Prognostic stratification and the healthcare approach in patients with multiple pathologies

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Polypathology" "titulo" => "Prognostic stratification and the healthcare approach in patients with multiple pathologies" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "410" "paginaFinal" => "419" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Bernabeu-Wittel, B. Barón-Franco, D. Nieto-Martín, L. Moreno-Gaviño, N. Ramírez-Duque, M. Ollero-Baturone" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Bernabeu-Wittel" "email" => array:1 [ 0 => "wittel@cica.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "B." "apellidos" => "Barón-Franco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "D." "apellidos" => "Nieto-Martín" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Moreno-Gaviño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "N." "apellidos" => "Ramírez-Duque" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Ollero-Baturone" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad Clínica de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Instituto de Salud Carlos III, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estratificación pronóstica y abordaje asistencial de los pacientes pluripatológicos" ] ] "textoCompleto" => "Polypathological patients. Paradigm of an emerging and homogeneous clinical-care populationLife expectancy has increased in recent years, and, as a result, there has been a gradual aging of the population. Socioeconomic advances and biomedical innovations have helped drastically reduce the mortality of numerous diseases (mainly infectious, cardiovascular and neoplastic diseases). The price of surviving these diseases is none other than the creation of chronic conditions.<a class="elsevierStyleCrossRefs" href="#bib0240">1,2</a> We increasingly treat patients with multiple concomitant diseases, many of them interrelated. A prevalent paradigm of this public health phenomenon is the polypathological patient (PPP).<a class="elsevierStyleCrossRef" href="#bib0250">3</a>PPPs constitute a homogeneous population with a series of common, easily identifiable characteristics such as advanced age, clinical vulnerability, a tendency toward functional impairment, high mortality during hospitalization and clinical follow-up, low health-related perceived quality of life and a high prevalence of dependence on the caregiver.<a class="elsevierStyleCrossRefs" href="#bib0255">4–9</a> Various studies have profiled the main clinical characteristics of these patients, finding numerous similarities, regardless of the environment and temporal framework. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the main clinical characteristics of PPPs in the various studies.<a class="elsevierStyleCrossRefs" href="#bib0255">4–9</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The PPP group has special clinical susceptibility and frailty that entail the frequent demand for care due to intercurrent exacerbations and the onset of interrelated disorders, which worsen the patient's condition with progressive impairment of their autonomy and functional capacity. PPPs constitute a group that is especially susceptible to the deleterious effects of healthcare fragmentation and superspecialization. PPPs can therefore be considered “sentinel” elements of the “overall health” of the healthcare system, as well as its level of coordination.Impact of comorbidity and polypathology on the patient's vital and functional prognosisImpact of comorbidityThere is evidence to confirm that the presence of comorbidity worsens the vital and functional prognosis, the health-related quality of life and the overall health results for all diseases evaluated on this subject. Paradigmatic examples of this are coronary artery disease, heart failure, pneumonia, other severe infections, surgery, chronic renal failure, chronic liver disease, cancer, cerebrovascular disease and chronic lung diseases.<a class="elsevierStyleCrossRefs" href="#bib0285">10–15</a> In the authors’ opinion, this deleterious effect could be due to 2 reasons: (1) the “domino” biological effect itself of the comorbidities in reducing the physiological reserve to various aggressions and (2) the “deterrent” effect exerted by the comorbidity on medical personnel when making diagnostic and therapeutic decisions that could entail adverse effects (which are more common and severe in these patients).Impact of polypathologyPolypathology has a marked impact on the patients’ prognoses, both in the primary care (PC) and hospital care settings. It is estimated that the annual mortality of PPPs is approximately 6% in PC, 19–20% during hospitalization, 36% at 1 year and 50% at 4 years of follow-up.<a class="elsevierStyleCrossRefs" href="#bib0280">9,16,17</a> This mortality is significantly higher than that of nonpolypathological patients (e.g., the mortality of patients without polypathology in internal medicine departments is usually no higher than 8%). The differences in mortality observed in PPP cohorts recruited in PC or hospital care probably lies in the progression stage and severity of the chronic diseases, which is much higher in populations treated in hospitals.Polypathology also influences the functional prognosis. In fact, these patients usually deteriorate more during hospitalizations than nonpolypathological patients, and the baseline functional condition usually does not recover after discharge. This indicates that specific plans that are better suited to the patient's needs are required for the care and prevention of functional impairment.<a class="elsevierStyleCrossRef" href="#bib0255">4</a> A classical comparative study on functional impairment between PPPs and nonpolypathological hospitalized patients showed that the mean drop in the Barthel index was significantly higher in the PPP group. PPPs also do not recover their baseline functionality at discharge, in contrast to the nonpolypathological patients.<a class="elsevierStyleCrossRef" href="#bib0255">4</a> In longer follow-ups, functional impairment dramatically affects PPPs. In a Spanish multicenter cohort study, the mean drop in the Barthel index at 12 months of follow-up was 11 points, and 37% of the patients reached 20 or more points.<a class="elsevierStyleCrossRef" href="#bib0325">18</a>The importance of prognostic assessment for polypathological patients and high-risk populationsThe establishment of an accurate prognosis is one of the core elements of healthcare practice and an ethical duty of health professionals for their patients, the patients’ relatives and society as a whole. This facet of the healthcare practitioner is of particular value in high-risk populations such as PPPs.We need to understand the prognosis so that the patient and their relatives can arrange their preferences, priorities and personal affairs. The prognosis is also useful for clinicians in the diagnostic and therapeutic decision-making process, thereby avoiding malpractice, unnecessary risks, futility and (for cases with better prognoses in which intensification of the actions could be fully justified) nihilism.<a class="elsevierStyleCrossRefs" href="#bib0280">9,17,19,20</a>From the clinical research perspective, having reliable prognostic instruments helps standardize populations and establish risk subgroups to assess the results of various interventions. This concept is especially relevant for populations with comorbidity and polypathology, which were traditionally excluded from many clinical trials, in part due to the prognostic uncertainties.Lastly, in terms of macromanagement, the establishment of healthcare population intervention strategies directed at patient subgroups should make use of these prognostic tools, among other sources.Prognostic indices in comorbidity and polypathologyPrognostic indices are clinimetric instruments that comprise several measures, with different weights. The indices help us stratify the risk of certain health outcomes for homogeneous patient populations. A patient cohort is usually employed to develop the index, thereby deriving the index in question (derivation cohort), for subsequent validation in a different population (validation cohort).Numerous instruments have been developed that assess the vital prognosis of patients with comorbidity.<a class="elsevierStyleCrossRefs" href="#bib0330">19–28</a> In contrast, there are fewer indices that have been constructed to predict the functional prognosis. It is essential that the instrument is developed under validity conditions (in its 4 measures: predictive, construct, intraobserver and interobserver), precise (well calibrated and with discriminative power) and, as much as possible, generalizable (i.e., reproducible and geographically, historically and methodologically transportable to similar diseases and to different follow-up periods).In the context of comorbidity, the 4 classical prognostic indices that have been used the most are the Charlson index,<a class="elsevierStyleCrossRef" href="#bib0330">19</a> the Cumulative Index Rating Scale,<a class="elsevierStyleCrossRef" href="#bib0335">20</a> the Index of Coexisting Diseases<a class="elsevierStyleCrossRef" href="#bib0340">21</a> and the Kaplan index (more focused on diabetes).<a class="elsevierStyleCrossRef" href="#bib0345">22</a> There are other more recently developed prognostic instruments such as those by Walter et al.,<a class="elsevierStyleCrossRef" href="#bib0350">23</a> Desai et al.,<a class="elsevierStyleCrossRef" href="#bib0355">24</a> Carey et al.,<a class="elsevierStyleCrossRef" href="#bib0360">25</a> Lee et al.<a class="elsevierStyleCrossRef" href="#bib0365">26</a> and Levine et al.,<a class="elsevierStyleCrossRef" href="#bib0370">27</a> as well as the Multidimensional Prognostic Index for Mortality Based on a Standardized Multidimensional Assessment Schedule (MPI-SVaMA).<a class="elsevierStyleCrossRef" href="#bib0375">28</a>The most notable of the prognostic instruments specifically for PPP is the PROFUND index.<a class="elsevierStyleCrossRef" href="#bib0280">9</a> The index was developed in a multicenter cohort recruited in 36 Spanish hospitals, within the Polypathological Patient and Advanced age workgroup of the Spanish Society of Internal Medicine. The cohort included 1632 patients, 1592 of whom completed the 1-year follow-up; the index was subsequently derived and validated. The index's measures are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The PROFUND index classifies PPPs into 4 risk groups, according to the score groupings. The mortality rate varies between 12% and 14% in the low-risk stratum and between 61% and 68% for patients with 11 or more points. The index's good calibration and discriminative power have recently been confirmed in the 4-year follow-up, such that mortality in the low-risk stratum was 52%, while that of patients with 11 or more points reached 92%.<a class="elsevierStyleCrossRef" href="#bib0320">17</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The PROFUND index has shown that its discrimination and calibration are maintained when applied to other PPP cohorts.<a class="elsevierStyleCrossRefs" href="#bib0380">29,30</a> The index's usefulness has also been tested in PC PPPs, where the score cutoffs have been recalibrated.<a class="elsevierStyleCrossRef" href="#bib0390">31</a>The CRONIGAL index has recently been developed from a mixed hospital cohort that included PPPs and other profiles of patients with chronic diseases. The measures that showed greater prognostic weight (and were therefore added to the index) were age, the presence of neoplasia, delirium, functional impairment, cognitive impairment, atrial fibrillation and creatinine levels.<a class="elsevierStyleCrossRef" href="#bib0395">32</a>Functional prognosis in polypathological patients. Frailty screeningThe functional prognosis for patients with comorbidity and polypathology is relevant, because functional decline dramatically affects the patients’ quality of life and that of their family and main caregiver and by extension the community environment and health and social services. Functional impairment also constitutes, in and of itself, a risk factor for morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0400">33</a> Therefore, knowing which PPP subgroups are at greater risk of functional impairment and of falling into the dependence cascade is of particular interest for establishing preventive interventions. There are few indices that enable us to predict the functional impairment of patients with comorbidity; these include the Triage Risk Screening Test (TRST)<a class="elsevierStyleCrossRef" href="#bib0405">34</a> and the Variable Indicative of Placement (VIP).