En la medicina , la comorbilidad es la presencia de una o más condiciones a menudo concurrentes (es decir, concomitante o concurrente ) con una condición primaria. La comorbilidad describe el efecto de todas las demás afecciones que un paciente individual podría tener, además de la afección principal de interés, y puede ser fisiológica o psicológica. En el contexto de la salud mental, la comorbilidad a menudo se refiere a trastornos que a menudo coexisten entre sí, como la depresión y los trastornos de ansiedad .
La comorbilidad puede indicar una afección que existe simultáneamente, pero de forma independiente, con otra afección o una afección médica relacionada. El último sentido del término provoca cierta superposición con el concepto de complicaciones . Por ejemplo, en la diabetes mellitus de larga duración , no es fácil medir hasta qué punto la enfermedad de las arterias coronarias es una comorbilidad independiente frente a una complicación diabética , porque ambas enfermedades son bastante multivariadas y hay aspectos probables tanto de simultaneidad como de consecuencia. Lo mismo ocurre con las enfermedades intercurrentes durante el embarazo . En otros ejemplos, la verdadera independencia o relación no se puede determinar porqueLos síndromes y las asociaciones a menudo se identifican mucho antes de que se confirmen las similitudes patogénicas (y, en algunos ejemplos, incluso antes de que se formulen hipótesis ). En los diagnósticos psiquiátricos se ha argumentado en parte que este "'uso de lenguaje impreciso puede conducir a un pensamiento correspondientemente impreciso', [y] este uso del término 'comorbilidad' probablemente debería evitarse". [1] Sin embargo, en muchos ejemplos médicos, como la diabetes mellitus comórbida y la enfermedad de las arterias coronarias, no importa qué palabra se use, siempre que se reconozca y aborde debidamente la complejidad médica.
Muchas pruebas intentan estandarizar el "peso" o el valor de las condiciones comórbidas, ya sean enfermedades secundarias o terciarias. Cada prueba intenta consolidar cada condición comórbida individual en una única variable predictiva que mide la mortalidad u otros resultados. Los investigadores han validado tales pruebas debido a su valor predictivo, pero hasta ahora ninguna prueba es reconocida como estándar.
El término "comórbido" tiene tres definiciones:
- para indicar una afección médica que existe de forma simultánea pero independiente con otra afección en un paciente.
- para indicar una afección médica en un paciente que causa, es causada por o está relacionada de otra manera con otra afección en el mismo paciente. [2]
- para indicar dos o más condiciones médicas que existen simultáneamente independientemente de su relación causal. [3]
Índice de Charlson
El índice de comorbilidad de Charlson [4] predice la mortalidad a un año para un paciente que puede tener una variedad de condiciones comórbidas, como enfermedad cardíaca , SIDA o cáncer (un total de 22 condiciones). A cada condición se le asigna una puntuación de 1, 2, 3 o 6, dependiendo del riesgo de muerte asociado a cada una. Las puntuaciones se suman para proporcionar una puntuación total para predecir la mortalidad. Se han presentado muchas variaciones del índice de comorbilidad de Charlson, incluidos los índices de comorbilidad de Charlson / Deyo, Charlson / Romano, Charlson / Manitoba y Charlson / D'Hoores.
Las condiciones clínicas y las puntuaciones asociadas son las siguientes:
- 1 de cada uno: infarto de miocardio, insuficiencia cardíaca congestiva, enfermedad vascular periférica, demencia, enfermedad cerebrovascular, enfermedad pulmonar crónica, enfermedad del tejido conectivo, úlcera, enfermedad hepática crónica, diabetes.
- 2 de cada uno: hemiplejía, enfermedad renal moderada o grave, diabetes con daño en los órganos terminales, tumor, leucemia, linfoma.
- 3 de cada uno: Enfermedad hepática moderada o grave.
- 6 de cada uno: tumor maligno, metástasis, sida.
Para un médico, esta puntuación es útil para decidir qué tan agresivamente tratar una afección. Por ejemplo, un paciente puede tener cáncer con enfermedad cardíaca comórbida y diabetes. Estas comorbilidades pueden ser tan graves que los costos y riesgos del tratamiento del cáncer superarían su beneficio a corto plazo.
Dado que los pacientes a menudo no saben qué tan graves son sus afecciones, originalmente se suponía que las enfermeras revisaban la historia clínica de un paciente y determinaban si una afección en particular estaba presente para calcular el índice. Estudios posteriores han adaptado el índice de comorbilidad en un cuestionario para pacientes.
