A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development.
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BACKGROUND: Patient complexity is often operationalized by counting multiple chronic conditions (MCC) without considering contextual factors that can affect patient risk for adverse outcomes. OBJECTIVE: Our objective was to develop a conceptual model of complexity addressing gaps identified in a review of published conceptual models. DATA SOURCES: We searched for English-language MEDLINE papers published between 1 January 2004 and 16 January 2014. Two reviewers independently evaluated abstracts and all authors contributed to the development of the conceptual model in an iterative process. RESULTS: From 1606 identified abstracts, six conceptual models were selected. One additional model was identified through reference review. Each model had strengths, but several constructs were not fully considered: 1) contextual factors; 2) dynamics of complexity; 3) patients' preferences; 4) acute health shocks; and 5) resilience. Our Cycle of Complexity model illustrates relationships between acute shocks and medical events, healthcare access and utilization, workload and capacity, and patient preferences in the context of interpersonal, organizational, and community factors. CONCLUSIONS/IMPLICATIONS: This model may inform studies on the etiology of and changes in complexity, the relationship between complexity and patient outcomes, and intervention development to improve modifiable elements of complex patients.
Published Version (Please cite this version)
Zullig, Leah L, Heather E Whitson, Susan N Hastings, Chris Beadles, Julia Kravchenko, Igor Akushevich and Matthew L Maciejewski (2016). A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development. J Gen Intern Med, 31(3). pp. 329–337. 10.1007/s11606-015-3512-2 Retrieved from https://hdl.handle.net/10161/14815.
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Leah L. Zullig, PhD, MPH is a health services researcher and an implementation scientist. She is a Professor in the Duke Department of Population Health Sciences and an investigator with the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham Veterans Affairs Health Care System. Dr. Zullig’s overarching research interests address three domains: improving cancer care delivery and quality; promoting cancer survivorship and chronic disease management; and improving medication adherence. Throughout these three area of foci Dr. Zullig uses an implementation science lens with the goal of providing equitable care for all by implementing evidence-based practices in a variety of health care environments. She has authored over 150 peer-reviewed publications.
Dr. Zullig completed her BS in Health Promotion, her MPH in Public Health Administration, and her PhD in Health Policy.
Areas of expertise: Implementation Science, Health Measurement, Health Policy, Health Behavior, Telehealth, and Health Services Research
Dr. Whitson's research is focused on improving care options and resilience for people with multiple chronic conditions. In particular, she has interest and expertise related to the link between age-related changes in the eye and brain (e.g., How does late-life vision loss impact the aging brain or cognitive outcomes? Is Alzheimer's disease associated with distinctive changes in the retina, and could such changes help diagnose Alzheimer's disease early in its course?). Dr. Whitson leads a collaborative Alzheimer's Disease initiative that brings together investigators from Duke University and the University of North Carolina (UNC) at Chapel Hill, with a bold vision to transform dementia research and care across Eastern North Carolina. Dr. Whitson is also interested in improving health services to better meet the needs of medically complex patients. Within the Duke Aging Center, she leads research efforts aimed at promoting resilience to late-life stressors (e.g., surgery, sensory loss, infection). She has developed a novel rehabilitation model for people with co-existing vision and cognitive deficits, and she is part of a inter-disciplinary team seeking to improve peri-operative outcomes for frail or at-risk seniors who must undergo surgery. As a co-leader of a national resilience collaborative, she seeks to better understand the biological and psychological factors that determine how well we "bounce back" after health stressors.
Matt Maciejewski, PhD is a Professor in the Department of Population Health Sciences. He is also a Senior Research Career Scientist and Director of the Non-randomized Design Lab in the Center of Innovation to Accelerate Discovery and Practice Transformation at the Durham VA Medical Center. Matt also holds Adjunct Professor appointments in the Schools of Public Health and Pharmacy at the University of North Carolina at Chapel Hill.
He has received funding from NIDDK, NIDA, CMS, AHRQ, VA HSR&D, and the RWJ Foundation to conduct evaluation of long-term clinical and economic outcomes of surgical interventions, behavioral interventions and Medicare program/policy changes on patients with obesity or cardiometabolic conditions. He is also interested in methods for addressing unobserved confounding in observational studies. Matt evaluated the first-ever population-based implementation of value-based insurance design and led the first-ever linkage of lab results and Medicare FFS claims. He has published over 250 papers in peer-reviewed journals such as JAMA, JAMA Internal Medicine, JAMA Surgery, Annals of Internal Medicine, Health Economics, Medical Care, Health Services Research, Journal of Clinical Epidemiology and Diabetes Care.
Areas of expertise: Health Services Research, Health Economics, Health Policy, Multimorbidity
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