Polypathology, an emerging phenomenon and a challenge for healthcare systems

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Polypathology" "titulo" => "Polypathology, an emerging phenomenon and a challenge for healthcare systems" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "229" "paginaFinal" => "237" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Román, A. Ruiz-Cantero" "autores" => array:2 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Román" "email" => array:1 [ 0 => "roman_pil@gva.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Ruiz-Cantero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital General de Requena, Requena, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna. Hospital de la Serranía de Ronda, Ronda, Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La pluripatología, un fenómeno emergente y un reto para los sistemas sanitarios" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1351 "Ancho" => 1500 "Tamanyo" => 100128 ] ] "descripcion" => array:1 [ "en" => "Number of medical errors according to the number of specialists who treated a patient. Abbreviations: AUS, Australia; CAN, Canada; FR, France; GER, Germany; NL, The Netherlands; NZ, New Zealand; UK, United Kingdom; US, United States. Own preparation. Modified from the 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.<a class="elsevierStyleCrossRef" href="#bib0360">21</a>" ] ] ] "textoCompleto" => "BackgroundUntil a few decades ago, most of the population died before reaching middle age, although there have always been exceptional cases of long-lived individuals in all societies. What was exceptional before is now standard in developed countries thanks to better living conditions and scientific advances that have managed to cure numerous previously fatal diseases. The worldwide aging of the population is a considerable societal achievement; however, it now represents a challenge because of the significant societal, healthcare, political and financial changes caused by aging.The success in treating numerous acute diseases has led to an increase in diseases for which there is no available treatment: chronic diseases, defined by the World Health Organization (WHO) as long-acting, generally noncommunicable and slow progression diseases. These noncommunicable chronic diseases are currently the leading cause of death worldwide. Many of these diseases share the same risk factors and are related to pronounced lifestyle changes (e.g., tobacco consumption, physical inactivity, alcohol abuse and unhealthy diets).<a class="elsevierStyleCrossRef" href="#bib0260">1</a>The 4 main types of chronic diseases are cardiovascular disease, cancer, chronic respiratory disease and diabetes. These diseases already disproportionately affect low-income and medium-income countries where almost 75% of the 28 million annually recorded deaths are due to these diseases. These diseases occur in all age groups and regions and are usually associated with the oldest age groups. However, the evidence shows that more than 16 million of the deaths attributed to these diseases occur in individuals younger than 70 years and that 82% of these premature deaths occur in low-income and medium-income countries.<a class="elsevierStyleCrossRef" href="#bib0260">1</a> Children, adults and the elderly are all vulnerable to risk factors that promote chronic diseases. According to Margaret Chan, director general of the World Health Organization (WHO), chronic diseases are a slow-motion catastrophe. Although their development is slow, the lifestyles that feed this epidemic are propagating at an impressive speed.<a class="elsevierStyleCrossRef" href="#bib0265">2</a>The aging of the population is a recent fact in Spain. Until the 1950s, individuals older than 65 years represented 7% of the population.<a class="elsevierStyleCrossRefs" href="#bib0270">3,4</a> In the past 40 years, this percentage has grown uninterrupted and will represent 25% by 2025. Although Spain has achieved one of longest life expectancies in the world, especially for women, there are other countries in our community that exceed Spain's life expectancy with good health.<a class="elsevierStyleCrossRefs" href="#bib0270">3–5</a> Good health is one of the pillars of an economically and socially prosperous society, and achieving life-years free of disability must be one of our healthcare goals.The increase in age directly affects individuals with chronic diseases, due to the addition and accumulation of these diseases over the course of life. In advanced age, there is a propensity to inflammation, mitochondrial dysfunction and epigenetic disorders that lead to a loss of functional reserve in various organs and systems (neurological, cardiovascular, musculoskeletal, respiratory, renal-urological, immune, etc.).<a class="elsevierStyleCrossRef" href="#bib0285">6</a> This loss, rooted in the biological determinants of the aging process, leads to greater susceptibility to chronic diseases such as dementia, ischemic heart disease, heart failure, osteoporosis, osteoarthritis, respiratory diseases and chronic renal disease. There is also a progressive development of functional impairment, which causes a loss of quality of life, increased disability, drug interactions, multiple hospitalizations and increased mortality.The concepts of multimorbidity and polypathologyThe most common chronic condition in adults is the coexistence of numerous chronic diseases.<a class="elsevierStyleCrossRef" href="#bib0290">7</a> Several terms have been designated to define this condition, depending on the language used: “multimorbidity” in English and “pluripatología” (polypathology) in Spanish. In any case, this type of patient with multiple chronic diseases is not the exception but rather the rule.<a class="elsevierStyleCrossRef" href="#bib0295">8</a> It would therefore be appropriate that the condition of “multiple chronic conditions” be included as another diagnosis in the International Classification of Diseases.<a class="elsevierStyleCrossRef" href="#bib0290">7</a>The term “multimorbidity” was first coined in 1976 by Brandlmeier.<a class="elsevierStyleCrossRef" href="#bib0300">9</a> In a 2008 report, the WHO defined the term as the simultaneous presence of 2 or more chronic diseases.<a class="elsevierStyleCrossRef" href="#bib0305">10</a> In 2015, the term was translated to 10 European languages for use in family medicine, defining the term “multimorbidity” in Spanish as “any combination of a chronic disease with at least one other disease (acute or chronic) or a biopsychosocial factor (associated or not) or a risk factor”.<a class="elsevierStyleCrossRef" href="#bib0310">11</a> “Multimorbidity” can modify health results and lead to greater disability, poorer quality of life and frailty.<a class="elsevierStyleCrossRef" href="#bib0310">11</a>In September 2016, the National Institute for Health and Care Excellence defined the term “multimorbidity” as the presence of 2 or more long-standing health conditions, which can include the following: defined physical and mental health disorders, such as diabetes and schizophrenia; complex conditions such as frailty and chronic pain; and sensory deficits such as reduced visual or auditory acuity.<a class="elsevierStyleCrossRef" href="#bib0315">12</a> In short, 2 or more long-term physical health conditions or a mental disease and another physical disease.The US has lately been using the expression “patients with high needs and high costs” to refer to individuals with 3 or more chronic diseases and functional dependence.<a class="elsevierStyleCrossRefs" href="#bib0320">13,14</a> The concept of “polypathology” (or that of multimorbidity) can be understood, from a strict perspective, as the coexistence of 2 or more chronic diseases with no other requirements. In 2002, this concept was defined differently in Andalusia as follows: the condition in which an individual experiences 2 or more diseases among 8 clinical categories included in a list of common defined chronic diseases with certain severity or complexity (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0330">15,16</a> In other words, to meet this definition, a person needs to have several chronic diseases; however, not all individuals with several chronic diseases meet the criteria for a polypathological patient.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Moreover, the concept of “complex chronic patient” has been coined to refer to patients who have 2 or more chronic progressive diseases, with frequent exacerbations or complex societal situations, which cause an impairment in autonomy and functional capacity and result in frequent use of healthcare services.<a class="elsevierStyleCrossRef" href="#bib0340">17</a>The Spanish Ministry of Health, Social Services and Equality, in its strategy for attention on chronicity in the Spanish National Health System, textually defines<a class="elsevierStyleCrossRef" href="#bib0345">18</a> a) “polypathology” if there are 2 or more coexisting chronic diseases; b) “comorbidity”, when any disease is associated with a main nosological entity, both acute and chronic, modulating its diagnosis and treatment; and c) “complex chronic patient” as an individual who presents greater complexity in their management by having changing needs that require continuous reassessments and requires the orderly use of various healthcare levels and, in some cases, healthcare and social services.In short, there is no consensus on the terms or concepts when referring to this type of patient.Magnitude of the problem. consequencesThe number of chronic diseases present in a person increases progressively with age, such that individuals 80 years or older have a mean of over 4 diseases.<a class="elsevierStyleCrossRef" href="#bib0350">19</a> In a study conducted in Scotland, the number of chronic diseases was greater than 8 among individuals older than 85 years.