El índice de Charlson, especialmente el Charlson / Deyo, seguido por el Elixhauser, han sido los más comúnmente referidos por los estudios comparativos de medidas de comorbilidad y multimorbilidad. [5]
Puntaje de comorbilidad-polifarmacia (CPS)
El puntaje de comorbilidad-polifarmacia (CPS) es una medida simple que consiste en la suma de todas las condiciones comórbidas conocidas y todos los medicamentos asociados. No existe una correspondencia específica entre las condiciones comórbidas y los medicamentos correspondientes. En cambio, se supone que el número de medicamentos es un reflejo de la "intensidad" de las condiciones comórbidas asociadas. Esta puntuación ha sido probada y validada extensamente en la población de trauma, demostrando una buena correlación con la mortalidad, morbilidad, triaje y reingresos hospitalarios. [6] [7] [8] Es interesante que los niveles crecientes de CPS se asociaron con una supervivencia a 90 días significativamente más baja en el estudio original de la puntuación en la población con traumatismos. [6]
Medida de comorbilidad de Elixhauser
La medida de comorbilidad de Elixhauser se desarrolló utilizando datos administrativos de una base de datos de pacientes hospitalizados en todo el estado de California de todas las estadías en hospitales comunitarios para pacientes hospitalizados no federales en California ( n = 1,779,167). La medida de comorbilidad de Elixhauser desarrolló una lista de 30 comorbilidades basándose en el manual de codificación ICD-9-CM. Las comorbilidades no se simplificaron como un índice porque cada comorbilidad afectó los resultados (duración de la estancia hospitalaria, cambios hospitalarios y mortalidad) de manera diferente entre los diferentes grupos de pacientes. Las comorbilidades identificadas por la medida de comorbilidad de Elixhauser se asocian significativamente con la mortalidad hospitalaria e incluyen afecciones tanto agudas como crónicas. van Walraven y col. han derivado y validado un índice de comorbilidad de Elixhauser que resume la carga de morbilidad y puede discriminar la mortalidad intrahospitalaria. [9] Además, una revisión sistemática y un análisis comparativo muestra que entre varios índices de comorbilidades, el índice de Elixhauser es un mejor predictor del riesgo, especialmente después de los 30 días de hospitalización. [5]
Los pacientes con enfermedades más graves tienden a requerir más recursos hospitalarios que los pacientes con enfermedades menos graves, aunque ingresan en el hospital por el mismo motivo. Reconociendo esto, el grupo relacionado con el diagnóstico (GRD) divide manualmente ciertos GRD en función de la presencia de diagnósticos secundarios para complicaciones o comorbilidades específicas (CC). Lo mismo se aplica a los grupos de recursos sanitarios (HRG) en el Reino Unido.
Salud mental
En psiquiatría , psicología y consejería en salud mental, la comorbilidad se refiere a la presencia de más de un diagnóstico en un individuo al mismo tiempo. Sin embargo, en la clasificación psiquiátrica, la comorbilidad no implica necesariamente la presencia de múltiples enfermedades, sino que puede reflejar la incapacidad actual para proporcionar un diagnóstico único que explique todos los síntomas. [10] En el Eje I del DSM , el trastorno depresivo mayor es un trastorno comórbido muy común. Los trastornos de la personalidad del Eje II son a menudo criticados porque sus tasas de comorbilidad son excesivamente altas, acercándose al 60% en algunos casos. Los críticos afirman que esto indica que estas categorías de enfermedades mentales se distinguen de manera demasiado imprecisa para ser válidas para fines de diagnóstico, lo que afecta el tratamiento y la asignación de recursos.
