Medicine has evolved a lot in the last decades, as shown by the great increase in life expectancy. These advances have also changed the profile of patients, especially those in primary care and internal medicine. As Dr. María Dolores Martín Escalante – spokesperson for the Spanish Society of Internal Medicine (SEMI) and head of the internal medicine section at the Costa del Sol Hospital in Marbella – tells us , diseases that previously shortened life significantly, now have Chronic disease, resulting in patients with more diseases at the same time and more vulnerable.
Today there are many more chronically ill patients than ever before. Does this mean that we get sicker? No, what it means is that medicine has advanced and diseases that we once died from are now treatable. Chronicity is, therefore, “a collective achievement due to social, scientific and technological advances. These advances have meant that diseases that used to kill us are now treated, but they are NOT cured. They become chronic diseases that each patient lives with ”, says Mª Dolores Martín.
In addition, it is estimated that “chronic diseases are added in the same person as age advances, so that, in those over 80 years of age, their average is higher than 4”. And it is that,When we increase longevity, diseases associated with age also increase and the probability of getting sick, and of accumulating diseases, “1.8% of the population is multi-pathological (two or more chronic diseases) and in the hospital, 36% of discharges from the Internal Medicine services are also discharges.
Nonagenarian elderly admitted were an exception 15 years ago and now centenarians are. In Andalusia, in the Internal Medicine services, in the last decade, the number of admissions has increased by 22%, mainly due to the increase in the population aged 80 or over, especially women ”, he points out.
What are the most common chronic diseases now?
There are many pathologies in Spain that can be classified as epidemic due to the enormous incidence they have. We speak, for example, of hypertension that affects almost 40% of adults, diabetes , obesity or cardiovascular diseases, which are the chronic diseases that we find most today, along with pulmonary (COPD), neurological, renal and neoplastic.
They are not infectious, but they are silent and, in the long run, very dangerous. The good news is that, although the risk of suffering from them increases with age, many of them are associated with risk factors that can be prevented . For this reason, Dr. María Dolores Martín Escalante insists very much that “it is necessary to guide our system health and focus on prevention, because many chronicities are preventable through health, social and economic policies ”.
How are the chronically ill now?
The profile of the chronic patient has changed in recent years. Now, in addition to being more numerous, they are older and more multipathological or patients with more multimorbidity, that is, they have more than one disease.
Another characteristic is that they are what is known as ‘complex chronic patients’, difficult-to-manage patients who “suffer frequent decompensations, with multiple health care and income, with dependence, and, in many cases, they are social and emotional problems, since they are more elderly, vulnerable… ”, he points out. In addition, these patients also tend “to functional deterioration and have a high mortality during hospitalization (close to 20%) and during clinical follow-up (36% at one year and 50% at 4 years)”. Furthermore, as Mª Dolores affirms, it is the whiting that bites its tail, because “hospital admissions will diminish their functionality and will make them even more vulnerable.”
Patients have changed, but it is not a system
One of the great problems that the health system has, in the opinion of the member of the Spanish Society of Internal Medicine (SEMI), is that patients have changed, but care has not, “because they are chronic patients in a model designed for care to acute pathologies, which are hospitals ”.And it is that, instead of taking chronically ill patients to hospitals, they should be removed from them, both because they are a risk for them, and because unnecessary resources are consumed.
“A fragmented healthcare system, frequent and prolonged hospitalizations and polypharmacy lead these patients to an increased risk of iatrogenesis (the damage caused by contact with healthcare), functional loss and premature mortality. And all this is generating a high consumption of resources, without results in health, “he says.
Life expectancy in Spain, threatened by chronic diseases and COVID-19
What should be done then? In the words of Mª Dolores, “a global and comprehensive care of these patients is essential; and Internal Medicine and Family and Community Medicine are the two specialties that I hope we will lead this change with more coordination and more versatility ”.
Among the changes that are proposed there is a project that, due to the pandemic, had to be parked, it is about “creating day hospitals in which to see these patients frequently, before they become severe, to avoid admissions. This is accompanied, for example, with regular calls from a nurse to check their health status and provide information to patients so that they are also participants in their care ”.
To achieve this, it would be necessary to take full advantage of new technologies, “which can contribute to this healthcare transformation, allowing care at home, making the patient responsible for their care and favoring shared decision-making.”
In addition, there should be a greater tendency to assess the prognoses of life expectancy, “those of us who work with this type of patient have developed a scale to see the prognosis -the PROFUND index- that allows us to adapt the treatments to the life expectancy. So, if we find, for example, a patient who has a six-month prognosis, perhaps what we have to do is give him quality of life. If it is two years, on the other hand, we will have to do more things, intervene more… ”, he concludes.