<a class="elsevierStyleCrossRef" href="#bib0355">20</a>The presence of several chronic diseases in an individual is very common. A document by the Organization for Economic Cooperation and Development listed a number of examples: heart failure is the only entity in only 3% of patients, stroke in 6%, atrial fibrillation in 7%, ischemic heart disease in 9%, diabetes in 14%, chronic obstructive pulmonary disease in 18% and dementia in 5%. By contrast, individuals with heart failure, stroke, diabetes and dementia who have 3 or more chronic diseases represent 74%, 62%, 47% and 64%, respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0350">19</a> It can therefore be emphatically stated that the most common chronic situation is the presence of several chronic diseases in a single individual. This report highlighted that the number of chronic diseases increases with age and inversely with the individual's socioeconomic status. As the number of these diseases increases, the degree of polypharmacy and medical errors increases, especially if the care is provided by various physicians or specialists (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0360">21</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>In a systematic review, the prevalence of multimorbidity in elderly individuals varied between 55% and 98%.<a class="elsevierStyleCrossRef" href="#bib0365">22</a> Advanced age, female sex and low socioeconomic level were the factors associated with multimorbidity, whose main consequences were disability, functional impairment, poor quality of life and high healthcare costs.In various studies conducted at the state and regional level, the estimated prevalence of polypathological patients was 1.38% of the general population and 5% of those older than 65 years.<a class="elsevierStyleCrossRefs" href="#bib0345">18,23</a> Depending on their characteristics, it is estimated that between 38% and 60% of patients hospitalized In internal medicine departments have multiple diseases.<a class="elsevierStyleCrossRef" href="#bib0375">24</a> In recent years, the prevalence of polypathology has increased dramatically in orthopedic surgery and trauma units (due mainly to hip fractures in the elderly) and in urology units due to prostate disease.The standard profile of a hospitalized polypathological patient is a 78-year-old individual, with a mean of 2.4 diseases in the clinical categories of the Andalusian classification (69% with 2 categories; 31% with ≥3 categories), predominantly cardiovascular, respiratory, neurological or renal type.<a class="elsevierStyleCrossRef" href="#bib0380">25</a> These are also polymedicated patients, with an average of 8 drugs, with greater functional dependence at hospital discharge and at 1 year (decrease in Barthel index of 11–20 points)<a class="elsevierStyleCrossRefs" href="#bib0380">25,26</a> and greater mortality compared with nonpolypathological patients.<a class="elsevierStyleCrossRef" href="#bib0390">27</a>Impact of polypathology/multimorbidity on healthcare managementFor many years, public health organizations worldwide have stated the urgent need to change the way in which we address health promotion and disease care. The evidence that social determinants of health (housing, education, food and hygiene) are the main risk factors for contracting disease, the overwhelming logic of “prevention is better than cure” and the “tsunami” of chronic diseases have resulted in a multitude of warnings and recommendations on the risk of financial ruin run by healthcare systems and the states themselves. Since 2000, the WHO has developed strategies and action plans to prevent and control chronic diseases.<a class="elsevierStyleCrossRef" href="#bib0395">28</a>In 2011, the United Nations, in a high-level general assembly in which the heads of member states met, put forth the “Declaration on the Prevention and Control of Non-communicable Diseases”.<a class="elsevierStyleCrossRef" href="#bib0400">29</a> All member states agreed that chronic diseases undermine social and economic development worldwide, are a threat for the economies of many states, promote poverty, increase inequalities among countries and populations and represent a threat to achieving the “Millennium Development Goals”, placing this topic among the priorities of political agendas. In their political declaration, the UN established the global objective “25 by 25”; i.e., to reduce by 25% the premature mortality associated with chronic diseases by 2025. The declaration also urged the inclusion of prevention for these diseases as a priority in all national and international programs.In 2006, the European Union prepared a “European Strategy for the Prevention and Control of Noncommunicable Diseases”.<a class="elsevierStyleCrossRef" href="#bib0405">30</a> In December 2010, The Council of the European Union adopted a number of conclusions for the development of action plans to decrease the impact of chronic diseases in Europe. Chronic diseases were considered a priority for the present and future of research and the design of intervention programs. The member states and the European Commission were requested to urgently implement specific and coordinated measures to confront this problem.<a class="elsevierStyleCrossRef" href="#bib0410">31</a> More specifically, the Council invited the member states to implement patient-focused policies to promote health, primary and secondary prevention and the treatment and care of chronic diseases, in cooperation with the responsible politicians and, especially, with the patient associations. The Council also invited the states to identify and exchange information on best practices in this setting and assess the incidence, prevalence and impact of this collection of diseases. A project funded by the European Union was created to care for individuals with multiple diseases (Improving care for people with multiple chronic conditions in Europe, ICARE4EU),<a class="elsevierStyleCrossRef" href="#bib0415">32</a> with the objective of assessing and promoting innovation and improvement in the care of patients with several chronic diseases.All the recommendations of international organizations advocate the need to facilitate access for all citizens to healthcare and to control risk factors, creating environments that promote health and health prevention and that prevent inequality.<a class="elsevierStyleCrossRef" href="#bib0420">33</a> Universal coverage is the only measure that, by itself, can profoundly improve social equity.<a class="elsevierStyleCrossRef" href="#bib0425">34</a> Additionally, all the recommendations urge changes in the way health care is provided. Due to the fact that communicable diseases have been the predominant type until the 1950s, care has traditionally been based on the disease and generally provided reactively by hospital specialists, with their actions based on the symptoms and focused on treatment. Although the pattern of diseases and the type of patient have changed, the healthcare systems continue acting in the same manner as in the past. Patients with several diseases are treated by several specialists who take care of the acute episode and the organ for which they are exclusively responsible. The specialists do not interrelate and do not cover the individual's biopsychosocial needs. Thus, examinations and treatments are unnecessarily multiplied, with the subsequent increase in their adverse effects and the prescription cascade to solve them. There is no coordinated and proactive action to prevent decompensations, and patients are admitted and readmitted over and over.The new focus of the healthcare model should be based on the “Comprehensive Care Model”<a class="elsevierStyleCrossRef" href="#bib0430">35</a>: a) focused on the individual and not on the disease, b) based in primary care and not in the hospital, c) focused on the needs of the population and not on those of the individual patient, d) organized for proactive and planned care, not reactive in the face of symptoms and e) focused on promotion and prevention, not treatment.Care must be integrated across time, places and health problems. The healthcare team members must collaborate with each other and with the patients and their relatives to achieve the treatment objectives. The implemented plans and strategies should be focused on the patient's needs, values and preferences. Collectively, health professionals must be able to provide a complete range of healthcare services, from prevention and rehabilitation to end-of-life care. Thus, integrated healthcare models that go beyond specific diseases and that place the individual as the main objective provide a viable solution for introducing efficient and effective care. Several specific recommendations have been developed in our setting for this patient group, both by healthcare administrations and scientific societies (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRefs" href="#bib0330">15,36–39</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Challenges in healthcare systemsPolypathology/multimorbidity is much more than the sum of the individual diseases, given that it adopts complex disease patterns that require diagnostic and therapeutic approaches that are substantially different from traditional practices focused on a single disease. Strengthening primary care and improving coordination and integration between primary care and hospital care and the health and social care would improve the intervention for individuals with polypathology. Healthcare systems face various challenges in promoting this change, challenges that are discussed below.ResearchWe need to generate quality measures for the care of individuals with multiple chronic diseases, focused on the performance of the healthcare system for individuals with more needs. Most of the current registries are directed toward individuals with specific diseases. The development of specific indicators for individuals with multiple diseases could help measure efficiency and compare results between various systems, departments and healthcare models.Clinical practice guidelinesThe current guidelines provide relevant recommendations on specific diseases. Guidelines need to be prepared for patients with several diseases that are