El término "comorbilidad" fue introducido en medicina por Feinstein (1970) para describir los casos en los que una "entidad clínica adicional distinta" ocurrió antes o durante el tratamiento de la "enfermedad índice", el diagnóstico original o primario. Desde que se acuñaron los términos, los metaestudios han demostrado que los criterios utilizados para determinar la enfermedad índice eran imperfectos y subjetivos y, además, tratar de identificar una enfermedad índice como la causa de las otras puede ser contraproducente para comprender y tratar afecciones interdependientes. En respuesta, se introdujo "multimorbilidad" para describir condiciones concurrentes sin relatividad o dependencia implícita de otra enfermedad, de modo que las interacciones complejas emerjan naturalmente bajo el análisis del sistema como un todo. [11]
Aunque el término 'comorbilidad' se ha puesto de moda recientemente en psiquiatría, se dice que su uso para indicar la concomitancia de dos o más diagnósticos psiquiátricos es incorrecto porque en la mayoría de los casos no está claro si los diagnósticos concomitantes realmente reflejan la presencia de entidades clínicas distintas. o referirse a múltiples manifestaciones de una única entidad clínica. Se ha argumentado que debido a que "'el uso de un lenguaje impreciso puede conducir a un pensamiento correspondientemente impreciso', este uso del término 'comorbilidad' probablemente debería evitarse". [12]
Debido a su naturaleza artefactual, la comorbilidad psiquiátrica ha sido considerada como una anomalía kuhniana que llevó al DSM a una crisis científica [13] y una revisión exhaustiva al respecto considera la comorbilidad como un desafío epistemológico para la psiquiatría moderna. [14]
Inicio del término
Hace muchos siglos, los médicos propagaron la viabilidad de un enfoque complejo en el diagnóstico de la enfermedad y el tratamiento del paciente, sin embargo, la medicina moderna, que cuenta con una amplia gama de métodos de diagnóstico y una variedad de procedimientos terapéuticos, enfatiza la especificación. Esto planteó una pregunta: ¿Cómo evaluar completamente el estado de un paciente que padece varias enfermedades simultáneamente, por dónde empezar y qué enfermedad (es) requiere (s) tratamiento primario y posterior? Durante muchos años esta pregunta permaneció sin respuesta, hasta 1970, cuando un reconocido médico epidemiólogo e investigador estadounidense, AR Feinstein , que había influido mucho en los métodos de diagnóstico clínico y, en particular, en los métodos utilizados en el campo de la epidemiología clínica, presentó el término de "comorbilidad". La aparición de la comorbilidad fue demostrada por Feinstein utilizando el ejemplo de pacientes que padecían físicamente fiebre reumática, descubriendo el peor estado de los pacientes, que simultáneamente padecían múltiples enfermedades. A su debido tiempo después de su descubrimiento, la comorbilidad se distinguió como una disciplina de investigación científica separada en muchas ramas de la medicina. [15]
Evolución del término
Actualmente no existe una terminología acordada de comorbilidad. Algunos autores plantean diferentes significados de comorbilidad y multimorbilidad, definiendo el primero, como la presencia de una serie de enfermedades en un paciente, conectadas entre sí a través de mecanismos patogénicos probados y el segundo, como la presencia de una serie de enfermedades en el paciente. un paciente, no tener ninguna conexión entre sí a través de ninguno de los mecanismos patogénicos probados hasta la fecha. [16] Otros afirman que la multimorbilidad es la combinación de una serie de enfermedades crónicas o agudas y síntomas clínicos en una persona y no enfatizan las similitudes o diferencias en su patogenia. [17] Sin embargo, HC Kraemer y M. van den Akker dieron la principal aclaración del término, determinando la comorbilidad como la combinación en un paciente de 2 o más enfermedades crónicas (trastornos), patogenéticamente relacionadas entre sí o coexistiendo en una sola paciente independientemente de la actividad de cada enfermedad en el paciente. [ cita requerida ]
Investigar
Psiquiatría
El estudio generalizado de la patología física y mental encontró su lugar en la psiquiatría. I. Jensen (1975), [18] JH Boyd (1984), [19] WC Sanderson (1990), [20] Yuri Nuller (1993), [21] DL Robins (1994), [22] AB Smulevich (1997) ), [23] CR Cloninger (2002) [24] y otros psiquiatras de renombre dedicaron muchos años al descubrimiento de una serie de enfermedades comórbidas en pacientes que padecían los más diversos trastornos psiquiátricos. Estos mismos investigadores desarrollaron los primeros modelos de comorbilidad. Algunos de los modelos estudiaron la comorbilidad como la presencia en una persona (paciente) de más de un trastorno (enfermedades) en un período determinado de la vida, mientras que otros elaboraron el riesgo relativo, para una persona que tiene una enfermedad, de contraer otros trastornos. . [ cita requerida ]
General medicine
The influence of comorbidity on the clinical progression of the primary (basic) physical disorder, effectiveness of the medicinal therapy and immediate and long-term prognosis of the patients was researched by talented physicians and scientists of various medical fields in many countries across the globe. These scientists and physicians included: M. H. Kaplan (1974),[25] T. Pincus (1986),[26] M. E. Charlson (1987),[27] F. G. Schellevis (1993),[28] H. C. Kraemer (1995),[29] M. van den Akker (1996),[30] A. Grimby (1997),[31] S. Greenfield (1999),[32] M. Fortin (2004) & A. Vanasse (2004),[33] C. Hudon (2005),[34] L. B. Lazebnik (2005),[35] A. L. Vertkin (2008),[36] G. E. Caughey (2008),[37] F. I. Belyalov (2009),[38] L. A. Luchikhin (2010)[39] and many others.
