Table 1
Distribution and characteristics of the Primary Care services that participated in the study.
| PRIMARY CARE CENTRE | POPULATION ≥14 YEARS OLD. REGISTERED* | SERVED* | %>75 YEARS OLD | MEDEA INDEX |
|---|---|---|---|---|
| NORD | 13,700 | 84.04% | 9.22% | 1.56 |
| CA N’ORIAC | 17,198 | 82.17% | 9.97% | 1.41 |
| CONCORDIA | 12,749 | 82.57% | 9.37% | 0.49 |
| Total | 43,647 |
[i] * Medically served, which are less than those registered.
Figure 1
Sampling framework for data collection.
Table 2
Chronicity Prevention and Care Programme (PPAC) criteria to determine complexity.
| COMPLEXITY CRITERIA | ANSWER |
|---|---|
| Patient-dependent criteria | |
| Multimorbidity (≥2 chronic diseases) | Yes/No/Don’t know |
| A single, severe chronic disease (including advanced frailty states) | Yes/No/Don’t know |
| A chronic progressive disease | Yes/No/Don’t know |
| High probability of undergoing decompensations with many symptoms and poor control | Yes/No/Don’t know |
| Patient with a variable, very dynamic evolution who needs continuous follow-up | Yes/No/Don’t know |
| High use of health services (emergency services, Primary care appointments) | Yes/No/Don’t know |
| Polypharmacy (≥5 medicines) and/or high cost of resources | Yes/No/Don’t know |
| Frail patients with functional loss, probability of acute deterioration (functional or cognitive) or new onset of geriatric syndromes | Yes/No/Don’t know |
| Professional-dependent criteria | |
| Need for multidisciplinary hospital management | Yes/No/Don’t know |
| Need to activate and manage access to different resources (often by priority routes) | Yes/No/Don’t know |
| Environment of special uncertainty in terms of decision-making or doubts in clinical management | Yes/No/Don’t know |
| Social complexity | |
| Patient with adverse psychosocial conditions | Yes/No/Don’t know |
| Patient whose management would benefit from integrated care strategies | Yes/No/Don’t know |
| Patient with relational problems | Yes/No/Don’t know |
| Patient with economic problems | Yes/No/Don’t know |
| Patient with loss of functional autonomy | Yes/No/Don’t know |
| Other specific criteria | |
| Patient with chronic neurological disease | Yes/No/Don’t know |
| Patient with severe mental disorder | Yes/No/Don’t know |
| Patient with dementia | Yes/No/Don’t know |
| Patient with intellectual disability | Yes/No/Don’t know |
| Elderly patient (≥75 years old) | Yes/No/Don’t know |
Table 3
Distribution of CCP patients in Primary Health Care centres according to gender, age (mean ± SD), risk of admission probability (mean ± SD) and GMA. In each of the centres, statistically significant differences were found between both genders in terms of age and risk of admission. Besides, statistically significant differences between centres were found in terms of the age and the risk of admission of the patients they served.
| PRIMARY HEALTH CARE CENTRE | MALE | FEMALE | TOTAL | GMA/n/% | |
|---|---|---|---|---|---|
| NORD | n (%) | 269 (15.5%) | 301 (17.3%) | 570 (32.8%) | GMA 1 0; 0% |
| Age (mean ± SD) | 70,57 ± 15.43 | 74.8 ± 14.11 | 72.81 ± 14.8 | GMA 2 36; 2.1% | |
| Risk of admission (mean ± SD) | 18.51 ± 13.59 | 13.58 ± 9.77 | 15.91 ± 11.98 | GMA 3 191; 11% | |
| GMA 4 343; 19.7% | |||||
| CA N’ORIAC | n (%) | 288 (16.6%) | 314 (18.1%) | 602 (34.7%) | GMA 1 5; 0.3% |
| Age (mean ± SD) | 75 ± 13.10 | 77.35 ± 13.57 | 76.23 ± 13.4 | GMA 2 42; 2.4% | |
| Risk of admission (mean ± SD) | 18.46 ± 11.9 | 14.13 ± 9.92 | 16.20 ± 11.13 | GMA 3 196; 11.3% | |
| GMA 4 359; 20.7% | |||||
| CONCORDIA | n (%) | 249 (14.3%) | 317 (18.2%) | 566 (32.5%) | GMA 1 4; 0.2% |
| Age (mean ± SD) | 75.28 ± 14.23 | 77.29 ± 14.57 | 76.4 ± 14.4 | GMA 2 41; 2.4% | |
| Risk of admission (mean ± SD) | 18.7 ± 12.03 | 14.96 ± 10.48 | 16.6 ± 11.33 | GMA 3 169; 9.7% | |
| GMA 4 352; 20.3% |
Table 4
Cluster characteristics. PPAC criteria: % of positive responses. The highest % in each variable is shown in bold.
