Complex Case Inpatient Evaluation

Nearly one in four people lives with two or more long-term conditions. Most hospital care is still organized around one disease at a time.

A study of 1,751,841 people registered with 314 medical practices in Scotland found that 42.2 percent had at least one long-term condition and 23.2 percent had two or more (Barnett and colleagues, The Lancet, 2012). Clinics, guidelines and specialists each deal with a single organ. The patient with heart failure, diabetes, failing kidneys and a new shadow on a scan belongs to four clinics and to none of them. A complex case inpatient evaluation brings those specialists to one bedside for a few days, so that the tests are done in sequence, the doctors talk to each other, and the patient leaves with a single plan. This page explains who benefits, how the evaluation runs at Biruni Hospital in Istanbul, and what the research says about team decisions.

What makes a case complex

Complexity in medicine rarely means a single exotic disease. Far more often the difficulty lies in several ordinary problems that interfere with one another, so that the right treatment for one becomes the wrong treatment for the next.

• Three or more long-term conditions treated by different specialists.
• Symptoms that have gone unexplained after tests in more than one clinic.
• A treatment for one condition that is risky because of another, such as surgery in someone with a weak heart or chemotherapy in someone with failing kidneys.
• Ten or more regular medicines, prescribed by several doctors.
• Specialists who have given conflicting advice.
• Repeated hospital admissions without a lasting improvement.

More than half of the people with multiple conditions in the Scottish study were younger than 65. In the poorest areas the pattern appeared 10 to 15 years earlier than in the richest.

Complex patients are common. The system that serves them was built for simple ones.

How the evaluation runs

Everything starts with the file. Review by the relevant specialists is free, and the more complete the file, the more useful their reply. Send these.

• Discharge summaries and clinic letters from the past two years.
• Every current medicine with its dose, including supplements and anything bought without a prescription.
• Imaging on a link or disc, with reports.
• Blood tests over time. A trend says more than a single value.
• A short account in your own words of what troubles you most.

If an admission is advised, the written plan sets out the days. A typical pattern looks like this.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Who sits at the table

One physician leads. For most adults this is a specialist in internal medicine, whose training covers the ground between the organs, and for a cancer question it is the oncologist. Around that person sit whichever of cardiology, nephrology, endocrinology, neurology, chest medicine, surgery, anesthesia, radiology and pathology the case demands. The clinical pharmacist or the lead physician goes through the medicines one by one.

What research shows

Multidisciplinary care was introduced for breast cancer in one Scottish health board in 1995. Among 13,722 women, breast cancer mortality there was 18 percent lower afterward than in neighboring areas, having been 11 percent higher before (Kesson and colleagues, BMJ, 2012).

That study compared regions over time, so it cannot prove cause, and its authors said as much. It remains the largest demonstration that the way doctors organize their decisions can show up in survival. A review of 27 studies of cancer team meetings supports the mechanism. Between 4 and 45 percent of patients had their diagnostic reports changed at the meeting, and patients discussed by a team were more likely to be staged completely before treatment (Pillay and colleagues, Cancer Treatment Reviews, 2016).

Limits of the evidence

Nearly all of this research comes from cancer. For people with several chronic conditions the case for team evaluation rests on reasoning and on smaller studies, and the Scottish authors themselves wrote that health systems need generalists who can look after the whole person, because single-disease services serve such patients poorly. Team meetings also have costs. They take time, the patient is absent from most of them, and the same Pillay review found little direct proof that they lengthen life outside the breast cancer example. A good evaluation therefore brings the conclusion back to the bedside and tests it against what the patient wants.

The plan you leave with

The written report is the product. It should contain the following.

1. A problem list in order of importance. Which condition threatens you most, and which can wait.
2. Diagnoses, with the level of certainty. Confirmed, probable, or still open, and what would settle it.
3. One medicine list. What to continue, what to stop, what to change, and why.
4. Recommended treatment, with alternatives. Including the option of doing less.
5. Follow-up. Which tests to repeat and when, written so that your own doctor can carry it out.

Medicines

A person with five conditions may take fifteen tablets a day, prescribed by five doctors who have never met. Some of those tablets treat the side effects of others. It adds up. Dizziness, falls, poor appetite, constipation and a clouded mind in an older person are as likely to come from the prescription list as from any disease, and no single prescriber is at fault. Doses set when the kidneys worked well continue after they have weakened, two drugs from different clinics turn out to belong to the same family, and a sleeping tablet started in the hospital three years ago is still on the list because nobody was given the job of stopping it. An admission lets one team lay every box on the table, check each against kidney and liver function measured that week, and watch what happens when a drug is withdrawn, which is safer on a ward than at home.

The family's part

Relatives hold knowledge that no file contains.

They know when the confusion started, what the patient could do last spring and cannot do now, which tablets are really taken and which stay in the drawer, and what the patient fears. Doctors evaluating a complicated illness need all of it, and an older or very sick patient often cannot supply it alone. One relative should plan to be present for the first history and for the final explanation, with the interpreter, and should feel free to write things down and to say when something has not been understood. The family also carries the plan home. Whoever fills the weekly pill box, books the blood tests and sits in the waiting room with the patient next month should hear the conclusions directly from the lead physician, because a plan relayed at second hand through a tired patient loses its detail somewhere over the sea. A second copy of the report should go to the doctor at home, and the number of the coordinator belongs in the phone of whoever will be making the calls.

Decide before the final meeting which questions matter most to you. Write them down. Hand the list to the doctor at the start.

Coming from abroad

One coordinator from the international patients office handles the arrangements from the first message through discharge, and the same WhatsApp number answers once you are back home. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages. It arranges the invitation letter for a visa, airport transfers, accommodation near the hospital for relatives and daily transport. Ward rooms have a companion bed.

Travel and the complex patient

People with several conditions need more thought before a flight than most travelers. Send the file first, and the doctors will say whether the journey is reasonable and what precautions it calls for, such as oxygen on board, a wheelchair at the airport or an adjusted dose of a blood thinner. Carry all medicines in hand luggage with a printed list. Most evaluations take three to six nights, and because no operation is involved most patients are fit to fly soon after the final meeting. The doctor will advise a longer stay in Istanbul if a biopsy, a change of heart medicine or the start of treatment makes that wise.

The kitchen prepares halal, vegetarian and diabetic meals. A prayer room is on site, and a request for a female physician is met wherever the rota allows. Chemotherapy and radiotherapy are given on the same site, so an evaluation that ends in a cancer diagnosis can move to treatment without a change of hospital.

Cost

File review costs nothing. The admission is estimated in advance from the planned tests, consultations and nights, and the estimate changes only if the doctors add investigations after examining you.

Hospitals in this market quote diagnostic admissions as itemized estimates. Read yours line by line.