Sinónimos
- Polymorbidity
- Multimorbidity
- Multifactorial diseases
- Polypathy
- Dual diagnosis, used for mental health issues
- Pluralpathology
Epidemiología
Comorbidity is widespread among the patients admitted at multidiscipline hospitals. During the phase of initial medical help, the patients having multiple diseases simultaneously are a norm rather than an exception. Prevention and treatment of chronic diseases declared by the World Health Organization, as a priority project for the second decade of the 20th century, are meant to better the quality of the global population.[40][41][42][43][44] This is the reason for an overall tendency of large-scale epidemiological researches in different medical fields, carried-out using serious statistical data. In most of the carried-out, randomized, clinical researches the authors study patients with single refined pathology, making comorbidity an exclusive criterion. This is why it is hard to relate researches, directed towards the evaluation of the combination of ones or the other separate disorders, to works regarding the sole research of comorbidity. The absence of a single scientific approach to the evaluation of comorbidity leads to omissions in clinical practice. It is hard not to notice the absence of comorbidity in the taxonomy (systematics) of disease, presented in ICD-10.[citation needed]
Clinico-pathological comparisons
All the fundamental researches of medical documentation, directed towards the study of the spread of comorbidity and influence of its structure, were conducted till the 1990s. The sources of information, used by the researchers and scientists, working on the matter of comorbidity, were case histories,[45][46] hospital records of patients[47] and other medical documentation, kept by family doctors, insurance companies[48] and even in the archives of patients in old houses.[49]
The listed methods of obtaining medical information are mainly based on clinical experience and qualification of the physicians, carrying out clinically, instrumentally and laboratorially confirmed diagnosis. This is why despite their competence, they are highly subjective. No analysis of the results of postmortem of deceased patients was carried out for any of the comorbidity researches.
"It is the duty of the doctor to carry out autopsy of the patients they treat", said once professor M. Y. Mudrov. Autopsy allows you to exactly determine the structure of comorbidity and the direct cause of death of each patient independent of his/her age, gender and gender specific characteristics. Statistical data of comorbid pathology, based on these sections, are mainly devoid of subjectivism.
Research
The analysis of a decade long Australian research based on the study of patients having 6 widespread chronic diseases demonstrated that nearly half of the elderly patients with arthritis also had hypertension, 20% had cardiac disorders and 14% had type 2 diabetes. More than 60% of asthmatic patients complained of concurrent arthritis, 20% complained of cardiac problems and 16% had type 2 diabetes.[50]
In patients with chronic kidney disease (renal insufficiency) the frequency of coronary heart disease is 22% higher and new coronary events 3.4 times higher compared to patients without kidney function disorders. Progression of CKD towards end stage renal disease requiring renal replacement therapy is accompanied by increasing prevalence of Coronary Heart Disease and sudden death from cardiac arrest.[51]
A Canadian research conducted upon 483 obesity patients, it was determined that spread of obesity related accompanying diseases was higher among females than males. The researchers discovered that nearly 75% of obesity patients had accompanying diseases, which mostly included dyslipidemia, hypertension and type 2 diabetes. Among the young obesity patients (from 18 to 29) more than two chronic diseases were found in 22% males and 43% females.[52]
Fibromyalgia is a condition which is comorbid with several others, including but not limited to; depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, rheumatoid arthritis,[53] migraine, and panic disorder.[54]
The number of comorbid diseases increases with age. Comorbidity increases by 10% in ages up to 19 years, up to 80% in people of ages 80 and older.[55] According to data by M. Fortin, based on the analysis of 980 case histories, taken from daily practice of a family doctor, the spread of comorbidity is from 69% in young patients, up to 93% among middle aged people and up to 98% patients of older age groups. At the same time the number of chronic diseases varies from 2.8 in young patients and 6.4 among older patients.[56]
According to Russian data, based on the study of more than three thousand postmortem reports (n=3239) of patients of physical pathologies, admitted at multidisciplinary hospitals for the treatment of chronic disorders (average age 67.8 ± 11.6 years), the frequency of comorbidity is 94.2%. Doctors mostly come across a combination of two to three disorders, but in rare cases (up to 2.7%) a single patient carried a combination of 6–8 diseases simultaneously.[57]