<a class="elsevierStyleCrossRef" href="#bib0410">35</a>The TRST evaluates (in a dichotomous format) 5 measures (cognitive impairment, difficulties walking/transferring, living alone without a main caregiver, polypharmacy and recent hospitalization). The presence of cognitive impairment or 2 or more of the remaining measures is considered a high risk for developing functional impairment.VIP is an index for predicting functional difficulties after discharge in hospitalized geriatric populations. The index also uses a dichotomous format of 3 measures (social-family situation, functional condition and cognitive state) and considers patients who have 2 of the 3 measures to be high risk.For PPPs, we only have 1 index, which was developed with a multicenter cohort in Spanish hospitals: the PROFUNCTION index.<a class="elsevierStyleCrossRef" href="#bib0325">18</a> This index helps us predict which patients will experience a reduction of 20 or more points on the Barthel index scale in the following 12 months. The index consists of 7 simple dimensions to obtain measures and classifies PPPs into 3 risk groups of functional decline according to the scores, ranging from 21% for those with scores of 0 and 46% for those with scores ≥4 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Frailty, sarcopenia, disability and dependence are intimately related to functional impairment.<a class="elsevierStyleCrossRefs" href="#bib0400">33,36</a> In fact, chronic diseases usually affect the various functions that enable an independent life, directly or indirectly, due to the limitations their symptoms entail or by the required treatments. Disability, dependence and cognitive impairment are very common among PPPs. In PC, 24.3% of PPPs are dependent for basic activities of daily life, and 37.7% have cognitive impairment.<a class="elsevierStyleCrossRef" href="#bib0315">16</a> In the hospital setting, the prevalence of dependence for basic activities of daily life is 55%, and the prevalence of cognitive impairment is 45.7%.<a class="elsevierStyleCrossRefs" href="#bib0325">18,37</a>There are fewer data on the prevalence of frailty in these populations, although preliminary studies in the hospital setting place the prevalence at >50% and the prevalence of sarcopenia at >40%.<a class="elsevierStyleCrossRef" href="#bib0425">38</a> Frailty in PPPs is an excellent sentinel marker of risk for developing disability and, ultimately, dependence. Frailty is also a good predictor of adverse health events in the short, medium and long term.<a class="elsevierStyleCrossRef" href="#bib0430">39</a> Frailty is easily detectable and susceptible to intervention. Acting on this condition therefore prevents the development of disability.<a class="elsevierStyleCrossRef" href="#bib0435">40</a> As a rule, frailty screening is recommended for all PPPs. Various tests may be used for this purpose. The tests recommended by the Spanish Ministry of Health, Social Services and Equality are the Short Performance Physical Battery (SPPB),<a class="elsevierStyleCrossRef" href="#bib0440">41</a> the gait speed test and timed up and go test.<a class="elsevierStyleCrossRefs" href="#bib0435">40,42</a>Healthcare approach for polypathological patientsFor the clinical approach for PPPs, the implementation of a “personalized action plan” (PAP), adapted to each patient's specific reality, is recommended.<a class="elsevierStyleCrossRefs" href="#bib0450">43,44</a> The PAP would be the result of identifying the individual's health problems, developing and agreeing upon with the patient and family the goals and objectives to be reached, the necessary actions to this effect and the follow-up of results and progress. This plan is intended to achieve a more proactive health model, focused on the individual's ability to manage their disease.The PAP should be performed in an interdisciplinary manner, among the practitioners who provide treatment, the patient and, in specific cases, the individual caregiver. A predefined regimen should be followed, one that starts by identifying the patient's main problems and continues by defining the goal, objectives and specific interventions after reaching an agreement with the patient, taking into account their preferences. The prognosis is essential for properly defining the goals and objectives in order to contextualize the clinical decisions according to the expected risks and benefits. <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> lists the main recommendations according to the prognosis determined using the PROFUND index.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Personalized action plans for polypathological patientsThere is a growing interest in patients with comorbidity and polypathology; however, based on the evidence, this population has been excluded from most clinical trials and intervention studies.<a class="elsevierStyleCrossRef" href="#bib0460">45</a> Nevertheless, there has been a steady increase in the number of interventions that have shown a benefit in terms of improved health and results and that are sometimes translated to PPPs, while others have been effective in similar populations.<a class="elsevierStyleCrossRefs" href="#bib0465">46,47</a>The main actions that can be incorporated to improve the overall health results of PPPs are usually encompassed in 6 large areas:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1)Health promotion and disease prevention. This area encompasses all recommendations on healthy lifestyles regarding tobacco, diet, physical activity, weight loss, basic sleep hygiene practices and immunizations.</li><li class="elsevierStyleListItem" id="lsti0010">2)Patient and caregiver activation and self-management. This area includes all actions aimed at increasing and consolidating self-efficacy and the level of involvement and understanding of the disease by the patient and caregiver. This area also includes strategies for addressing the disease and actions to decrease caregiver stress.</li><li class="elsevierStyleListItem" id="lsti0015">3)Activation of the support network and social support. This broad area includes all actions aimed at directing and stimulating community assets for the patient (e.g., associations, volunteerism, municipal facilities networks, vacations programs, thermalism, cultural activities and physical fitness), as well as specific support resources (telephone assistance, processing of dependencies, disability counseling, residential resources, family rest, etc.).</li><li class="elsevierStyleListItem" id="lsti0020">4)Pharmacotherapy optimization. In this area, special care is placed on the appropriateness of the prescription, reconciliation in healthcare transitions, polypharmacy and dosage adjustments depending on renal function. The area also includes actions to promote adherence and patient education in detecting and self-monitoring adverse effects.</li><li class="elsevierStyleListItem" id="lsti0025">5)Rehabilitation and measures to preserve functional and cognitive abilities. It is advisable to combine the actions to prevent and treat frailty and the risk of falls, along with the implementation of specific programs for the patient's specific diseases. It is important to first consider the patient's vital and functional prognosis in order to establish the objectives. For the prevention and approach to frailty, various physical activity programs have been proposed (general, multicomponent activity, etc.), as well as activities that decrease the risk of falls in susceptible patients. A possible approach is outlined in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>. The objective of the specific rehabilitation and cognitive preservation programs is none other than having a synergistic effect with the generic programs to address frailty and is focused on the categories and diseases shown by each patient (e.g., cardiac, respiratory, cognitive and rehabilitation). The objectives and hence the proposed activities will vary depending on each patient's vital and functional prognosis stratification. Patients with low scores on the PROFUND and PROFUNCTION indices will be directed toward preserving and even improving their functionality, while those with very high scores will be directed toward delaying the loss of functionality.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030">6)Advanced planning of decisions. These activities are designed to facilitate a voluntary framework for communicating, establishing and recording the values and preferences of PPPs as to how they wish to be treated, especially in the final moments of life or if they temporarily or permanently lose the ability to decide. The approach to this transcendent area can vary depending on certain factors (healthcare setting, clinical situation, vital prognosis) from a mere examination of values and preferences to the explicit offering of their consignment and recording in the medical history, as detailed in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.</li></ul>Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres907023" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec887307" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres907024" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec887306" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Polypathological patients. Paradigm of an emerging and homogeneous clinical-care population" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Impact of comorbidity and polypathology on the patient's vital and functional prognosis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Impact of comorbidity" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Impact of polypathology" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "The importance of prognostic assessment for polypathological patients and high-risk populations" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Prognostic indices in comorbidity and polypathology" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Functional prognosis in polypathological patients. Frailty screening" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Healthcare approach for polypathological patients" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Personalized action plans for polypathological patients" ] 11 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-30" "fechaAceptado" => "2017-01-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec887307" "palabras" => array:5 [ 0 => "Patients with multiple pathologies" 1 => "Prognostics" 2 => "Personalized action plan" 3 => "Comorbidity" 4 => "Multimorbidity" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec887306" "palabras" => array:5 [ 0 => "Paciente pluripatológico" 1 => "Pronóstico" 2 => "Plan de acción personalizado" 3 => "Comorbilidad" 4 => "Multimorbilidad" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Polypathological patients constitute a prevalent, fairly homogeneous population, which is characterized by high clinical complexity, substantial vulnerability and significant resource consumption, in addition to high mortality and the need for comprehensive, coordinated care. It is particularly important to establish a reliable prognosis in these patients. It is also extremely useful for professionals involved in the decision-making process for patients and their families in vital planning and their preferences, for strategic health planning in management fields, and for clinical research, by facilitating their incorporation into clinical trials and other intervention studies. Two prognostic instruments stand out in terms of suitability for polypathological patients: PROFUND and PROFUNCTION. The former faithfully stratifies the risk of dying at 12 months and four years and the latter, the risk of suffering a significant functional deterioration at 12 months. In terms of the healthcare approach in patients with multiple pathologies, creating and executing a consensual, personalized action plan that is adapted to the patient's reality is encouraged. The plan will consider the prognosis, and the evidence and viability of interventions; its ultimate aim will be to ensure the synergy and alignment of the health team's goals and strategies with peoples’ values and preferences, in order to achieve a more proactive health model focused on supporting patients in their ability to manage their illnesses. In the personalized action plan, the main areas of intervention are: health promotion and prevention; patient and caregiver activation and self-management; activation of a social support network and social support; optimization of pharmacotherapy; rehabilitation, functional and cognitive preservation measures; and anticipated decision planning." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los pacientes pluripatológicos constituyen una población prevalente y homogénea, caracterizada por su complejidad clínica, vulnerabilidad, consumo de recursos y mortalidad que requiere una asistencia integral y coordinada. Establecer un pronóstico certero en esta población resulta de utilidad para la toma de decisiones clínicas por parte de los profesionales, la planificación de las preferencias de pacientes y familiares, y el diseño de estrategias en el ámbito de la gestión sanitaria. También es importante para la investigación clínica, al facilitar la posible incorporación de estos pacientes a ensayos clínicos y otros estudios de intervención. Los índices PROFUND y PROFUNCTION son 2 instrumentos pronósticos que predicen de manera fidedigna el riesgo de fallecer o de sufrir un deterioro funcional, respectivamente. Para el abordaje asistencial de los pacientes pluripatológicos se propugna la construcción y ejecución de un plan de acción personalizado, consensuado y adaptado a la realidad del paciente. Este tendrá en cuenta el pronóstico, la evidencia y viabilidad de las intervenciones, así como la sinergia de las metas y estrategias del equipo sanitario con los valores y las preferencias de las personas para conseguir un modelo de salud centrado en apoyar la capacidad de las mismas para gestionar sus enfermedades. En este plan los principales ámbitos de intervención son: la promoción y prevención de la salud, la activación y autogestión del paciente y el cuidador, la red de apoyo social, la optimización farmacoterapéutica, la rehabilitación y medidas de preservación funcional y cognitiva, y la planificación anticipada de decisiones." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Bernabeu-Wittel M, Barón-Franco B, Nieto-Martín D, Moreno-Gaviño L, Ramírez-Duque N, Ollero-Baturone M. Estratificación pronóstica y abordaje asistencial de los pacientes pluripatológicos. Rev Clin Esp. 2017;217:410–419." ] ] "multimedia" => array:5 [ 0 => array:9 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Bernabeu-Wittel et al.<a class="elsevierStyleCrossRefs" href="#bib0265">6,7,9</a> and Díez-Manglano et al.<a class="elsevierStyleCrossRef" href="#bib0275">8</a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: mMRC, modified Medical Research Council; NYHA, New York Heart Association." "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">Clinical characteristic \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">Mean, median or percentage \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">Mean age, y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76–78 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51–54% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of defining categories per patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.4–2.7 \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">Patients with 3 or more categories \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30–50% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Prevalence of defining categories</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Category A (heart disease) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72–77% \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 (lung disease) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45–49% \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 (neurological disease) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35–38% \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 (kidney disease) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20–32% \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 (malignancies/chronic anemia) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26% \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 (peripheral artery disease/diabetes with neuropathy) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25% \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 (degenerative musculoskeletal disease) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17% \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 (liver disease) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of other comorbidities per patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.5–2.7 \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">Cardiovascular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.2 \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">Endocrine metabolic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5 \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">Neuropsychiatric \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Most common comorbidities</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72% \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">Atrial fibrillation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35% \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">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29% \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">Diabetes without visceral repercussion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29% \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">Anxiety or depression disorders \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11% \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">Benign prostatic hyperplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Common symptoms</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with baseline dyspnea NYHA III–IV/III–IV of the mMRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44–48% \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">Delirium during the last hospitalization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12–15% \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">1 or more falls in the past 12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17–20% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Charlson index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3–4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PROFUND index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Baseline Barthel index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65–70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of long-term prescription drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6–8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prevalence of polypharmacy (5 or more long-term prescription drugs) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of hospitalizations in the past 12 months/3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.9/1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mortality during hospitalization due to an event \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mortality at 12 months in prospective hospital cohorts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525546.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Main clinical characteristics of polypathological patients from various single-center and multicenter studies." ] ] 1 => 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:3 [ "leyenda" => "Abbreviations: mMRC, modified Medical Research Council; NYHA, New York Heart Association." "tablatextoimagen" => array:2 [ 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">Measure \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">Score \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Demography</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≥85 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Clinical characteristics</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Active neoplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \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">Dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \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">NYHA Functional class III–IV or mMRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \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">Delirium during the last hospitalization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Laboratory parameters</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hemoglobin <10g/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Psycho-functional-socio-family characteristics</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Barthel index <60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \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">Lack of caregiver or nonspousal caregiver \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Healthcare characteristics</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 or more hospital admissions in the past 12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total no. of items=9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0–30 points \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525548.png" ] ] 1 => 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">Group \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">PROFUND score \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">Mortality at 12 months (%) \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">Mortality at 4 years (%) \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">Low risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0–2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.1–14.6<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52<a class="elsevierStyleCrossRef" href="#tblfn0010">b</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">Low-intermediate risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3–6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21.5–31.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73.5 \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">Intermediate-high risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45–50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85 \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">High risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68–61.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525549.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Referral and validation cohorts." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Validation cohort." ] ] ] "descripcion" => array:1 [ "en" => "Measures of the PROFUND index for polypathological patients and mortality risk groups at 12 months and 4 years according to the score." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Functional impairment at 12 months is defined as a drop of 20 or more points on the Barthel index compared with baseline.Abbreviations: mMRC, modified Medical Research Council; NYHA, New York Heart Association." "tablatextoimagen" => array:2 [ 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">Measure \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">Simplified PROFUNCTION index \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Demography</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≥85 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Clinical characteristics</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic neurological disease<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \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">Chronic osteoarticular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \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">Dyspnea NYHA class III–IV or mMRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \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">Four or more categories of polypathology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Psycho-functional-socio-family characteristics</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Baseline Barthel index <60 points \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \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">Social risk or established social problem<a class="elsevierStyleCrossRef" href="#tblfn0020">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total items=7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0–7 points \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525551.png" ] ] 1 => 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">Risk group \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">Score on the PROFUNCTION index \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">Functional impairment at 12 months (%) \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">Low risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21–24 \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">Intermediate risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30–34 \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">High risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38–46 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525545.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "Cerebrovascular disease or any other neurological disease with functional/cognitive impairment." ] 1 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "b" "nota" => "According to the Gijón scale." ] ] ] "descripcion" => array:1 [ "en" => "Measures of the simplified PROFUNCTION index for polypathological patients and functional impairment risk groups at 12 months." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "+: lower priority; ++: medium priority; +++: higher priority." "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">Risk group \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">Objective \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">Approach \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">Prescription \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">Advanced planning \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">Low (0–2 points) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Survival +++ Functionality +++ Quality of life +++ Wellbeing +++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Etiopathogenic, avoidance of nihilism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intensified. Medium to long-term objectives \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Informational \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low-intermediate (3–6 points) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Survival ++ Functionality ++ Quality of life +++ Wellbeing +++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pathogenic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rationalized. Medium-term objectives \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Informational. Offering of living wills \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intermediate-high (7–10 points) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Functionality + Quality of life +++ Wellbeing +++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pathogenic-symptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rationalized and with progressive weight of the symptomatic objective in the short to medium term \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Systematic. Recommendation of living wills Approach to the patient's and relatives’ values and preferences Recommendation for choosing a person as a representative/substitute Recording in the medical history \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High (≥11 points) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Quality of life +++ Wellbeing +++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Symptomatic, avoidance of malpractice, and futility/bitterness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mainly symptomatic with short-term objective, assessing deprescription \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Systematic. Recommendation of living wills Approach to the patient's and relatives’ values and preferences Recommendation for choosing a person as a representative/substitute Recording in the medical history Spiritual support programs \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525550.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations on the objectives and approach for polypathological patients depending on their prognosis according to the PROFUND index." ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Negative walking test: walks 4m in less than 5s.Positive walking test: walks 4m in more than 5s.Positive fall test: risk of falls (positive response to 1 or more of the 3 screening questions: Have you had a fall in the past year that required medical care? Have you had 2 or more falls in 1 year? Do you have a gait disorder that is considered significant?).Abbreviation: PPP, polypathological patient." "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">Profile of the polypathological patient \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">Screening results \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">Clinical objectives \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">Intervention targets \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">Interventions \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">Setting of interventions \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">Nonfrail, with no risk of falls \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Barthel ≥90 Negative walking test Negative falls test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Maintain function Strengthen social network \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patient Community network \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Standard recommendations for active aging Specific rehabilitation program depending on the PPP category \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Community resources Primary care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nonfrail, risk of falls \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Barthel ≥90 Negative walking test Positive falls test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Maintain function Strengthen social network Avoid falls \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patient Community network Patient's home Prescription \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Standard recommendations for active aging Specific rehabilitation program depending on the PPP category Home conditioning Review of drugs with a potential effect on falls \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Community resources Primary care Social work \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frail \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Barthel ≥90 Positive walking test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reverse/delay progression of frailty Strengthen social network Avoid falls \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patient Community network Patient's home Prescription \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Standard recommendations for active aging Multicomponent physical activity program Specific rehabilitation program depending on the PPP category Home conditioning Review of drugs with a potential effect on falls \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Community resources Primary care Hospital care Reference internist Rehabilitator/physiotherapist Social work \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dependent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Barthel <90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Delay progression of the dependence cascade Maintain social network Avoid falls Care for the caregiver \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patient Community network Patient's home Prescription Caregiver \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Disability adaptation programs Specific rehabilitation program depending on the PPP category Home conditioning Review of drugs with a potential effect on falls Specific interventions for the caregiver \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Community resources Primary care Hospital care Reference internist Rehabilitator/physiotherapist Social work Nurse liaison \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525547.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Synthetic Schematic for the Approach to Frailty in Polypathological Patients." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:47 [ 0 => array:3 [ "identificador" => "bib0240" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Estrategia para el abordaje de la cronicidad en el Sistema Nacional de Salud" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2012" "editorial" => "Ministerio de Sanidad Política Social e Igualdad" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0245" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Plan Andaluz de Atención Integrada a Pacientes con Enfermedades Crónicas" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2012" "editorial" => "Consejería de Salud, Junta de Andalucía" "editorialLocalizacion" => "Sevilla" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0250" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[accessed 15.01.17]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atención al paciente pluripatológico. 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Symposium. Polypathology

Prognostic stratification and the healthcare approach in patients with multiple pathologies

Estratificación pronóstica y abordaje asistencial de los pacientes pluripatológicos

M. Bernabeu-Wittela,b,

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wittel@cica.es

Corresponding author.

, B. Barón-Francoa, D. Nieto-Martína,b, L. Moreno-Gaviñoa, N. Ramírez-Duquea, M. Ollero-Baturonea

a Unidad Clínica de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain

b Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Instituto de Salud Carlos III, Spain

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            "entidad" => "Red de Investigaci&#243;n en Servicios de Salud en Enfermedades Cr&#243;nicas &#40;REDISSEC&#41;&#44; Instituto de Salud Carlos III&#44; Spain"
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    "titulosAlternativos" => array:1 [
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        "titulo" => "Estratificaci&#243;n pron&#243;stica y abordaje asistencial de los pacientes pluripatol&#243;gicos"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Polypathological patients&#46; Paradigm of an emerging and homogeneous clinical-care population</span><p id="par0005" class="elsevierStylePara elsevierViewall">Life expectancy has increased in recent years&#44; and&#44; as a result&#44; there has been a gradual aging of the population&#46; Socioeconomic advances and biomedical innovations have helped drastically reduce the mortality of numerous diseases &#40;mainly infectious&#44; cardiovascular and neoplastic diseases&#41;&#46; The price of surviving these diseases is none other than the creation of chronic conditions&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">1&#44;2</span></a> We increasingly treat patients with multiple concomitant diseases&#44; many of them interrelated&#46; A prevalent paradigm of this public health phenomenon is the polypathological patient &#40;PPP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">PPPs constitute a homogeneous population with a series of common&#44; easily identifiable characteristics such as advanced age&#44; clinical vulnerability&#44; a tendency toward functional impairment&#44; high mortality during hospitalization and clinical follow-up&#44; low health-related perceived quality of life and a high prevalence of dependence on the caregiver&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">4&#8211;9</span></a> Various studies have profiled the main clinical characteristics of these patients&#44; finding numerous similarities&#44; regardless of the environment and temporal framework&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the main clinical characteristics of PPPs in the various studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">4&#8211;9</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The PPP group has special clinical susceptibility and frailty that entail the frequent demand for care due to intercurrent exacerbations and the onset of interrelated disorders&#44; which worsen the patient&#39;s condition with progressive impairment of their autonomy and functional capacity&#46; PPPs constitute a group that is especially susceptible to the deleterious effects of healthcare fragmentation and superspecialization&#46; PPPs can therefore be considered &#8220;sentinel&#8221; elements of the &#8220;overall health&#8221; of the healthcare system&#44; as well as its level of coordination&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Impact of comorbidity and polypathology on the patient&#39;s vital and functional prognosis</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Impact of comorbidity</span><p id="par0020" class="elsevierStylePara elsevierViewall">There is evidence to confirm that the presence of comorbidity worsens the vital and functional prognosis&#44; the health-related quality of life and the overall health results for all diseases evaluated on this subject&#46; Paradigmatic examples of this are coronary artery disease&#44; heart failure&#44; pneumonia&#44; other severe infections&#44; surgery&#44; chronic renal failure&#44; chronic liver disease&#44; cancer&#44; cerebrovascular disease and chronic lung diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">10&#8211;15</span></a> In the authors&#8217; opinion&#44; this deleterious effect could be due to 2 reasons&#58; &#40;1&#41; the &#8220;domino&#8221; biological effect itself of the comorbidities in reducing the physiological reserve to various aggressions and &#40;2&#41; the &#8220;deterrent&#8221; effect exerted by the comorbidity on medical personnel when making diagnostic and therapeutic decisions that could entail adverse effects &#40;which are more common and severe in these patients&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Impact of polypathology</span><p id="par0025" class="elsevierStylePara