usually associated (clusters of diseases)<a class="elsevierStyleCrossRef" href="#bib0455">40</a> typically with a significant burden of therapeutic compliance (lifestyle, complex treatments, visits to various practitioners, etc.). The guidelines need to also consider the patient's prognosis and recommendations in the various stages over the course of the patient's life cycle.Information systemsInformation systems need to be improved to achieve integration of all the patient's data, which should be accessible to any healthcare or social professional and to the patients themselves. These information systems should also facilitate the exploitation of results so that the organization of the various healthcare systems can be compared, opening new lines of research.Communication technologyNew technology can improve coordination among the various healthcare settings and with the patients themselves. Online health technologies offer a promising solution for providing better care and support for individuals (and their caregivers) who have multiple diseases and complex care needs. These technologies can include electronic medical records, telemonitoring systems, web portals and mobile health technologies (“mHealth”), which help exchange information among healthcare providers, patients and their families. There are various experiences, such as in Ontario (Canada), Scotland and Kaiser Permanente in Colorado (US) where electronic health tools have been adopted for individuals with multimorbidity and complex care needs.<a class="elsevierStyleCrossRef" href="#bib0460">41</a>Healthy agingThe unprecedented demographic change is revealing the shortcomings of the healthcare and social systems. For 2050, the WHO predicts that the number of people older than 60 years will double, that more than 1 in every 5 individuals will be older than 60 years and that 80% will live in countries with medium to low incomes.<a class="elsevierStyleCrossRef" href="#bib0465">42</a>The elderly are not all equal; some need permanent assistance for basic activities of life while others, conversely, will maintain a good functional level. Individual factors influence this condition, such as age-related changes, behavior, genetics and diseases, as do environmental factors, such as housing, healthcare devices, social facilities and transport. A change is therefore needed in how we see aging and the elderly, creating adapted environments, suiting the healthcare systems to their needs and establishing long-term care systems. We will thus achieve healthy aging, which consists of being able to do those things that we value, for as long as possible, ensuring an appropriate retirement through the pension system.Policies should therefore be established with sufficient potential to mitigate the demographic changes in society and help elderly individuals continue as active and productive citizens, either through flexible work, gradual retirement and ongoing learning; in short, as volunteers or caregivers. Investment in this field will be highly rewarding for society.<a class="elsevierStyleCrossRef" href="#bib0465">42</a>Health promotion and disease preventionThe social determinants of health are the socioeconomic, political, cultural and environmental conditions in which individuals live and grow. These determinants create risk factors that in turn promote the presence of chronic diseases.<a class="elsevierStyleCrossRef" href="#bib0470">43</a>There are many ways to promote and preserve health, some of which are found at the border of the competencies of the healthcare sector. The circumstances in which individuals grow, work and age influence in considerable measure the form in which individuals live and die. Education, housing, diet and employment all affect health. Reducing inequalities in these aspects will in turn decrease the inequalities resulted from the acquisition of diseases and in the access to healthcare.Healthcare systems should promote Antonovsky's “salutogenic model”,<a class="elsevierStyleCrossRef" href="#bib0475">44</a> i.e., those individual or group factors that promote the creation of health; resilience or the capacity to resist and adapt<a class="elsevierStyleCrossRef" href="#bib0480">45</a> and health asset maps. A health asset is any factor or resource that strengthens the ability of individuals, groups or populations to maintain or improve their health and wellbeing. These assets can act in the individual, family or community as protective elements to counter stressful conditions.<a class="elsevierStyleCrossRef" href="#bib0485">46</a>Integration of healthcare and social servicesThe method for integrating healthcare and social services represents a significant challenge for most countries. Individuals with multiple chronic diseases are more predisposed to disability and therefore need assistance in their daily activities. Traditionally, this type of social care has not been a part of healthcare itself, which multiplies the need for resources and services. Greater mesointegration results in better health results at lower costs, as has been shown by the impact of the US Program for All-Inclusive Care for the Elderly (PACE)<a class="elsevierStyleCrossRef" href="#bib0490">47</a> and the Canadian System of Integrated Services for Aged Persons (SIPA).<a class="elsevierStyleCrossRef" href="#bib0495">48</a> Legislation was recently passed in Scotland on the integration of healthcare and social services.<a class="elsevierStyleCrossRef" href="#bib0500">49</a> The Spanish Ministry of Health has established the basis for social and healthcare coordination.<a class="elsevierStyleCrossRef" href="#bib0505">50</a>Funding and universal coverageThe WHO, in its report “Health Systems Financing. The path to universal coverage”,<a class="elsevierStyleCrossRef" href="#bib0510">51</a> indicated that 20–40% of healthcare expenditures are lost due to inefficiencies in the system itself. Initiatives were proposed to achieve proper financing: 1) increase the efficiency in revenue collection, preventing evasion and inefficient collection, thereby increasing the funds for providing services; 2) re-establish the priorities of state budgets given that governments often give relatively low importance to health care when creating budgets; 3) provide innovative financing: with increased taxes on foreign exchange transactions, solidarity taxes on a variety of products and services, taxes on products that are harmful for health such as tobacco, alcohol, sugary drinks and food with high salt content or trans-fatty acids. These taxes will thereby decrease the consumption of unhealthy products, promoting health and generating revenue to devote to healthcare; and 4) provide development assistance for healthcare in global solidarity for low-income countries. If countries immediately meet their current international commitments, external financing for health for low-income countries would more than double immediately.Reducing unnecessary expenditures in drug products and the more appropriate use of these drugs could save the system up to 5% of the total healthcare expenditure. To increase the efficiency of the system, we need to get the most out of healthcare technologies and services, improve hospital efficiency, reduce medical errors, critically assess the necessary healthcare services and eliminate unnecessary expenditures.ProfessionalsA focus on public health promotion needs to be one of the fundamental values of healthcare practitioners. Investments should be directed toward developing methodologies for integration that favor a general approach and not a subspecialized and fragmented approach to health problems. Instruments need to be developed in relation to the health results of patient groups (e.g., those who require home care, who are institutionalized, who have many needs and entail high costs), which are more useful than those related to individual diseases.Healthcare practitioners have not followed the changes in their patients, the patients’ needs and their health problems. It is important to include multimorbidity/polypathology in medical education, as well as the necessary skills for improving the care for this type of patient. Healthcare practitioners need to be trained in a) the shared decision-making process; b) in providing value to the patient, avoiding overdiagnosis and overtreatment, including the use of preventive drugs in individuals with limited life expectancy; c) the training of teams; d) helping patients and caregivers to acquire greater responsibility for their health; e) preventing disability; and f) end-of-life care.Conflict of interestsThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres834097" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec830142" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres834096" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec830143" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "The concepts of multimorbidity and polypathology" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Magnitude of the problem. consequences" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Impact of polypathology/multimorbidity on healthcare management" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Challenges in healthcare systems" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Research" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical practice guidelines" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Information systems" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Communication technology" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Healthy aging" ] 5 => array:2 [ "identificador" => "sec0055" "titulo" => "Health promotion and disease prevention" ] 6 => array:2 [ "identificador" => "sec0060" "titulo" => "Integration of healthcare and social services" ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Funding and universal coverage" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Professionals" ] ] ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-20" "fechaAceptado" => "2017-01-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec830142" "palabras" => array:5 [ 0 => "Polypathology" 1 => "Multimorbidity" 2 => "Challenges of healthcare systems" 3 => "Aging" 4 => "Chronic diseases" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec830143" "palabras" => array:5 [ 0 => "Pluripatología" 1 => "Multimorbilidad" 2 => "Retos de los sistemas sanitarios" 3 => "Envejecimiento" 4 => "Enfermedades crónicas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Improvements in living conditions and scientific advances have led to an unprecedented demographic change. The curing of numerous acute diseases and the growing adoption of unhealthy lifestyles have caused a pandemic of cumulative chronic diseases that constitute the leading cause of death worldwide. Currently, the most common situation is the coexistence of multiple chronic diseases (or polypathology). This situation undermines socio-economic development and increases inequality. This results in an overriding need to change the way in which health and disease are addressed. Healthcare systems are not prepared to meet the needs of complex polypathological patients. In this article, we summarize the challenges facing healthcare systems and states, as well as the main recommendations from the organizations responsible for healthcare." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La mejoría de las condiciones de vida y los avances científicos han propiciado un cambio demográfico sin precedentes. La curación de muchas enfermedades agudas y la adopción creciente de estilos de vida no saludables han provocado una pandemia de enfermedades crónicas acumulativas que constituyen la primera causa de mortalidad mundial. Lo más frecuente, actualmente, es la coexistencia de múltiples enfermedades crónicas o pluripatología. Esta situación socava el desarrollo socioeconómico y aumenta las desigualdades. Ello condiciona una necesidad imperiosa de cambiar el modo de abordar la salud y la enfermedad. Los sistemas sanitarios no están preparados para satisfacer las necesidades de los pacientes pluripatológicos complejos. En el presente artículo se resumen los desafíos a los que se enfrentan los sistemas sanitarios y los propios estados, así como las principales recomendaciones de los organismos responsables de la salud de las personas." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Román P, Ruiz-Cantero A. La pluripatología, un fenómeno emergente y un reto para los sistemas sanitarios. Rev Clin Esp. 2017;217:229–237." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 993 "Ancho" => 1526 "Tamanyo" => 105226 ] ] "descripcion" => array:1 [ "en" => "Percentage of patients with several diseases. Abbreviations: AF, atrial fibrillation; AHT, arterial hypertension; COPD, chronic obstructive pulmonary disease; dis, diseases; HF, heart failure; IHD, ischemic heart disease. Own preparation. Modified from Bruce Guthrie, Sally Wyke, Jane Gunn, Marjan van den Akker and Stewart Mercer by OECD.<a class="elsevierStyleCrossRef" href="#bib0350">19</a>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1351 "Ancho" => 1500 "Tamanyo" => 100128 ] ] "descripcion" => array:1 [ "en" => "Number of medical errors according to the number of specialists who treated a patient. Abbreviations: AUS, Australia; CAN, Canada; FR, France; GER, Germany; NL, The Netherlands; NZ, New Zealand; UK, United Kingdom; US, United States. Own preparation. Modified from the 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.<a class="elsevierStyleCrossRef" href="#bib0360">21</a>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A.1. Heart failure that in a clinically stable state has been in NYHA class ii<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> (symptoms with regular physical activity) A.2. Ischemic heart disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">B.1. Vasculitis and systemic autoimmune diseases B.2. Chronic kidney disease defined by a glomerular filtration rate<60mL/m or proteinuria<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a>, maintained for 3 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C.1. Chronic respiratory disease that in a clinically stable state has occurred with: dyspnea grade ii of the MRC scale<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> (dyspnea at normal pace on a level surface) or FEV1<65%, or Sat O2≤90% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category D \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D.1. Chronic inflammatory bowel disease D.2. Chronic liver disease with hepatocellular insufficiency<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> or portal hypertension<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> data \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">E.1. Stroke E.2. Neurological disease with permanent motor deficit that restricts basic activities of daily life (Barthel index<60) E.3. Neurological disease with permanent cognitive impairment, at least moderate (Pfeiffer with 5 or more errors) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category F \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F.1. Symptomatic peripheral arteriopathy F.2. Diabetes mellitus with proliferative retinopathy or symptomatic neuropathy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category G \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">G.1. Chronic anemia due to gastrointestinal losses or acquired blood disorder not responsive to curative treatment, which presents Hb levels<10mg/dL in 2 measurements separated by more than 3 months G.2. Solid or hematologically neoplasm not responsive to treatment with intent to heal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category H \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H.1. Chronic osteoarticular disease that by itself restricts basic activities of daily life (Barthel index<60) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of inclusion categories: 2–3–4–5–6–7–8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1406609.png" ] ] ] "notaPie" => array:5 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Slight restriction of physical activity. Normal physical activity causes dyspnea, angina, fatigue or palpitations." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Albumin/creatinine index >300mg/g, microalbuminuria >3mg/dL in urine sample or albumin >300mg/day in 24h urine or >200μg/min." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Unable to maintain the pace of another individual of the same age (walking on a level surface) due to respiratory difficulty or having to stop and rest when walking on a level surface at their own pace." ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "INR>1.7; albumin<3.5g/dL; bilirubin>2mg/dL." ] 4 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "e" "nota" => "Defined as the presence of clinical, laboratory, ultrasound or endoscopic data. Source: Care of polypathological patients.<a class="elsevierStyleCrossRef" href="#bib0330">15</a>" ] ] ] "descripcion" => array:1 [ "en" => "Definition of polypathological patient." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Organization \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Title \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ministry of Health and Social Policy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Polypathological patient unit. Standards and Recommendations<a class="elsevierStyleCrossRef" href="#bib0435">36</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Government of Andalusia Ministry of Health \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2002 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Care of polypathological patients<a class="elsevierStyleCrossRef" href="#bib0330">15</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Government of Andalusia Ministry of Health \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Care of polypathological patients. 2nd Edition<a class="elsevierStyleCrossRef" href="#bib0335">16</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Government of Navarra. Department of Health \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Navarra strategy for the comprehensive care of chronically ill and polypathological patients<a class="elsevierStyleCrossRef" href="#bib0440">37</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spanish Society of Internal Medicine (SEMI) Spanish Society of Family and Community Medicine (SEMFYC). Federation of Associations of Community Nursing and Primary Care (FAECAP). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Development of clinical practice guidelines for patients with comorbidity and polypathology.<a class="elsevierStyleCrossRef" href="#bib0445">38</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spanish Society of Internal Medicine (SEMI) Spanish Society of Family and Community Medicine (SEMFYC). Federation of Associations of Community Nursing and Primary Care (FAECAP). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Healthcare process for polypathological patients with complex chronic diseases<a class="elsevierStyleCrossRef" href="#bib0340">17</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Government of Castilla y León Ministry of Health Regional Health Management of Castilla y León \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Healthcare process for complex chronic polypathological patients<a class="elsevierStyleCrossRef" href="#bib0450">39</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1406608.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for managing polypathological patients." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:51 [ 0 => array:3 [ "identificador" => "bib0260" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Organización Mundial de la Salud. 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Symposium. Polypathology

Polypathology, an emerging phenomenon and a challenge for healthcare systems

La pluripatología, un fenómeno emergente y un reto para los sistemas sanitarios

P. Romána,

Corresponding author

roman_pil@gva.es

Corresponding author.

