What makes patients complex? Ask their primary care physicians

As Americans live longer with multiple medical conditions, managing their care is becoming increasingly challenging. Being able to define and measure patient complexity has important implications for how care is organized, how physicians and health care systems are paid, and how resources are allocated. In an article in the Dec. 20 Annals of Internal Medicine, a team of Massachusetts General Hospital (MGH) researchers report finding that primary care physicians define patient complexity using a broader range of factors – including mental health, social factors and financial issues – than do commonly used approaches based only on diagnoses and prior costs.

"Simply counting the number of co-morbid conditions does not really capture whether a patient is complex," explains Richard W. Grant, MD, MPH, the paper's lead author. "All primary care physicians can point to patients of theirs with very complicated medical histories who are relatively straightforward to manage, whereas other patients can be a real challenge despite relatively few medical diagnoses. Our results emphasize the importance of social and behavioral contexts that can create important barriers to delivering high-quality primary care."

The study enrolled 40 primary care physicians from 12 MGH-affiliated practices and community health centers. Participating physicians used a web-based tool to review a list of 120 of their own patients and indicated those who, in their view, were complex. For those complex patients, they were asked to indicate which of five domains – medical decision-making, coordinating care, mental health or substance abuse problems, health-related behaviors, and social or economic circumstances – were involved in that determination.

The authors found that primary care physicians designated about one-quarter of their patients as complex – with older, more experienced physicians and those working in community health centers reporting higher proportions of complex patients. Compared to non-complex patients, complex patients were older, more often women, and had more clinic visits to many different providers. Complex patients were also prescribed more medicines – including prescriptions for anti-psychotic medicines – were more likely to miss appointments, and were more likely to live in neighborhoods with lower income and educational levels. The authors then found that the results of physician assessment differed substantially from those of other common methods for assessing complexity.

"Managing complex patients requires greater clinician effort, increased health care resources, and substantial family and community support," says Grant, who recently joined the division of Research at Kaiser Permanente Northern California (http://www.dor.kaiser.org). "In order to redesign our health care systems to more effectively care for complex patients, we need a better handle on exactly who they are. By asking primary care physicians about their experiences with their own patients in a systematic and quantitative way, we were able to bring out the importance of social and behavioral factors, in addition to specific medical problems. This work may help guide efforts to redesign health care systems so that we can deliver high quality, cost-effective care tailored to individual patient needs."