| VARIABLE | CLUSTER 1 AMBULATORY LOW COST CCP | CLUSTER 2 PSYCHOSOCIAL CCP | CLUSTER 3 HIGH-NEED, HIGH-COST | P VALUE |
|---|---|---|---|---|
| Patient characteristics | ||||
| n (%) | 640 (36.8%) | 678 (39%) | 420 (24.2%) | |
| Age (mean ± SD) | 79.5 ± 11,6 | 68.7 ± 16.5 | 78.9 ± 9.5 | .000 |
| Risk of admission (%) (mean ± SD) | 16.2 ± 10,2 | 13 ± 10.4 | 21.4 ± 13 | .000 |
| Women (%) | 54.60 | 50.90 | 56.70 | .145 |
| Adjusted Morbidity Groups | ||||
| GMA 1 (%) | 0.5 | 0.9 | 0.0 | .000 |
| GMA 2 (%) | 5.2 | 12.1 | 1.0 | |
| GMA 3 (%) | 31.4 | 38.6 | 22.1 | |
| GMA 4 (%) | 63.0 | 48.4 | 76.9 | |
| Chronicity Care and Prevention Program (PPAC) criteria | ||||
| Multimorbidity | 96.6 | 94.1 | 99.3 | .000 |
| 1 chronic severe | 27.7 | 30.5 | 26.7 | .56 |
| 1 chronic progressive | 71.4 | 74.6 | 89.3 | .000 |
| Decompensation, many symptoms and poor control | 37.8 | 42.3 | 92.9 | .000 |
| Very dynamic evolution, continuous monitoring | 19.2 | 19.3 | 68.3 | .000 |
| High use (Emergency services, Primary care appointments) | 29.4 | 51.3 | 78.3 | .000 |
| Polipharmacy (≥5 medicines) | 92.2 | 84.2 | 98.6 | .000 |
| Frailty+, acute deterioration, geriatric syndromes | 58.3 | 53.7 | 93.6 | .000 |
| Age >75 | 73.6 | 43.2 | 73.1 | .000 |
| Neurological disease | 19.7 | 17.6 | 28.6 | .000 |
| Severe mental disorder | 4.4 | 16.5 | 8.8 | .000 |
| Dementia | 23.1 | 13.6 | 24 | .000 |
| Psychic impairment | 6.3 | 10 | 8.3 | .000 |
| Multidisciplinary hospital management | 27.2 | 42.6 | 70.7 | .000 |
| Priority routes | 6.7 | 17.3 | 64.5 | .000 |
| Uncertainty in decision-making, doubts in clinical management | 10.9 | 40 | 58.3 | .000 |
| Advanced chronic disease and limited-life prognosis | 15.3 | 14.6 | 33.8 | .000 |
| Adverse psychosocial conditions | 13.3 | 41.4 | 32.4 | .000 |
| Integration benefit | 30.1 | 50.6 | 72.4 | .000 |
| Relational problems | 11.1 | 28.6 | 24 | .000 |
| Economic problems | 0.6 | 16.1 | 8.8 | .000 |
| Loss of functional autonomy | 50.6 | 44.4 | 76 | .000 |
Figure 2
Prevalence of complexity by age and cluster.
Figure 3
(i) Physicians’ perspective as the gold standard vs. GMA 4. a = False Positive, TP = True Positive, b = False Negative; (ii) GMA 4 as the gold standard vs. physicians’ perspective. a = False Negative, TP = True Positive, b = False Positive.
In our data, 60.6% of CCPs are located in the GMA 4 stratum, 32% of CCPs are located in the GMA3 stratum and 7.4% of them are located in the GMA 2 stratum.
Table 5
PPAC social criteria. % of Unknown responses. The highest % in each variable is shown in bold.
| VARIABLE | AMBULATORY LOW COST CCP CLUSTER | PSYCHOSOCIAL CCP CLUSTER | HIGH-NEED, HIGH-COST CLUSTER | P VALUE |
|---|---|---|---|---|
| Adverse psychosocial conditions | 0.6 | 51.2 | 2.1 | .000 |
| Integration benefit | 5.6 | 39.8 | 1.7 | .000 |
| Relational problems | 1.9 | 54.6 | 6.2 | .000 |
| Economic problems | 13.4 | 75.4 | 24.5 | .000 |
| Loss of functional autonomy | 1.3 | 9.4 | 1.4 | .000 |
Table 6
A holistic approach to care that helps CCPs access the right services. +: Priority for patients with complex needs.
| AMBULATORY LOW COST CHRONIC COMPLEX PATIENTS CLUSTER | PSYCHOSOCIAL CHRONIC COMPLEX PATIENTS CLUSTER | HIGH-NEED, HIGH-COST CLUSTER | |
|---|---|---|---|
| Preventive approach | ++ | +++ | + |
| Palliative approach | + | + | +++ |
| Self-care | +++ | ++ | + |
| Collaborative health care | + | +++ | +++ |
| Integrated care (social) | + | +++ | +++ |