The fourteen-year research conducted on 883 patients of idiopathic thrombocytopenic purpura (Werlhof disease), conducted in Great Britain, shows that the given disease is related to a wide range of physical pathologies. In the comorbid structure of these patients, most frequently present are malignant neoplasms, locomotorium disorders, skin and genitourinary system disorders, as well as haemorrhagic complications and other autoimmune diseases, the risk of whose progression during the first five years of the primary disease exceeds the limit of 5%.[58]
In a research conducted on 196 larynx cancer patients, it was determined that the survival rate of patients at various stages of cancer differs depending upon the presence or absence of comorbidity. At the first stage of cancer the survival rate in the presence of comorbidity is 17% and in its absence it is 83%, in the second stage of cancer the rate of survivability is 14% and 76%, in the third stage it is 28% and 66% and in the fourth stage of cancer it is 0% and 50% respectively. Overall the survivability rate of comorbid larynx cancer patients is 59% lower than the survivability rate of patients without comorbidity.[59]
Except for therapists and general physicians, the problem of comorbidity is also often faced by specialists. Regretfully they seldom pay attention to the coexistence of a whole range of disorders in a single patient and mostly conduct the treatment of specific to their specialization diseases. In current practice urologists, gynecologists, ENT specialists, eye specialists, surgeons and other specialists all too often mention only the diseases related to "own" field of specialization, passing on the discovery of other accompanying pathologies "under the control" of other specialists. It has become an unspoken rule for any specialized department to carry out consultations of the therapist, who feels obliged to carry out symptomatic analysis of the patient, as well as to the form the diagnostic and therapeutic concept, taking in view the potential risks for the patient and his long-term prognosis.[citation needed]
Based on the available clinical and scientific data it is possible to conclude that comorbidity has a range of undoubted properties, which characterize it as a heterogeneous and often encountered event, which enhances the seriousness of the condition and worsens the patient's prospects. The heterogeneous character of comorbidity is due to the wide range of reasons causing it.[60][61]
Causas
- Anatomic proximity of diseased organs
- Singular pathogenetic mechanism of a number of diseases
- Terminable cause-effect relation between the diseases
- One disease resulting from complications of another
- Pleiotropy[62]
The factors responsible for the development of comorbidity can be chronic infections, inflammations, involutional and systematic metabolic changes, iatrogenesis, social status, ecology and genetic susceptibility.
Tipos
- Trans-syndromal comorbidity: coexistence, in a single patient, of two and/or more syndromes, pathogenetically related to each other.
- Trans-nosological comorbidity: coexistence, in a single patient, of two and/or more syndromes, pathogenetically not related to each other.
The division of comorbidity as per syndromal and nosological principles is mainly preliminary and inaccurate, however it allows us to understand that comorbidity can be connected to a singular cause or common mechanisms of pathogenesis of the conditions, which sometimes explains the similarity in their clinical aspects, which makes it difficult to differentiate between nosologies.
- Etiological comorbidity:[63] It is caused by concurrent damage to different organs and systems, which is caused by a singular pathological agent (for example due to alcoholism in patients suffering from chronic alcohol intoxication; pathologies associated with smoking; systematic damage due to collagenoses).
- Complicated comorbidity: It is the result of the primary disease and often subsequent after sometime after its destabilization appears in the shape of target lesions (for example chronic nephratony resulting from diabetic nephropathy (Kimmelstiel-Wilson disease) in patients with type 2 diabetes; development of brain infarction resulting from complications due to hypertensive crisis in patients suffering from hypertension).
- Iatrogenic comorbidity: It appears as a result of necessitated negative effect of the doctor on the patient, under the conditions of pre determine danger of one or the other medical procedure (for example, glucocorticosteroid osteoporosis in patients treated for a long time using systematic hormonal agents (preparations); drug-induced hepatitis resulting from chemotherapy against TB, prescribed due to the conversion of tubercular tests).