, A. Ruiz-Canterob

a Servicio de Medicina Interna, Hospital General de Requena, Requena, Valencia, Spain

b Servicio de Medicina Interna. Hospital de la Serranía de Ronda, Ronda, Málaga, Spain

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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Number of medical errors according to the number of specialists who treated a patient&#46; Abbreviations&#58; AUS&#44; Australia&#59; CAN&#44; Canada&#59; FR&#44; France&#59; GER&#44; Germany&#59; NL&#44; The Netherlands&#59; NZ&#44; New Zealand&#59; UK&#44; United Kingdom&#59; US&#44; United States&#46;</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Own preparation&#46; Modified from the 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">21</span></a></p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Until a few decades ago&#44; most of the population died before reaching middle age&#44; although there have always been exceptional cases of long-lived individuals in all societies&#46; What was exceptional before is now standard in developed countries thanks to better living conditions and scientific advances that have managed to cure numerous previously fatal diseases&#46; The worldwide aging of the population is a considerable societal achievement&#59; however&#44; it now represents a challenge because of the significant societal&#44; healthcare&#44; political and financial changes caused by aging&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The success in treating numerous acute diseases has led to an increase in diseases for which there is no available treatment&#58; chronic diseases&#44; defined by the World Health Organization &#40;WHO&#41; as long-acting&#44; generally noncommunicable and slow progression diseases&#46; These noncommunicable chronic diseases are currently the leading cause of death worldwide&#46; Many of these diseases share the same risk factors and are related to pronounced lifestyle changes &#40;e&#46;g&#46;&#44; tobacco consumption&#44; physical inactivity&#44; alcohol abuse and unhealthy diets&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The 4 main types of chronic diseases are cardiovascular disease&#44; cancer&#44; chronic respiratory disease and diabetes&#46; These diseases already disproportionately affect low-income and medium-income countries where almost 75&#37; of the 28 million annually recorded deaths are due to these diseases&#46; These diseases occur in all age groups and regions and are usually associated with the oldest age groups&#46; However&#44; the evidence shows that more than 16 million of the deaths attributed to these diseases occur in individuals younger than 70 years and that 82&#37; of these premature deaths occur in low-income and medium-income countries&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">1</span></a> Children&#44; adults and the elderly are all vulnerable to risk factors that promote chronic diseases&#46; According to Margaret Chan&#44; director general of the World Health Organization &#40;WHO&#41;&#44; chronic diseases are a slow-motion catastrophe&#46; Although their development is slow&#44; the lifestyles that feed this epidemic are propagating at an impressive speed&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aging of the population is a recent fact in Spain&#46; Until the 1950s&#44; individuals older than 65 years represented 7&#37; of the population&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">3&#44;4</span></a> In the past 40 years&#44; this percentage has grown uninterrupted and will represent 25&#37; by 2025&#46; Although Spain has achieved one of longest life expectancies in the world&#44; especially for women&#44; there are other countries in our community that exceed Spain&#39;s life expectancy with good health&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">3&#8211;5</span></a> Good health is one of the pillars of an economically and socially prosperous society&#44; and achieving life-years free of disability must be one of our healthcare goals&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The increase in age directly affects individuals with chronic diseases&#44; due to the addition and accumulation of these diseases over the course of life&#46; In advanced age&#44; there is a propensity to inflammation&#44; mitochondrial dysfunction and epigenetic disorders that lead to a loss of functional reserve in various organs and systems &#40;neurological&#44; cardiovascular&#44; musculoskeletal&#44; respiratory&#44; renal-urological&#44; immune&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">6</span></a> This loss&#44; rooted in the biological determinants of the aging process&#44; leads to greater susceptibility to chronic diseases such as dementia&#44; ischemic heart disease&#44; heart failure&#44; osteoporosis&#44; osteoarthritis&#44; respiratory diseases and chronic renal disease&#46; There is also a progressive development of functional impairment&#44; which causes a loss of quality of life&#44; increased disability&#44; drug interactions&#44; multiple hospitalizations and increased mortality&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">The concepts of multimorbidity and polypathology</span><p id="par0030" class="elsevierStylePara elsevierViewall">The most common chronic condition in adults is the coexistence of numerous chronic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">7</span></a> Several terms have been designated to define this condition&#44; depending on the language used&#58; &#8220;multimorbidity&#8221; in English and &#8220;pluripatolog&#237;a&#8221; &#40;polypathology&#41; in Spanish&#46; In any case&#44; this type of patient with multiple chronic diseases is not the exception but rather the rule&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">8</span></a> It would therefore be appropriate that the condition of &#8220;multiple chronic conditions&#8221; be included as another diagnosis in the International Classification of Diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The term &#8220;multimorbidity&#8221; was first coined in 1976 by Brandlmeier&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">9</span></a> In a 2008 report&#44; the WHO defined the term as the simultaneous presence of 2 or more chronic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">10</span></a> In 2015&#44; the term was translated to 10 European languages for use in family medicine&#44; defining the term &#8220;multimorbidity&#8221; in Spanish as &#8220;any combination of a chronic disease with at least one other disease &#40;acute or chronic&#41; or a biopsychosocial factor &#40;associated or not&#41; or a risk factor&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">11</span></a> &#8220;Multimorbidity&#8221; can modify health results and lead to greater disability&#44; poorer quality of life and frailty&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In September 2016&#44; the National Institute for Health and Care Excellence defined the term &#8220;multimorbidity&#8221; as the presence of 2 or more long-standing health conditions&#44; which can include the following&#58; defined physical and mental health disorders&#44; such as diabetes and schizophrenia&#59; complex conditions such as frailty and chronic pain&#59; and sensory deficits such as reduced visual or auditory acuity&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">12</span></a> In short&#44; 2 or more long-term physical health conditions or a mental disease and another physical disease&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The US has lately been using the expression &#8220;patients with high needs and high costs&#8221; to refer to individuals with 3 or more chronic diseases and functional dependence&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">13&#44;14</span></a> The concept of &#8220;polypathology&#8221; &#40;or that of multimorbidity&#41; can be understood&#44; from a strict perspective&#44; as the coexistence of 2 or more chronic diseases with no other requirements&#46; In 2002&#44; this concept was defined differently in Andalusia as follows&#58; the condition in which an individual experiences 2 or more diseases among 8 clinical categories included in a list of common defined chronic diseases with certain severity or complexity &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">15&#44;16</span></a> In other words&#44; to meet this definition&#44; a person needs to have several chronic diseases&#59; however&#44; not all individuals with several chronic diseases meet the criteria for a polypathological patient&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Moreover&#44; the concept of &#8220;complex chronic patient&#8221; has been coined to refer to patients who have 2 or more chronic progressive diseases&#44; with frequent exacerbations or complex societal situations&#44; which cause an impairment in autonomy and functional capacity and result in frequent use of healthcare services&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The Spanish Ministry of Health&#44; Social Services and Equality&#44; in its strategy for attention on chronicity in the Spanish National Health System&#44; textually defines<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">18</span></a> a&#41; &#8220;polypathology&#8221; if there are 2 or more coexisting chronic diseases&#59; b&#41; &#8220;comorbidity&#8221;&#44; when any disease is associated with a main nosological entity&#44; both acute and chronic&#44; modulating its diagnosis and treatment&#59; and c&#41; &#8220;complex chronic patient&#8221; as an individual who presents greater complexity in their management by having changing needs that require continuous reassessments and requires the orderly use of various healthcare levels and&#44; in some cases&#44; healthcare and social services&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In short&#44; there is no consensus on the terms or concepts when referring to this type of patient&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Magnitude of the problem&#46; consequences</span><p id="par0065" class="elsevierStylePara elsevierViewall">The number of chronic diseases present in a person increases progressively with age&#44; such that individuals 80 years or older have a mean of over 4 diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">19</span></a> In a study conducted in Scotland&#44; the number of chronic diseases was greater than 8 among individuals older than 85 years&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">20</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The presence of several chronic diseases in an individual is very common&#46; A document by the Organization for Economic Cooperation and Development listed a number of examples&#58; heart failure is the only entity in only 3&#37; of patients&#44; stroke in 6&#37;&#44; atrial fibrillation in 7&#37;&#44; ischemic heart disease in 9&#37;&#44; diabetes in 14&#37;&#44; chronic obstructive pulmonary disease in 18&#37; and dementia in 5&#37;&#46; By contrast&#44; individuals with heart failure&#44; stroke&#44; diabetes and dementia who have 3 or more chronic diseases represent 74&#37;&#44; 62&#37;&#44; 47&#37; and 64&#37;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">19</span></a> It can therefore be emphatically stated that the most common chronic situation is the presence of several chronic diseases in a single individual&#46; This report highlighted that the number of chronic diseases increases with age and inversely with the individual&#39;s socioeconomic status&#46; As the number of these diseases increases&#44; the degree of polypharmacy and medical errors increases&#44; especially if the care is provided by various physicians or specialists &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">21</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">In