elsevierViewall">Polypathology has a marked impact on the patients&#8217; prognoses&#44; both in the primary care &#40;PC&#41; and hospital care settings&#46; It is estimated that the annual mortality of PPPs is approximately 6&#37; in PC&#44; 19&#8211;20&#37; during hospitalization&#44; 36&#37; at 1 year and 50&#37; at 4 years of follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">9&#44;16&#44;17</span></a> This mortality is significantly higher than that of nonpolypathological patients &#40;e&#46;g&#46;&#44; the mortality of patients without polypathology in internal medicine departments is usually no higher than 8&#37;&#41;&#46; The differences in mortality observed in PPP cohorts recruited in PC or hospital care probably lies in the progression stage and severity of the chronic diseases&#44; which is much higher in populations treated in hospitals&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Polypathology also influences the functional prognosis&#46; In fact&#44; these patients usually deteriorate more during hospitalizations than nonpolypathological patients&#44; and the baseline functional condition usually does not recover after discharge&#46; This indicates that specific plans that are better suited to the patient&#39;s needs are required for the care and prevention of functional impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">4</span></a> A classical comparative study on functional impairment between PPPs and nonpolypathological hospitalized patients showed that the mean drop in the Barthel index was significantly higher in the PPP group&#46; PPPs also do not recover their baseline functionality at discharge&#44; in contrast to the nonpolypathological patients&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">4</span></a> In longer follow-ups&#44; functional impairment dramatically affects PPPs&#46; In a Spanish multicenter cohort study&#44; the mean drop in the Barthel index at 12 months of follow-up was 11 points&#44; and 37&#37; of the patients reached 20 or more points&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">18</span></a></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">The importance of prognostic assessment for polypathological patients and high-risk populations</span><p id="par0035" class="elsevierStylePara elsevierViewall">The establishment of an accurate prognosis is one of the core elements of healthcare practice and an ethical duty of health professionals for their patients&#44; the patients&#8217; relatives and society as a whole&#46; This facet of the healthcare practitioner is of particular value in high-risk populations such as PPPs&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We need to understand the prognosis so that the patient and their relatives can arrange their preferences&#44; priorities and personal affairs&#46; The prognosis is also useful for clinicians in the diagnostic and therapeutic decision-making process&#44; thereby avoiding malpractice&#44; unnecessary risks&#44; futility and &#40;for cases with better prognoses in which intensification of the actions could be fully justified&#41; nihilism&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">9&#44;17&#44;19&#44;20</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">From the clinical research perspective&#44; having reliable prognostic instruments helps standardize populations and establish risk subgroups to assess the results of various interventions&#46; This concept is especially relevant for populations with comorbidity and polypathology&#44; which were traditionally excluded from many clinical trials&#44; in part due to the prognostic uncertainties&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Lastly&#44; in terms of macromanagement&#44; the establishment of healthcare population intervention strategies directed at patient subgroups should make use of these prognostic tools&#44; among other sources&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Prognostic indices in comorbidity and polypathology</span><p id="par0055" class="elsevierStylePara elsevierViewall">Prognostic indices are clinimetric instruments that comprise several measures&#44; with different weights&#46; The indices help us stratify the risk of certain health outcomes for homogeneous patient populations&#46; A patient cohort is usually employed to develop the index&#44; thereby deriving the index in question &#40;derivation cohort&#41;&#44; for subsequent validation in a different population &#40;validation cohort&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Numerous instruments have been developed that assess the vital prognosis of patients with comorbidity&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">19&#8211;28</span></a> In contrast&#44; there are fewer indices that have been constructed to predict the functional prognosis&#46; It is essential that the instrument is developed under validity conditions &#40;in its 4 measures&#58; predictive&#44; construct&#44; intraobserver and interobserver&#41;&#44; precise &#40;well calibrated and with discriminative power&#41; and&#44; as much as possible&#44; generalizable &#40;i&#46;e&#46;&#44; reproducible and geographically&#44; historically and methodologically transportable to similar diseases and to different follow-up periods&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the context of comorbidity&#44; the 4 classical prognostic indices that have been used the most are the Charlson index&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">19</span></a> the Cumulative Index Rating Scale&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">20</span></a> the Index of Coexisting Diseases<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">21</span></a> and the Kaplan index &#40;more focused on diabetes&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">22</span></a> There are other more recently developed prognostic instruments such as those by Walter et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">23</span></a> Desai et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">24</span></a> Carey et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">25</span></a> Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">26</span></a> and Levine et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">27</span></a> as well as the Multidimensional Prognostic Index for Mortality Based on a Standardized Multidimensional Assessment Schedule &#40;MPI-SVaMA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">28</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The most notable of the prognostic instruments specifically for PPP is the PROFUND index&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">9</span></a> The index was developed in a multicenter cohort recruited in 36 Spanish hospitals&#44; within the Polypathological Patient and Advanced age workgroup of the Spanish Society of Internal Medicine&#46; The cohort included 1632 patients&#44; 1592 of whom completed the 1-year follow-up&#59; the index was subsequently derived and validated&#46; The index&#39;s measures are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The PROFUND index classifies PPPs into 4 risk groups&#44; according to the score groupings&#46; The mortality rate varies between 12&#37; and 14&#37; in the low-risk stratum and between 61&#37; and 68&#37; for patients with 11 or more points&#46; The index&#39;s good calibration and discriminative power have recently been confirmed in the 4-year follow-up&#44; such that mortality in the low-risk stratum was 52&#37;&#44; while that of patients with 11 or more points reached 92&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">17</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The PROFUND index has shown that its discrimination and calibration are maintained when applied to other PPP cohorts&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">29&#44;30</span></a> The index&#39;s usefulness has also been tested in PC PPPs&#44; where the score cutoffs have been recalibrated&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">31</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The CRONIGAL index has recently been developed from a mixed hospital cohort that included PPPs and other profiles of patients with chronic diseases&#46; The measures that showed greater prognostic weight &#40;and were therefore added to the index&#41; were age&#44; the presence of neoplasia&#44; delirium&#44; functional impairment&#44; cognitive impairment&#44; atrial fibrillation and creatinine levels&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">32</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Functional prognosis in polypathological patients&#46; Frailty screening</span><p id="par0085" class="elsevierStylePara elsevierViewall">The functional prognosis for patients with comorbidity and polypathology is relevant&#44; because functional decline dramatically affects the patients&#8217; quality of life and that of their family and main caregiver and by extension the community environment and health and social services&#46; Functional impairment also constitutes&#44; in and of itself&#44; a risk factor for morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">33</span></a> Therefore&#44; knowing which PPP subgroups are at greater risk of functional impairment and of falling into the dependence cascade is of particular interest for establishing preventive interventions&#46; There are few indices that enable us to predict the functional impairment of patients with comorbidity&#59; these include the Triage Risk Screening Test &#40;TRST&#41;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">34</span></a> and the Variable Indicative of Placement &#40;VIP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">35</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The TRST evaluates &#40;in a dichotomous format&#41; 5 measures &#40;cognitive impairment&#44; difficulties walking&#47;transferring&#44; living alone without a main caregiver&#44; polypharmacy and recent hospitalization&#41;&#46; The presence of cognitive impairment or 2 or more of the remaining measures is considered a high risk for developing functional impairment&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">VIP is an index for predicting functional difficulties after discharge in hospitalized geriatric populations&#46; The index also uses a dichotomous format of 3 measures &#40;social-family situation&#44; functional condition and cognitive state&#41; and considers patients who have 2 of the 3 measures to be high risk&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">For PPPs&#44; we only have 1 index&#44; which was developed with a multicenter cohort in Spanish hospitals&#58; the PROFUNCTION index&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">18</span></a> This index helps us predict which patients will experience a reduction of 20 or more points on the Barthel index scale in the following 12 months&#46; The index consists of 7 simple dimensions to obtain measures and classifies PPPs into 3 risk groups of functional decline according to the scores&#44; ranging from 21&#37; for those with scores of 0 and 46&#37; for those with scores &#8805;4 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Frailty&#44; sarcopenia&#44; disability and dependence are intimately related to functional impairment&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">33&#44;36</span></a> In fact&#44; chronic diseases usually affect the various functions that enable an independent life&#44; directly or indirectly&#44; due to the limitations their symptoms entail or by the required treatments&#46; Disability&#44; dependence and cognitive impairment are very common among PPPs&#46; In PC&#44; 24&#46;3&#37; of PPPs are dependent for basic activities of daily life&#44; and 37&#46;7&#37; have cognitive impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">16</span></a> In the hospital setting&#44; the prevalence of dependence for basic activities of daily life is 55&#37;&#44; and the prevalence of cognitive impairment is 45&#46;7&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">18&#44;37</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">There are fewer data on the prevalence of frailty in these populations&#44; although preliminary studies in the hospital setting place the prevalence at &#62;50&#37; and the prevalence of sarcopenia at &#62;40&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">38</span></a> Frailty in PPPs is an excellent sentinel marker of risk for developing disability and&#44; ultimately&#44; dependence&#46; Frailty is also a good predictor of adverse health events in the short&#44; medium and long term&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">39</span></a> Frailty is easily detectable and susceptible to intervention&#46; Acting on this condition therefore