- Unspecified (NOS) comorbidity: This type assumes the presence of singular pathogenetic mechanisms of development of diseases, comprising this combination, but require a number of tests, proving the hypothesis of the researcher or physician (for example, erectile dysfunction as an early sign of general atherosclerosis (ASVD); occurrence of erosive-ulcerative lesions in the mucous membrane of the upper gastrointestinal tract in "vascular" patients).
- "Arbitrary" comorbidity: initial alogism of the combination of diseases is not proven, but soon can be explained with clinical and scientific point of view (for example, combination of coronary heart disease (CHD) and choledocholithiasis; combination of acquired heart valvular disease and psoriasis).
Estructura
There are a number of rules for the formulation of clinical diagnosis for comorbid patients, which must be followed by a practitioner. The main principle is to distinguish in diagnosis the primary and background diseases, as well as their complications and accompanying pathologies.[64][65]
- Primary disease: This is the nosological form, which itself or as a result of complications calls for the foremost necessity for treatment at the time due to threat to the patient's life and danger of disability. Primary is the disease, which becomes the cause of seeking medical help or the reason for the patient's death. If the patient has several primary diseases it is important to first of all understand the combined primary diseases (rival or concomitant).
- Rival diseases: These are the concurrent nosological forms in a patient, interdependent in etiologies and pathogenesis, but equally sharing the criterion of a primary disease (for example, transmural myocardial infarction and massive thromboembolism of pulmonary artery, caused by phlebemphraxis of lower limbs). For practicing pathologist rival are two or more diseases, exhibited in a single patient, each of which by itself or through its complications could cause the patient's death.
- Polypathia: Diseases with different etiologies and pathogenesis, each of which separately could not cause death, but, concurring during development and reciprocally exacerbating each other, they cause the patient's death (for example, osteoporotic fracture of the surgical neck of the femur and hypostatic pneumonia).
- Background disease: This helps in the occurrence of or adverse development of the primary disease increases its dangers and helps in the development of complications. This disease as well as the primary one requires immediate treatment (for example, type 2 diabetes).
- Complications: Nosologies having pathogenetic relation to the primary disease, supporting the adverse progression of the disorder, causing acute worsening of the patient's conditions (are a part of the complicated comorbidity). In a number of cases the complications of the primary disease and related to it etiological and pathogenetic factors, are indicated as conjugated disease. In this case they must be identified as the cause of comorbidity. Complications are listed in a descending order of prognostic or disabling significance.
- Associating diseases: Nosological units not connected etiologically and pathogenetically with the primary disease (Listed in the order of significance).
Diagnóstico
There is no doubt in the significance of comorbidity, but how is it evaluated (measured) in a given patient?
Clinical example
Patient S., 73 years, called an ambulance because of a sudden pressing pain in the chest. It was known from the case history that the patient suffered from CHD for many years. Such chest pains were experienced by her earlier as well, but they always disappeared after a few minutes of sublingual administration of organic nitrates. This time taking three tablets of nitroglycerine did not kill the pain. It was also known from the case history that the patient had twice suffered during the last ten years from myocardial infarction, as well as from Acute Cerebrovascular Event with sinistral hemiplegia more than 15 years ago. Apart from that the patient suffers from hypertension, type 2 diabetes with diabetic nephropathy, hysteromyoma, cholelithiasis, osteoporosis and varicose pedi-vein disease. It also came to knowledge that the patient regularly takes a number of antihypertensive drugs, urinatives and oral antihyperglycemic remedies, as well as statins, antiplatelet and nootropics. In the past the patient had undergone cholecystectomy due to cholelithiasis more than 20 years ago, as well as the extraction of a cataract of the right eye 4 years ago. The patient was admitted to cardiac intensive care unit at a general hospital diagnosed for acute transmural myocardial infarction. During the check-up moderate azotemia, mild erythronormoblastic anemia, proteinuria and lowering of left vascular ejection fraction were also identified.