a systematic review&#44; the prevalence of multimorbidity in elderly individuals varied between 55&#37; and 98&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">22</span></a> Advanced age&#44; female sex and low socioeconomic level were the factors associated with multimorbidity&#44; whose main consequences were disability&#44; functional impairment&#44; poor quality of life and high healthcare costs&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In various studies conducted at the state and regional level&#44; the estimated prevalence of polypathological patients was 1&#46;38&#37; of the general population and 5&#37; of those older than 65 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">18&#44;23</span></a> Depending on their characteristics&#44; it is estimated that between 38&#37; and 60&#37; of patients hospitalized In internal medicine departments have multiple diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">24</span></a> In recent years&#44; the prevalence of polypathology has increased dramatically in orthopedic surgery and trauma units &#40;due mainly to hip fractures in the elderly&#41; and in urology units due to prostate disease&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The standard profile of a hospitalized polypathological patient is a 78-year-old individual&#44; with a mean of 2&#46;4 diseases in the clinical categories of the Andalusian classification &#40;69&#37; with 2 categories&#59; 31&#37; with &#8805;3 categories&#41;&#44; predominantly cardiovascular&#44; respiratory&#44; neurological or renal type&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">25</span></a> These are also polymedicated patients&#44; with an average of 8 drugs&#44; with greater functional dependence at hospital discharge and at 1 year &#40;decrease in Barthel index of 11&#8211;20 points&#41;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">25&#44;26</span></a> and greater mortality compared with nonpolypathological patients&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Impact of polypathology&#47;multimorbidity on healthcare management</span><p id="par0090" class="elsevierStylePara elsevierViewall">For many years&#44; public health organizations worldwide have stated the urgent need to change the way in which we address health promotion and disease care&#46; The evidence that social determinants of health &#40;housing&#44; education&#44; food and hygiene&#41; are the main risk factors for contracting disease&#44; the overwhelming logic of &#8220;prevention is better than cure&#8221; and the &#8220;tsunami&#8221; of chronic diseases have resulted in a multitude of warnings and recommendations on the risk of financial ruin run by healthcare systems and the states themselves&#46; Since 2000&#44; the WHO has developed strategies and action plans to prevent and control chronic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">28</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In 2011&#44; the United Nations&#44; in a high-level general assembly in which the heads of member states met&#44; put forth the &#8220;Declaration on the Prevention and Control of Non-communicable Diseases&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">29</span></a> All member states agreed that chronic diseases undermine social and economic development worldwide&#44; are a threat for the economies of many states&#44; promote poverty&#44; increase inequalities among countries and populations and represent a threat to achieving the &#8220;Millennium Development Goals&#8221;&#44; placing this topic among the priorities of political agendas&#46; In their political declaration&#44; the UN established the global objective &#8220;25 by 25&#8221;&#59; i&#46;e&#46;&#44; to reduce by 25&#37; the premature mortality associated with chronic diseases by 2025&#46; The declaration also urged the inclusion of prevention for these diseases as a priority in all national and international programs&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In 2006&#44; the European Union prepared a &#8220;European Strategy for the Prevention and Control of Noncommunicable Diseases&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">30</span></a> In December 2010&#44; The Council of the European Union adopted a number of conclusions for the development of action plans to decrease the impact of chronic diseases in Europe&#46; Chronic diseases were considered a priority for the present and future of research and the design of intervention programs&#46; The member states and the European Commission were requested to urgently implement specific and coordinated measures to confront this problem&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">31</span></a> More specifically&#44; the Council invited the member states to implement patient-focused policies to promote health&#44; primary and secondary prevention and the treatment and care of chronic diseases&#44; in cooperation with the responsible politicians and&#44; especially&#44; with the patient associations&#46; The Council also invited the states to identify and exchange information on best practices in this setting and assess the incidence&#44; prevalence and impact of this collection of diseases&#46; A project funded by the European Union was created to care for individuals with multiple diseases &#40;Improving care for people with multiple chronic conditions in Europe&#44; ICARE4EU&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">32</span></a> with the objective of assessing and promoting innovation and improvement in the care of patients with several chronic diseases&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">All the recommendations of international organizations advocate the need to facilitate access for all citizens to healthcare and to control risk factors&#44; creating environments that promote health and health prevention and that prevent inequality&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">33</span></a> Universal coverage is the only measure that&#44; by itself&#44; can profoundly improve social equity&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">34</span></a> Additionally&#44; all the recommendations urge changes in the way health care is provided&#46; Due to the fact that communicable diseases have been the predominant type until the 1950s&#44; care has traditionally been based on the disease and generally provided reactively by hospital specialists&#44; with their actions based on the symptoms and focused on treatment&#46; Although the pattern of diseases and the type of patient have changed&#44; the healthcare systems continue acting in the same manner as in the past&#46; Patients with several diseases are treated by several specialists who take care of the acute episode and the organ for which they are exclusively responsible&#46; The specialists do not interrelate and do not cover the individual&#39;s biopsychosocial needs&#46; Thus&#44; examinations and treatments are unnecessarily multiplied&#44; with the subsequent increase in their adverse effects and the prescription cascade to solve them&#46; There is no coordinated and proactive action to prevent decompensations&#44; and patients are admitted and readmitted over and over&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The new focus of the healthcare model should be based on the &#8220;Comprehensive Care Model&#8221;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">35</span></a>&#58; a&#41; focused on the individual and not on the disease&#44; b&#41; based in primary care and not in the hospital&#44; c&#41; focused on the needs of the population and not on those of the individual patient&#44; d&#41; organized for proactive and planned care&#44; not reactive in the face of symptoms and e&#41; focused on promotion and prevention&#44; not treatment&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Care must be integrated across time&#44; places and health problems&#46; The healthcare team members must collaborate with each other and with the patients and their relatives to achieve the treatment objectives&#46; The implemented plans and strategies should be focused on the patient&#39;s needs&#44; values and preferences&#46; Collectively&#44; health professionals must be able to provide a complete range of healthcare services&#44; from prevention and rehabilitation to end-of-life care&#46; Thus&#44; integrated healthcare models that go beyond specific diseases and that place the individual as the main objective provide a viable solution for introducing efficient and effective care&#46; Several specific recommendations have been developed in our setting for this patient group&#44; both by healthcare administrations and scientific societies &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">15&#44;36&#8211;39</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Challenges in healthcare systems</span><p id="par0120" class="elsevierStylePara elsevierViewall">Polypathology&#47;multimorbidity is much more than the sum of the individual diseases&#44; given that it adopts complex disease patterns that require diagnostic and therapeutic approaches that are substantially different from traditional practices focused on a single disease&#46; Strengthening primary care and improving coordination and integration between primary care and hospital care and the health and social care would improve the intervention for individuals with polypathology&#46; Healthcare systems face various challenges in promoting this change&#44; challenges that are discussed below&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Research</span><p id="par0125" class="elsevierStylePara elsevierViewall">We need to generate quality measures for the care of individuals with multiple chronic diseases&#44; focused on the performance of the healthcare system for individuals with more needs&#46; Most of the current registries are directed toward individuals with specific diseases&#46; The development of specific indicators for individuals with multiple diseases could help measure efficiency and compare results between various systems&#44; departments and healthcare models&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Clinical practice guidelines</span><p id="par0130" class="elsevierStylePara elsevierViewall">The current guidelines provide relevant recommendations on specific diseases&#46; Guidelines need to be prepared for patients with several diseases that are usually associated &#40;clusters of diseases&#41;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">40</span></a> typically with a significant burden of therapeutic compliance &#40;lifestyle&#44; complex treatments&#44; visits to various practitioners&#44; etc&#46;&#41;&#46; The guidelines need to also consider the patient&#39;s prognosis and recommendations in the various stages over the course of the patient&#39;s life cycle&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Information systems</span><p id="par0135" class="elsevierStylePara elsevierViewall">Information systems need to be improved to achieve integration of all the patient&#39;s data&#44; which should be accessible to any healthcare or social professional and to the patients themselves&#46; These information systems should also facilitate the exploitation of results so that the organization of the various healthcare systems can be compared&#44; opening new lines of research&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Communication technology</span><p id="par0140" class="elsevierStylePara elsevierViewall">New technology can improve coordination among the various healthcare settings and with the patients themselves&#46; Online health technologies offer a promising solution for providing better care and support for individuals &#40;and their caregivers&#41; who have multiple diseases and complex care