prevents the development of disability&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">40</span></a> As a rule&#44; frailty screening is recommended for all PPPs&#46; Various tests may be used for this purpose&#46; The tests recommended by the Spanish Ministry of Health&#44; Social Services and Equality are the Short Performance Physical Battery &#40;SPPB&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">41</span></a> the gait speed test and timed up and go test&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">40&#44;42</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Healthcare approach for polypathological patients</span><p id="par0115" class="elsevierStylePara elsevierViewall">For the clinical approach for PPPs&#44; the implementation of a &#8220;personalized action plan&#8221; &#40;PAP&#41;&#44; adapted to each patient&#39;s specific reality&#44; is recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">43&#44;44</span></a> The PAP would be the result of identifying the individual&#39;s health problems&#44; developing and agreeing upon with the patient and family the goals and objectives to be reached&#44; the necessary actions to this effect and the follow-up of results and progress&#46; This plan is intended to achieve a more proactive health model&#44; focused on the individual&#39;s ability to manage their disease&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The PAP should be performed in an interdisciplinary manner&#44; among the practitioners who provide treatment&#44; the patient and&#44; in specific cases&#44; the individual caregiver&#46; A predefined regimen should be followed&#44; one that starts by identifying the patient&#39;s main problems and continues by defining the goal&#44; objectives and specific interventions after reaching an agreement with the patient&#44; taking into account their preferences&#46; The prognosis is essential for properly defining the goals and objectives in order to contextualize the clinical decisions according to the expected risks and benefits&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> lists the main recommendations according to the prognosis determined using the PROFUND index&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Personalized action plans for polypathological patients</span><p id="par0125" class="elsevierStylePara elsevierViewall">There is a growing interest in patients with comorbidity and polypathology&#59; however&#44; based on the evidence&#44; this population has been excluded from most clinical trials and intervention studies&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">45</span></a> Nevertheless&#44; there has been a steady increase in the number of interventions that have shown a benefit in terms of improved health and results and that are sometimes translated to PPPs&#44; while others have been effective in similar populations&#46;<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">46&#44;47</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The main actions that can be incorporated to improve the overall health results of PPPs are usually encompassed in 6 large areas&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Health promotion and disease prevention&#46; This area encompasses all recommendations on healthy lifestyles regarding tobacco&#44; diet&#44; physical activity&#44; weight loss&#44; basic sleep hygiene practices and immunizations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Patient and caregiver activation and self-management&#46; This area includes all actions aimed at increasing and consolidating self-efficacy and the level of involvement and understanding of the disease by the patient and caregiver&#46; This area also includes strategies for addressing the disease and actions to decrease caregiver stress&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Activation of the support network and social support&#46; This broad area includes all actions aimed at directing and stimulating community assets for the patient &#40;e&#46;g&#46;&#44; associations&#44; volunteerism&#44; municipal facilities networks&#44; vacations programs&#44; thermalism&#44; cultural activities and physical fitness&#41;&#44; as well as specific support resources &#40;telephone assistance&#44; processing of dependencies&#44; disability counseling&#44; residential resources&#44; family rest&#44; etc&#46;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#41;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Pharmacotherapy optimization&#46; In this area&#44; special care is placed on the appropriateness of the prescription&#44; reconciliation in healthcare transitions&#44; polypharmacy and dosage adjustments depending on renal function&#46; The area also includes actions to promote adherence and patient education in detecting and self-monitoring adverse effects&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Rehabilitation and measures to preserve functional and cognitive abilities&#46; It is advisable to combine the actions to prevent and treat frailty and the risk of falls&#44; along with the implementation of specific programs for the patient&#39;s specific diseases&#46; It is important to first consider the patient&#39;s vital and functional prognosis in order to establish the objectives&#46; For the prevention and approach to frailty&#44; various physical activity programs have been proposed &#40;general&#44; multicomponent activity&#44; etc&#46;&#41;&#44; as well as activities that decrease the risk of falls in susceptible patients&#46; A possible approach is outlined in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46; The objective of the specific rehabilitation and cognitive preservation programs is none other than having a synergistic effect with the generic programs to address frailty and is focused on the categories and diseases shown by each patient &#40;e&#46;g&#46;&#44; cardiac&#44; respiratory&#44; cognitive and rehabilitation&#41;&#46; The objectives and hence the proposed activities will vary depending on each patient&#39;s vital and functional prognosis stratification&#46; Patients with low scores on the PROFUND and PROFUNCTION indices will be directed toward preserving and even improving their functionality&#44; while those with very high scores will be directed toward delaying the loss of functionality&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Advanced planning of decisions&#46; These activities are designed to facilitate a voluntary framework for communicating&#44; establishing and recording the values and preferences of PPPs as to how they wish to be treated&#44; especially in the final moments of life or if they temporarily or permanently lose the ability to decide&#46; The approach to this transcendent area can vary depending on certain factors &#40;healthcare setting&#44; clinical situation&#44; vital prognosis&#41; from a mere examination of values and preferences to the explicit offering of their consignment and recording in the medical history&#44; as detailed in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2016-12-30"
    "fechaAceptado" => "2017-01-24"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec887307"
          "palabras" => array:5 [
            0 => "Patients with multiple pathologies"
            1 => "Prognostics"
            2 => "Personalized action plan"
            3 => "Comorbidity"
            4 => "Multimorbidity"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec887306"
          "palabras" => array:5 [
            0 => "Paciente pluripatol&#243;gico"
            1 => "Pron&#243;stico"
            2 => "Plan de acci&#243;n personalizado"
            3 => "Comorbilidad"
            4 => "Multimorbilidad"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Polypathological patients constitute a prevalent&#44; fairly homogeneous population&#44; which is characterized by high clinical complexity&#44; substantial vulnerability and significant resource consumption&#44; in addition to high mortality and the need for comprehensive&#44; coordinated care&#46; It is particularly important to establish a reliable prognosis in these patients&#46; It is also extremely useful for professionals involved in the decision-making process for patients and their families in vital planning and their preferences&#44; for strategic health planning in management fields&#44; and for clinical research&#44; by facilitating their incorporation into clinical trials and other intervention studies&#46; Two prognostic instruments stand out in terms of suitability for polypathological patients&#58; PROFUND and PROFUNCTION&#46; The former faithfully stratifies the risk of dying at 12 months and four years and the latter&#44; the risk of suffering a significant functional deterioration at 12 months&#46; In terms of the healthcare approach in patients with multiple pathologies&#44; creating and executing a consensual&#44; personalized action plan that is adapted to the patient&#39;s reality is encouraged&#46; The plan will consider the prognosis&#44; and the evidence and viability of interventions&#59; its ultimate aim will be to ensure the synergy and alignment of the health team&#39;s goals and strategies with peoples&#8217; values and preferences&#44; in order to achieve a more proactive health model focused on supporting patients in their ability to manage their illnesses&#46; In the personalized action plan&#44; the main areas of intervention are&#58; health promotion and prevention&#59; patient and caregiver activation and self-management&#59; activation of a social support network and social support&#59; optimization of pharmacotherapy&#59; rehabilitation&#44; functional and cognitive preservation measures&#59; and anticipated decision planning&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los pacientes pluripatol&#243;gicos constituyen una poblaci&#243;n prevalente y homog&#233;nea&#44; caracterizada por su complejidad cl&#237;nica&#44; vulnerabilidad&#44; consumo de recursos y mortalidad que requiere una asistencia integral y coordinada&#46; Establecer un pron&#243;stico certero en esta poblaci&#243;n resulta de utilidad para la toma de decisiones cl&#237;nicas por parte de los profesionales&#44; la planificaci&#243;n de las preferencias de pacientes y familiares&#44; y el dise&#241;o de estrategias en el &#225;mbito de la gesti&#243;n sanitaria&#46; Tambi&#233;n es importante para la investigaci&#243;n cl&#237;nica&#44; al facilitar la posible incorporaci&#243;n de estos pacientes a ensayos cl&#237;nicos y otros estudios de intervenci&#243;n&#46; Los &#237;ndices PROFUND y PROFUNCTION son 2 instrumentos pron&#243;sticos que predicen de manera fidedigna el riesgo de fallecer o de sufrir un deterioro funcional&#44; respectivamente&#46; Para el abordaje asistencial de los pacientes pluripatol&#243;gicos se propugna la construcci&#243;n y ejecuci&#243;n de un plan de acci&#243;n personalizado&#44; consensuado y adaptado a la realidad del paciente&#46; Este tendr&#225; en cuenta el pron&#243;stico&#44; la evidencia y viabilidad de las intervenciones&#44; as&#237; como la sinergia de las metas y estrategias del equipo sanitario con los valores y las preferencias de las personas para conseguir un modelo de salud centrado en apoyar la capacidad de las mismas para gestionar sus enfermedades&#46; En este plan los principales &#225;mbitos de intervenci&#243;n son&#58; la promoci&#243;n y prevenci&#243;n de la salud&#44; la activaci&#243;n y autogesti&#243;n del paciente y el cuidador&#44; la red de apoyo social&#44; la optimizaci&#243;n farmacoterap&#233;utica&#44; la rehabilitaci&#243;n y medidas de preservaci&#243;n funcional y cognitiva&#44; y la planificaci&#243;n anticipada de decisiones&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; Bernabeu-Wittel M&#44; Bar&#243;n-Franco B&#44; Nieto-Mart&#237;n D&#44; Moreno-Gavi&#241;o L&#44; Ram&#237;rez-Duque N&#44; Ollero-Baturone M&#46; Estratificaci&#243;n pron&#243;stica y abordaje asistencial de los pacientes pluripatol&#243;gicos&#46; Rev Clin Esp&#46; 2017&#59;217&#58;410&#8211;419&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:9 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Bernabeu-Wittel et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">6&#44;7&#44;9</span></a> and D&#237;ez-Manglano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">8</span></a>"
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; mMRC&#44; modified Medical Research Council&#59; NYHA&#44; New York Heart Association&#46;</p>"