Methods of evaluation
There are currently several generally accepted methods of evaluating (measuring) comorbidity:[66]
- Cumulative Illness Rating Scale (CIRS): Developed in 1968 by B. S. Linn, it became a revolutionary discovery, because it gave the practicing doctors a chance to calculate the number and severity of chronic illnesses in the structure of the comorbid state of their patients. The proper use of CIRS means separate cumulative evaluation of each of the biological systems: "0" The selected system corresponds to the absence of disorders, "1": Slight (mild) abnormalities or previously suffered disorders, "2": Illness requiring the prescription of medicinal therapy, "3": Disease, which caused disability and "4": Acute organ insufficiency requiring emergency therapy. The CIRS system evaluates comorbidity in cumulative score, which can be from 0 to 56. As per its developers, the maximum score is not compatible with the patient's life.[67]
- Cumulative Illness Rating Scale for Geriatrics (CIRS-G): This system is similar to CIRS, but for aged patients, offered by M. D. Miller in 1991. This system takes into account the age of the patient and the peculiarities of the old age disorders.[68][69]
- The Kaplan–Feinstein Index: This index was created in 1973 based on the study of the effect of the associated diseases on patients suffering from type 2 diabetes during a period of 5 years. In this system of comorbidity evaluation all the present (in a patient) diseases and their complications, depending on the level of their damaging effect on body organs, are classified as mild, moderate and severe. In this case the conclusion about cumulative comorbidity is drawn on the basis of the most decompensated biological system. This index gives cumulative, but less detailed as compared to CIRS, assessment of the condition of each of the biological systems: "0": Absence of disease, "1": Mild course of the disease, "2": Moderate disease, "3": Severe disease. The Kaplan–Feinstein Index evaluates comorbidity by cumulative score, which can vary from 0 to 36. Apart from that the notable deficiency of this method of evaluating comorbidity is the excessive generalization of diseases (nosologies) and the absence of a large number of illnesses in the scale, which, probably, should be noted in the "miscellaneous" column, which undermines (decreases) this method's objectivity and productivity of this method. However the indisputable advantage of the Kaplan–Feinstein Index as compared to CIRS is in the capability of independent analysis of malignant neoplasms and their severities.[70] Using this method patient S's, age 73, comorbidity can be evaluated as of moderate severity (16 out of 36 points), however its prognostic value is unclear, because of the absence of the interpretation of the overall score, resulting from the accumulation of the patient's diseases.
- Charlson Index: This index is meant for the long-term prognosis of comorbid patients and was developed by M. E. Charlson in 1987. This index is based on a point scoring system (from 0 to 40) for the presence of specific associated diseases and is used for prognosis of lethality. For its calculation the points are accumulated, according to associated diseases, as well as the addition of a single point for each 10 years of age for patients of ages above forty years (in 50 years 1 point, 60 years 2 points etc.). The distinguishing feature and undisputed advantage of the Charlson Index is the capability of evaluating the patient's age and determination of the patient's mortality rate, which in the absence of comorbidity is 12%, at 1–2 points it is 26%; at 3–4 points it is 52% and with the accumulation of more than 5 points it is 85%. Regretfully this method has some deficiencies: Evaluating comorbidity severity of many diseases is not considered, as well as the absence of many important for prognosis disorders. Apart from that it is doubtful that possible prognosis for a patient suffering from bronchial asthma and chronic leukemia is comparable to the prognosis for the patient ailing from myocardial infarction and cerebral infarction.[4] In this case comorbidity of patient S, 73 years of age according to this method, is equivalent to mild state (9 out of 40 points).
- Modified Charlson Index: R. A. Deyo, D. C. Cherkin, and Marcia Ciol added chronic forms of ischemic cardiac disorder and the stages of chronic cardiac insufficiency to this index in 1992.[71]
- Elixhauser Index: The Elixhauser comorbidity measure include 30 comorbidities, which are not simplified as an index. Elixhauser shows a better predictive performance for mortality risk especially beyond 30 days of hospitalization.[5]
- Index of Co-Existent Disease (ICED): This Index was first developed in 1993 by S. Greenfield to evaluate comorbidity in patients with malignant neoplasms, later it also became useful for other categories of patients. This method helps in calculating the duration of a patient's stay at a hospital and the risks of repeated admittance of the same at a hospital after going through surgical procedures. For the evaluation of comorbidity the ICED index suggests to evaluate the patient's condition separately as per two different components: Physiological functional characteristics. The first component comprises 19 associated disorders, each of which is assessed on a 4-point scale, where "0" indicates the absence of disease and "3" indicates the disease's severe form. The second component evaluates the effect of associated diseases on the physical condition of the patient. It assesses 11 physical functions using a 3-point scale, where "0" means normal functionality and "2" means the impossibility of functionality.