needs&#46; These technologies can include electronic medical records&#44; telemonitoring systems&#44; web portals and mobile health technologies &#40;&#8220;mHealth&#8221;&#41;&#44; which help exchange information among healthcare providers&#44; patients and their families&#46; There are various experiences&#44; such as in Ontario &#40;Canada&#41;&#44; Scotland and Kaiser Permanente in Colorado &#40;US&#41; where electronic health tools have been adopted for individuals with multimorbidity and complex care needs&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">41</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Healthy aging</span><p id="par0145" class="elsevierStylePara elsevierViewall">The unprecedented demographic change is revealing the shortcomings of the healthcare and social systems&#46; For 2050&#44; the WHO predicts that the number of people older than 60 years will double&#44; that more than 1 in every 5 individuals will be older than 60 years and that 80&#37; will live in countries with medium to low incomes&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">42</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The elderly are not all equal&#59; some need permanent assistance for basic activities of life while others&#44; conversely&#44; will maintain a good functional level&#46; Individual factors influence this condition&#44; such as age-related changes&#44; behavior&#44; genetics and diseases&#44; as do environmental factors&#44; such as housing&#44; healthcare devices&#44; social facilities and transport&#46; A change is therefore needed in how we see aging and the elderly&#44; creating adapted environments&#44; suiting the healthcare systems to their needs and establishing long-term care systems&#46; We will thus achieve healthy aging&#44; which consists of being able to do those things that we value&#44; for as long as possible&#44; ensuring an appropriate retirement through the pension system&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Policies should therefore be established with sufficient potential to mitigate the demographic changes in society and help elderly individuals continue as active and productive citizens&#44; either through flexible work&#44; gradual retirement and ongoing learning&#59; in short&#44; as volunteers or caregivers&#46; Investment in this field will be highly rewarding for society&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Health promotion and disease prevention</span><p id="par0160" class="elsevierStylePara elsevierViewall">The social determinants of health are the socioeconomic&#44; political&#44; cultural and environmental conditions in which individuals live and grow&#46; These determinants create risk factors that in turn promote the presence of chronic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">43</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">There are many ways to promote and preserve health&#44; some of which are found at the border of the competencies of the healthcare sector&#46; The circumstances in which individuals grow&#44; work and age influence in considerable measure the form in which individuals live and die&#46; Education&#44; housing&#44; diet and employment all affect health&#46; Reducing inequalities in these aspects will in turn decrease the inequalities resulted from the acquisition of diseases and in the access to healthcare&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Healthcare systems should promote Antonovsky&#39;s &#8220;salutogenic model&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">44</span></a> i&#46;e&#46;&#44; those individual or group factors that promote the creation of health&#59; resilience or the capacity to resist and adapt<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">45</span></a> and health asset maps&#46; A health asset is any factor or resource that strengthens the ability of individuals&#44; groups or populations to maintain or improve their health and wellbeing&#46; These assets can act in the individual&#44; family or community as protective elements to counter stressful conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Integration of healthcare and social services</span><p id="par0175" class="elsevierStylePara elsevierViewall">The method for integrating healthcare and social services represents a significant challenge for most countries&#46; Individuals with multiple chronic diseases are more predisposed to disability and therefore need assistance in their daily activities&#46; Traditionally&#44; this type of social care has not been a part of healthcare itself&#44; which multiplies the need for resources and services&#46; Greater mesointegration results in better health results at lower costs&#44; as has been shown by the impact of the US Program for All-Inclusive Care for the Elderly &#40;PACE&#41;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">47</span></a> and the Canadian System of Integrated Services for Aged Persons &#40;SIPA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">48</span></a> Legislation was recently passed in Scotland on the integration of healthcare and social services&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">49</span></a> The Spanish Ministry of Health has established the basis for social and healthcare coordination&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">50</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding and universal coverage</span><p id="par0180" class="elsevierStylePara elsevierViewall">The WHO&#44; in its report &#8220;Health Systems Financing&#46; The path to universal coverage&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">51</span></a> indicated that 20&#8211;40&#37; of healthcare expenditures are lost due to inefficiencies in the system itself&#46; Initiatives were proposed to achieve proper financing&#58; 1&#41; increase the efficiency in revenue collection&#44; preventing evasion and inefficient collection&#44; thereby increasing the funds for providing services&#59; 2&#41; re-establish the priorities of state budgets given that governments often give relatively low importance to health care when creating budgets&#59; 3&#41; provide innovative financing&#58; with increased taxes on foreign exchange transactions&#44; solidarity taxes on a variety of products and services&#44; taxes on products that are harmful for health such as tobacco&#44; alcohol&#44; sugary drinks and food with high salt content or trans-fatty acids&#46; These taxes will thereby decrease the consumption of unhealthy products&#44; promoting health and generating revenue to devote to healthcare&#59; and 4&#41; provide development assistance for healthcare in global solidarity for low-income countries&#46; If countries immediately meet their current international commitments&#44; external financing for health for low-income countries would more than double immediately&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Reducing unnecessary expenditures in drug products and the more appropriate use of these drugs could save the system up to 5&#37; of the total healthcare expenditure&#46; To increase the efficiency of the system&#44; we need to get the most out of healthcare technologies and services&#44; improve hospital efficiency&#44; reduce medical errors&#44; critically assess the necessary healthcare services and eliminate unnecessary expenditures&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Professionals</span><p id="par0190" class="elsevierStylePara elsevierViewall">A focus on public health promotion needs to be one of the fundamental values of healthcare practitioners&#46; Investments should be directed toward developing methodologies for integration that favor a general approach and not a subspecialized and fragmented approach to health problems&#46; Instruments need to be developed in relation to the health results of patient groups &#40;e&#46;g&#46;&#44; those who require home care&#44; who are institutionalized&#44; who have many needs and entail high costs&#41;&#44; which are more useful than those related to individual diseases&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Healthcare practitioners have not followed the changes in their patients&#44; the patients&#8217; needs and their health problems&#46; It is important to include multimorbidity&#47;polypathology in medical education&#44; as well as the necessary skills for improving the care for this type of patient&#46; Healthcare practitioners need to be trained in a&#41; the shared decision-making process&#59; b&#41; in providing value to the patient&#44; avoiding overdiagnosis and overtreatment&#44; including the use of preventive drugs in individuals with limited life expectancy&#59; c&#41; the training of teams&#59; d&#41; helping patients and caregivers to acquire greater responsibility for their health&#59; e&#41; preventing disability&#59; and f&#41; end-of-life care&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres834097"
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          "identificador" => "sec0005"
          "titulo" => "Background"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "The concepts of multimorbidity and polypathology"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Magnitude of the problem&#46; consequences"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Impact of polypathology&#47;multimorbidity on healthcare management"
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          "titulo" => "Challenges in healthcare systems"
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              "titulo" => "Clinical practice guidelines"
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              "titulo" => "Information systems"
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              "identificador" => "sec0045"
              "titulo" => "Communication technology"
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            4 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Healthy aging"
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            5 => array:2 [
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              "titulo" => "Health promotion and disease prevention"
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              "titulo" => "Integration of healthcare and social services"
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              "titulo" => "Funding and universal coverage"
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    "fechaRecibido" => "2016-10-20"
    "fechaAceptado" => "2017-01-12"
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          "clase" => "keyword"
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            0 => "Polypathology"
            1 => "Multimorbidity"
            2 => "Challenges of healthcare systems"
            3 => "Aging"
            4 => "Chronic diseases"
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          "palabras" => array:5 [
            0 => "Pluripatolog&#237;a"
            1 => "Multimorbilidad"
            2 => "Retos de los sistemas sanitarios"
            3 => "Envejecimiento"