          "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">Clinical characteristic&nbsp;\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">Mean&#44; median or percentage&nbsp;\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"><span class="elsevierStyleItalic">Mean age&#44; y</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">76&#8211;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Male sex</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&#8211;54&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Number of defining categories per patient</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;4&#8211;2&#46;7&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>Patients with 3 or more categories&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Prevalence of defining categories</span></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>Category A &#40;heart disease&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#8211;77&#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="elsevierStyleHsp" style=""></span>Category C &#40;lung disease&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&#8211;49&#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="elsevierStyleHsp" style=""></span>Category E &#40;neurological disease&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#8211;38&#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="elsevierStyleHsp" style=""></span>Category B &#40;kidney disease&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#8211;32&#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="elsevierStyleHsp" style=""></span>Category G &#40;malignancies&#47;chronic anemia&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#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="elsevierStyleHsp" style=""></span>Category F &#40;peripheral artery disease&#47;diabetes with neuropathy&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#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="elsevierStyleHsp" style=""></span>Category H &#40;degenerative musculoskeletal disease&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#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="elsevierStyleHsp" style=""></span>Category D &#40;liver disease&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Number of other comorbidities per patient</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;5&#8211;2&#46;7&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>Cardiovascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;2&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>Endocrine metabolic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;5&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>Neuropsychiatric&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Most common comorbidities</span></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>Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#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="elsevierStyleHsp" style=""></span>Atrial fibrillation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#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="elsevierStyleHsp" style=""></span>Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&#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="elsevierStyleHsp" style=""></span>Diabetes without visceral repercussion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&#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="elsevierStyleHsp" style=""></span>Anxiety or depression disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#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="elsevierStyleHsp" style=""></span>Benign prostatic hyperplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Common symptoms</span></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>Patients with baseline dyspnea NYHA <span class="elsevierStyleSmallCaps">III</span>&#8211;<span class="elsevierStyleSmallCaps">IV</span>&#47;III&#8211;IV of the mMRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&#8211;48&#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="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Delirium</span> during the last hospitalization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#8211;15&#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="elsevierStyleHsp" style=""></span>1 or more falls in the past 12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#8211;20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Charlson index</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#8211;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">PROFUND index</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Baseline Barthel index</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#8211;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Number of long-term prescription drugs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#8211;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Prevalence of polypharmacy &#40;5 or more long-term prescription drugs&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Number of hospitalizations in the past 12 months&#47;3 months</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;9&#47;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Mortality during hospitalization due to an event</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Mortality at 12 months in prospective hospital cohorts</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1525546.png"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Main clinical characteristics of polypathological patients from various single-center and multicenter studies&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; mMRC&#44; modified Medical Research Council&#59; NYHA&#44; New York Heart Association&#46;</p>"
          "tablatextoimagen" => array:2 [
            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">Measure&nbsp;\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">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Demography</span></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>&#8805;85 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Clinical characteristics</span></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>Active neoplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&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>Dementia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&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>NYHA Functional class III&#8211;IV or mMRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&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><span class="elsevierStyleItalic">Delirium</span> during the last hospitalization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Laboratory parameters</span></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>Hemoglobin &#60;10<span class="elsevierStyleHsp" style=""></span>g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Psycho-functional-socio-family characteristics</span></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>Barthel index &#60;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&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>Lack of caregiver or nonspousal caregiver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Healthcare characteristics</span></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>4 or more hospital admissions in the past 12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Total no&#46; of items</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">9</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#8211;30 points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1525548.png"
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            1 => 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">Group&nbsp;\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">PROFUND score&nbsp;\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">Mortality at 12 months &#40;&#37;&#41;&nbsp;\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">Mortality at 4 years &#40;&#37;&#41;&nbsp;\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">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#8211;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;1&#8211;14&#46;6<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">Low-intermediate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#8211;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;5&#8211;31&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&#46;5&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">Intermediate-high risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&#8211;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&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">High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&#8211;61&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Referral and validation cohorts&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Validation cohort&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Measures of the PROFUND index for polypathological patients and mortality risk groups at 12 months and 4 years according to the score&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Functional impairment at 12 months is defined as a drop of 20 or more points on the Barthel index compared with baseline&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; mMRC&#44; modified Medical Research Council&#59; NYHA&#44; New York Heart Association&#46;</p>"
          "tablatextoimagen" => array:2 [
            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">Measure&nbsp;\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">Simplified PROFUNCTION index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Demography</span></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>&#8805;85 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Clinical characteristics</span></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>Chronic neurological disease<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&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>Chronic osteoarticular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&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>Dyspnea NYHA class III&#8211;IV or mMRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&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>Four or more categories of polypathology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Psycho-functional-socio-family characteristics</span></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>Baseline Barthel index &#60;60 points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&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>Social risk or established social problem<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></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">Total items</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">7</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#8211;7 points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1525551.png"
              ]
            ]
            1 => 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">Risk group&nbsp;\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">Score on the PROFUNCTION index&nbsp;\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">Functional impairment at 12 months &#40;&#37;&#41;&nbsp;\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">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#8211;24&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">Intermediate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;34&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">High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#8211;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0015"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Cerebrovascular disease or any other neurological disease with functional&#47;cognitive impairment&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">According to the Gij&#243;n scale&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Measures of the simplified PROFUNCTION index for polypathological patients and functional impairment risk groups at 12 months&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#43;&#58; lower priority&#59; &#43;&#43;&#58; medium priority&#59; &#43;&#43;&#43;&#58; higher priority&#46;</p>"
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                  <table border="0" frame="\n