- Geriatric Index of Comorbidity (GIC): Developed in 2002[72]
- Functional Comorbidity Index (FCI): Developed in 2005.[73]
- Total Illness Burden Index (TIBI): Developed in 2007.[74]
Analyzing the comorbid state of patient S, 73 years of age, using the most used international comorbidity assessment scales, a doctor would come across totally different evaluation. The uncertainty of these results would somewhat complicate the doctors judgment about the factual level of severity of the patient's condition and would complicate the process of prescribing rational medicinal therapy for the identified disorders. Such problems are faced by doctors on everyday basis, despite all their knowledge about medical science. The main hurdle in the way of inducting comorbidity evaluation systems in broad based diagnostic-therapeutic process is their inconsistency and narrow focus. Despite the variety of methods of evaluation of comorbidity, the absence of a singular generally accepted method, devoid of the deficiencies of the available methods of its evaluation, causes disturbance. The absence of a unified instrument, developed on the basis of colossal international experience, as well as the methodology of its use does not allow comorbidity to become doctor "friendly". At the same time due to the inconsistency in approach to the analysis of comorbid state and absence of components of comorbidity in medical university courses, the practitioner is unclear about its prognostic effect, which makes the generally available systems of associated pathology evaluation unreasoned and therefore un-needed as well.
Tratamiento del paciente comórbido
The effect of comorbid pathologies on clinical implications, diagnosis, prognosis and therapy of many diseases is polyhedral and patient-specific. The interrelation of the disease, age and drug pathomorphism greatly affect the clinical presentation and progress of the primary nosology, character and severity of the complications, worsens the patient's life quality and limit or make difficult the remedial-diagnostic process. Comorbidity affects life prognosis and increases the chances of fatality. The presence of comorbid disorders increases bed days, disability, hinders rehabilitation, increases the number of complications after surgical procedures, and increases the chances of decline in aged people.[75]
The presence of comorbidity must be taken into account when selecting the algorithm of diagnosis and treatment plans for any given disease. It is important to enquire comorbid patients about the level of functional disorders and anatomic status of all the identified nosological forms (diseases). Whenever a new, as well as mildly notable symptom appears, it is necessary to conduct a deep examination to uncover its causes. It is also necessary to be remembered that comorbidity leads to polypragmasy (polypharmacy), i.e. simultaneous prescription of a large number of medicines, which renders impossible the control over the effectiveness of the therapy, increases monetary expenses and therefore reduces compliance. At the same time, polypragmasy, especially in aged patients, renders possible the sudden development of local and systematic, unwanted medicinal side-effects. These side-effects are not always considered by the doctors, because they are considered as the appearance of comorbidity and as a result become the reason for the prescription of even more drugs, sealing-in the vicious circle. Simultaneous treatment of multiple disorders requires strict consideration of compatibility of drugs and detailed adherence of rules of rational drug therapy, based on E. M. Tareev's principles, which state: "Each non-indicated drug is contraindicated"[This quote needs a citation] and B. E. Votchal said: "If the drug does not have any side-effects, one must think if there is any effect at all".[This quote needs a citation]
A study of inpatient hospital data in the United States in 2011 showed that the presence of a major complication or comorbidity was associated with a great risk of intensive-care unit utilization, ranging from a negligible change for acute myocardial infarction with major complication or comorbidity to nearly nine times more likely for a major joint replacement with major complication or comorbidity.[76]
Ver también
- Coinfection
- Conditions comorbid to autism spectrum disorders
- Superinfection
- Syndemic
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Otras lecturas
- Comorbidity: Addiction and Other Mental Illness. Rockville, MD: U.S. Dept. of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, 2010.
- Sharabiani, M.; Aylin, P.; Bottle, A. (2012). "Systematic review of comorbidity indices for administrative data". Medical Care. 50 (12): 1109–18. doi:10.1097/MLR.0b013e31825f64d0. PMID 22929993. S2CID 25852524.
- Elixhauser, Anne; Steiner, Claudia; Harris, D. Robert; Coffey, Rosanna M. (1998). "Comorbidity Measures for Use with Administrative Data". Medical Care. 36 (1): 8–27. doi:10.1097/00005650-199801000-00004. JSTOR 3766985. PMID 9431328. S2CID 29229635.
- Van Walraven, Carl; Austin, Peter C.; Jennings, Alison; Quan, Hude; Forster, Alan J. (2009). "A Modification of the Elixhauser Comorbidity Measures into a Point System for Hospital Death Using Administrative Data". Medical Care. 47 (6): 626–33. doi:10.1097/MLR.0b013e31819432e5. PMID 19433995. S2CID 35832401.
enlaces externos
- Online comorbidity scoring tools
- MDCalc – Medical calculators, equations, scores, and guidelines