            4 => "Enfermedades cr&#243;nicas"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Improvements in living conditions and scientific advances have led to an unprecedented demographic change&#46; The curing of numerous acute diseases and the growing adoption of unhealthy lifestyles have caused a pandemic of cumulative chronic diseases that constitute the leading cause of death worldwide&#46; Currently&#44; the most common situation is the coexistence of multiple chronic diseases &#40;or polypathology&#41;&#46; This situation undermines socio-economic development and increases inequality&#46; This results in an overriding need to change the way in which health and disease are addressed&#46; Healthcare systems are not prepared to meet the needs of complex polypathological patients&#46; In this article&#44; we summarize the challenges facing healthcare systems and states&#44; as well as the main recommendations from the organizations responsible for healthcare&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La mejor&#237;a de las condiciones de vida y los avances cient&#237;ficos han propiciado un cambio demogr&#225;fico sin precedentes&#46; La curaci&#243;n de muchas enfermedades agudas y la adopci&#243;n creciente de estilos de vida no saludables han provocado una pandemia de enfermedades cr&#243;nicas acumulativas que constituyen la primera causa de mortalidad mundial&#46; Lo m&#225;s frecuente&#44; actualmente&#44; es la coexistencia de m&#250;ltiples enfermedades cr&#243;nicas o pluripatolog&#237;a&#46; Esta situaci&#243;n socava el desarrollo socioecon&#243;mico y aumenta las desigualdades&#46; Ello condiciona una necesidad imperiosa de cambiar el modo de abordar la salud y la enfermedad&#46; Los sistemas sanitarios no est&#225;n preparados para satisfacer las necesidades de los pacientes pluripatol&#243;gicos complejos&#46; En el presente art&#237;culo se resumen los desaf&#237;os a los que se enfrentan los sistemas sanitarios y los propios estados&#44; as&#237; como las principales recomendaciones de los organismos responsables de la salud de las personas&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Please cite this article as&#58; Rom&#225;n P&#44; Ruiz-Cantero A&#46; La pluripatolog&#237;a&#44; un fen&#243;meno emergente y un reto para los sistemas sanitarios&#46; Rev Clin Esp&#46; 2017&#59;217&#58;229&#8211;237&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Percentage of patients with several diseases&#46; Abbreviations&#58; AF&#44; atrial fibrillation&#59; AHT&#44; arterial hypertension&#59; COPD&#44; chronic obstructive pulmonary disease&#59; dis&#44; diseases&#59; HF&#44; heart failure&#59; IHD&#44; ischemic heart disease&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Own preparation&#46; Modified from Bruce Guthrie&#44; Sally Wyke&#44; Jane Gunn&#44; Marjan van den Akker and Stewart Mercer by OECD&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">19</span></a></p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Number of medical errors according to the number of specialists who treated a patient&#46; Abbreviations&#58; AUS&#44; Australia&#59; CAN&#44; Canada&#59; FR&#44; France&#59; GER&#44; Germany&#59; NL&#44; The Netherlands&#59; NZ&#44; New Zealand&#59; UK&#44; United Kingdom&#59; US&#44; United States&#46;</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Own preparation&#46; Modified from the 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">21</span></a></p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Category A</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>A&#46;1&#46; Heart failure that in a clinically stable state has been in NYHA class <span class="elsevierStyleSmallCaps">ii</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;symptoms with regular physical activity&#41;<br><span class="elsevierStyleHsp" style=""></span>A&#46;2&#46; Ischemic heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Category B</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>B&#46;1&#46; Vasculitis and systemic autoimmune diseases<br><span class="elsevierStyleHsp" style=""></span>B&#46;2&#46; Chronic kidney disease defined by a glomerular filtration rate<span class="elsevierStyleHsp" style=""></span>&#60;60<span class="elsevierStyleHsp" style=""></span>mL&#47;m or proteinuria<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&#44; maintained for 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Category C</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>C&#46;1&#46; Chronic respiratory disease that in a clinically stable state has occurred with&#58;<br>dyspnea grade <span class="elsevierStyleSmallCaps">ii</span> of the MRC scale<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> &#40;dyspnea at normal pace on a level surface&#41; or FEV1<span class="elsevierStyleHsp" style=""></span>&#60;65&#37;&#44; or Sat O<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8804;90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>D&#46;1&#46; Chronic inflammatory bowel disease<br><span class="elsevierStyleHsp" style=""></span>D&#46;2&#46; Chronic liver disease with hepatocellular insufficiency<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a> or portal hypertension<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a> data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Category E</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>E&#46;1&#46; Stroke<br><span class="elsevierStyleHsp" style=""></span>E&#46;2&#46; Neurological disease with permanent motor deficit that restricts basic activities of daily life &#40;Barthel index<span class="elsevierStyleHsp" style=""></span>&#60;60&#41;<br><span class="elsevierStyleHsp" style=""></span>E&#46;3&#46; Neurological disease with permanent cognitive impairment&#44; at least moderate &#40;Pfeiffer with 5 or more errors&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Category F</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>F&#46;1&#46; Symptomatic peripheral arteriopathy<br><span class="elsevierStyleHsp" style=""></span>F&#46;2&#46; Diabetes mellitus with proliferative retinopathy or symptomatic neuropathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Category G</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>G&#46;1&#46; Chronic anemia due to gastrointestinal losses or acquired blood disorder not responsive to curative treatment&#44; which&#160;presents Hb levels<span class="elsevierStyleHsp" style=""></span>&#60;10<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in 2 measurements separated&#160;by more than 3 months<br><span class="elsevierStyleHsp" style=""></span>G&#46;2&#46; Solid or hematologically neoplasm not responsive to treatment with intent to heal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of inclusion categories&#58; 2&#8211;3&#8211;4&#8211;5&#8211;6&#8211;7&#8211;8&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Defined as the presence of clinical&#44; laboratory&#44; ultrasound or endoscopic data&#46;</p> <p class="elsevierStyleNotepara" id="npar0030"><span class="elsevierStyleItalic">Source</span>&#58; Care of polypathological patients&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">15</span></a></p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ministry of Health and Social Policy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Polypathological patient unit&#46; Standards and Recommendations<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">36</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Government of Andalusia<br>Ministry of Health&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Care of polypathological patients<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Government of Andalusia<br>Ministry of Health&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Care of polypathological patients&#46; 2nd Edition<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Government of Navarra&#46;<br>Department of Health&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Navarra strategy for the comprehensive care of chronically ill and polypathological patients<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">37</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spanish Society of Internal Medicine &#40;SEMI&#41;<br>Spanish Society of Family and Community Medicine &#40;SEMFYC&#41;&#46;<br>Federation of Associations of Community Nursing and Primary Care &#40;FAECAP&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Development of clinical practice guidelines for patients with comorbidity and polypathology&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">38</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spanish Society of Internal Medicine &#40;SEMI&#41;<br>Spanish Society of Family and Community Medicine &#40;SEMFYC&#41;&#46;<br>Federation of Associations of Community Nursing and Primary Care &#40;FAECAP&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Healthcare process for polypathological patients with complex chronic diseases<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">17</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Government of Castilla y Le&#243;n<br>Ministry of Health<br>Regional Health Management of Castilla y Le&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Healthcare process for complex chronic polypathological patients<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">39</span></a>&nbsp;\t\t\t\t\t\t\n
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        0 => array:2 [
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              "referencia" => array:1 [
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            1 => array:3 [
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              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Dra&#46; Margaret Chan Directora General de la Organizaci&#243;n Mundial de la Salud&#46; Alocuci&#243;n pronunciada en la Reuni&#243;n de alto nivel de la Asamblea General de las Naciones Unidas sobre enfermedades no transmisibles&#46; Nueva York&#44; Estados Unidos de Am&#233;rica&#46; 19 de septiembre de 2011&#46; Accesible en&#58; <a href="http://www.who.int/dg/speeches/2011/un_ncds_09_19/es/">http&#58;&#47;&#47;www&#46;who&#46;int&#47;dg&#47;speeches&#47;2011&#47;un&#95;ncds&#95;09&#95;19&#47;es&#47;</a> &#91;accessed 02&#46;12&#46;16&#93;&#46;"
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                  "referenciaCompleta" => "Ministerio de Sanidad&#44; Servicios Sociales e Igualdad&#46; Indicadores de salud 2013&#46; Evoluci&#243;n de los indicadores de salud en Espa&#241;a y su magnitud en el contexto de la Uni&#243;n Europea&#46; Madrid&#58; Ministerio de Sanidad&#44; Servicios Sociales e Igualdad&#44; 2014&#46; Available from&#58; <a href="http://www.msssi.gob.es/estadEstudios/estadisticas/inforRecopilaciones/docs/Indicadores2013.pdf">http&#58;&#47;&#47;www&#46;msssi&#46;gob&#46;es&#47;estadEstudios&#47;estadisticas&#47;inforRecopilaciones&#47;docs&#47;Indicadores2013&#46;pdf</a> &#91;accessed 04&#46;10&#46;16&#93;&#46;"
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            4 => array:3 [
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                  "host" => array:1 [
                    0 => array:2 [
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                          "etal" => false
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                        0 => array:2 [
                          "etal" => true
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                            0 => "J&#46;Y&#46; Le Reste"
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                            2 => "C&#46; Rivet"
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                  "host" => array:1 [
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                        "fecha" => "2015"
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                0 => array:1 [
                  "referenciaCompleta" => "Salzberg CA&#44; Hayes SL&#44; McCarthy D&#44; Radley DC&#44; Abrams MK&#44; Shah T&#44; et al&#46; Health system performance for the high-need patient&#58; A look at access to care and patient care experiences&#46; The Commonwealth Fund&#44; August 2016 &#91;accessed 02&#46;12&#46;16&#93;&#46;"
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                    0 => array:2 [
                      "titulo" => "Caring for high-need&#44; high-cost patients - an urgent priority"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2017.01.001

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