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                  \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">Risk group&nbsp;\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">Objective&nbsp;\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">Approach&nbsp;\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">Prescription&nbsp;\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">Advanced planning&nbsp;\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">Low &#40;0&#8211;2 points&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Survival &#43;&#43;&#43;<br>Functionality &#43;&#43;&#43;<br>Quality of life &#43;&#43;&#43;<br>Wellbeing &#43;&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Etiopathogenic&#44; avoidance of nihilism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intensified&#46; Medium to long-term objectives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Informational&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low-intermediate &#40;3&#8211;6 points&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Survival &#43;&#43;<br>Functionality &#43;&#43;<br>Quality of life &#43;&#43;&#43;<br>Wellbeing &#43;&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pathogenic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rationalized&#46; Medium-term objectives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Informational&#46; Offering of living wills&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pathogenic-symptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rationalized and with progressive weight of the symptomatic objective in the short to medium term&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systematic&#46; Recommendation of living wills<br>Approach to the patient&#39;s and relatives&#8217; values and preferences<br>Recommendation for choosing a person as a representative&#47;substitute<br>Recording in the medical history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High &#40;&#8805;11 points&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Quality of life &#43;&#43;&#43;<br>Wellbeing &#43;&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Symptomatic&#44; avoidance of malpractice&#44; and futility&#47;bitterness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mainly symptomatic with short-term objective&#44; assessing deprescription&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systematic&#46; Recommendation of living wills<br>Approach to the patient&#39;s and relatives&#8217; values and preferences<br>Recommendation for choosing a person as a representative&#47;substitute<br>Recording in the medical history<br>Spiritual support programs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Recommendations on the objectives and approach for polypathological patients depending on their prognosis according to the PROFUND index&#46;</p>"
        ]
      ]
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Negative walking test&#58; walks 4<span class="elsevierStyleHsp" style=""></span>m in less than 5<span class="elsevierStyleHsp" style=""></span>s&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Positive walking test&#58; walks 4<span class="elsevierStyleHsp" style=""></span>m in more than 5<span class="elsevierStyleHsp" style=""></span>s&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Positive fall test&#58; risk of falls &#40;positive response to 1 or more of the 3 screening questions&#58; Have you had a fall in the past year that required medical care&#63; Have you had 2 or more falls in 1 year&#63; Do you have a gait disorder that is considered significant&#63;&#41;&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>&#58; PPP&#44; polypathological patient&#46;</p>"
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                  <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">Profile of the polypathological patient&nbsp;\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">Screening results&nbsp;\t\t\t\t\t\t\n
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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">Setting of interventions&nbsp;\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">Nonfrail&#44; with no risk of falls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Barthel &#8805;90<br>Negative walking test<br>Negative falls test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maintain function<br>Strengthen social network&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patient<br>Community network&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Standard recommendations for active aging<br>Specific rehabilitation program depending on the PPP category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Community resources<br>Primary care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nonfrail&#44; risk of falls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Barthel &#8805;90<br>Negative walking test<br>Positive falls test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maintain function<br>Strengthen social network<br>Avoid falls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patient<br>Community network<br>Patient&#39;s home<br>Prescription&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Standard recommendations for active aging<br>Specific rehabilitation program depending on the PPP category<br>Home conditioning<br>Review of drugs with a potential effect on falls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Community resources<br>Primary care<br>Social work&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frail&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Barthel &#8805;90<br>Positive walking test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reverse&#47;delay progression of frailty<br>Strengthen social network<br>Avoid falls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patient<br>Community network<br>Patient&#39;s home<br>Prescription&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Standard recommendations for active aging<br>Multicomponent physical activity program<br>Specific rehabilitation program depending on the PPP category<br>Home conditioning<br>Review of drugs with a potential effect on falls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Community resources<br>Primary care<br>Hospital care<br>Reference internist<br>Rehabilitator&#47;physiotherapist<br>Social work&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dependent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Barthel &#60;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Delay progression of the dependence cascade<br>Maintain social network<br>Avoid falls<br>Care for the caregiver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patient<br>Community network<br>Patient&#39;s home<br>Prescription<br>Caregiver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Disability adaptation programs<br>Specific rehabilitation program depending on the PPP category<br>Home conditioning<br>Review of drugs with a potential effect on falls<br>Specific interventions for the caregiver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Community resources<br>Primary care<br>Hospital care<br>Reference internist<br>Rehabilitator&#47;physiotherapist<br>Social work<br>Nurse liaison&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Synthetic Schematic for the Approach to Frailty in Polypathological Patients&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
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            0 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "1"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2012"
                        "editorial" => "Ministerio de Sanidad Pol&#237;tica Social e Igualdad"
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                    ]
                  ]
                ]
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              "identificador" => "bib0245"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Plan Andaluz de Atenci&#243;n Integrada a Pacientes con Enfermedades Cr&#243;nicas"
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2012"
                        "editorial" => "Consejer&#237;a de Salud&#44; Junta de Andaluc&#237;a"
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                      ]
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                ]
              ]
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              "identificador" => "bib0250"
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                0 => array:3 [
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                    0 => array:2 [
                      "titulo" => "Atenci&#243;n al paciente pluripatol&#243;gico&#46; Proceso asistencial integrado"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Ollero-Baturone"
                            1 => "M&#46; Alvarez"
                            2 => "B&#46; Bar&#243;n-Franco"
                            3 => "M&#46; Bernabeu-Wittel"
                            4 => "A&#46; Codina"
                            5 => "A&#46; Fern&#225;ndez-Moyano"
                          ]
                        ]
                      ]
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                  ]
                  "host" => array:2 [
                    0 => array:1 [
                      "Libro" => array:4 [
                        "edicion" => "2nd ed&#46;"
                        "fecha" => "2007"
                        "editorial" => "Consejer&#237;a de Salud&#44; Junta de Andaluc&#237;a"
                        "editorialLocalizacion" => "Sevilla"
                      ]
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                    1 => array:1 [
                      "WWW" => array:1 [
                        "link" => "http&#58;&#47;&#47;www&#46;juntadeandalucia&#46;es&#47;salud&#47;sites&#47;csalud&#47;contenidos&#47;Informacion&#95;General&#47;p&#95;3&#95;p&#95;3&#95;procesos&#95;asistenciales&#95;integrados&#47;pai&#47;atencion&#95;pacientes&#95;pluripatologicos&#95;v3&#63;perfil&#61;org"
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              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidencia y caracter&#237;sticas cl&#237;nicas de los pacientes con pluripatolog&#237;a ingresados en una unidad de Medicina Interna"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;S&#46; Garc&#237;a-Morillo"
                            1 => "M&#46; Bernabeu-Wittel"
                            2 => "M&#46; Ollero-Baturone"
                            3 => "M&#46; Aguilar-Guisado"
                            4 => "N&#46; Ram&#237;rez-Duque"
                            5 => "P&#46; Limpo"
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                    0 => array:1 [
                      "Revista" => array:5 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perceived quality of healthcare in a multicenter&#44; community-based population of polypathological patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Rinc&#243;n-G&#243;mez"
                            1 => "M&#46; Bernabeu-Wittel"
                            2 => "P&#46; Boh&#243;rquez-Colombo"
                            3 => "L&#46; Moreno-Gavi&#241;o"
                            4 => "M&#46; Cassani-Garza"
                            5 => "M&#46;A&#46; Ortiz-Cam&#250;&#241;ez"
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                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.archger.2010.03.003"
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                        "tituloSerie" => "Arch Gerontol Geriatr"
                        "fecha" => "2011"
                        "volumen" => "52"
                        "paginaInicial" => "142"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20346523"
                            "web" => "Medline"
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              "identificador" => "bib0265"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Peeking through the cracks&#58; an assessment of the prevalence&#44; clinical characteristics and health-related quality of life of people with polypathology in a hospital setting"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Bernabeu-Wittel"
                            1 => "A&#46; Jadad"
                            2 => "L&#46; Moreno-Gavi&#241;o"
                            3 => "C&#46; Hern&#225;ndez-Quiles"
                            4 => "F&#46; Toscano"
                            5 => "M&#46; Cassani"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.archger.2009.10.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Gerontol Geriatr"
                        "fecha" => "2010"
                        "volumen" => "51"
                        "paginaInicial" => "185"
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                            "web" => "Medline"
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                ]
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              "etiqueta" => "7"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A multi-institutional&#44; hospital-based assessment of clinical&#44; functional&#44; sociofamilial and health-care characteristics of polypathological patients"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "On Behalf of the PROFUND Researchers"
                          "etal" => true
                          "autores" => array:6 [
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2017.01.004

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