage their widespread use in order to expand the horizons of minimally disruptive medicine and, at the same time, strengthen the validity of their evaluation instruments. They should also take note of "Minimally Disruptive Medicine: a pragmatically comprehensive model for delivering care to patients with multiple chronic conditions", an article where they will find a kit of practical instruments and a case argued from a formative perspective.

KER Unit proposes a useful theoretical model for clinical and social work with complex patients based on the bio-psycho-social vision of medicine, which surpasses the old (but still valid) model of organic vision of diseases. The integral evaluation of each ill person and the elaboration of therapeutic plans adjusted to their capacity and situation is the basis of minimally disruptive medicine, a model that will help them to finally deploy the clinical practice demanded by today's times.

Jordi Varela

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