Comorbidity Management Model in Elderly in China Based on the Theory of Complexity Science

doi:10.12114/j.issn.1007-9572.2019.00.629

Abstract

Abstract: Currently，clinical research on comorbidity is still insufficient in China，and there is no systematic，scientific and effective management path for managing comorbidity patients.As aging continues and the problem of comorbidity in the elderly becoming more serious，the management of comorbidity in the elderly has become a major challenge in the medical field.This paper combined the complexity science theory with the management of comorbidity care.From the perspective of system management of complexity theory and the international experience of comorbidity care，it designed a management model of comorbidity based on the national conditions of our country.The aim was to provide ideas and opinions for the research and development of the management scheme to meet the caring needs of comorbidity patients，and reference for health policy makers and health service providers.

Key words: Theory of complexity science, Comorbidity, Nursing administration, Management model, Aged

摘要： 我国当前对共病临床研究仍处于起步阶段，对共病患者的护理尚缺乏系统、科学、有效的管理路径。在老龄化持续推进、老年共病问题日趋严重的情况下，老年人共病护理已成为我国健康领域的一大挑战。本文将复杂性科学理论与共病护理管理相结合，从复杂性理论的系统管理视角出发，结合共病护理的国际经验，提出基于我国国情的共病护理管理模式设计，旨在为研究和开发满足共病患者护理需求的管理方案提供思路与见解，供卫生政策决定者、医疗服务提供者参考。

关键词: 复杂性科学理论, 共病现象, 护理管理, 管理模式, 老年人

WU Tingting,LU Yun,AI Dandan, et al. Comorbidity Management Model in Elderly in China Based on the Theory of Complexity Science　[J]. Chinese General Practice, 2019, 22(34): 4197-4201. DOI: 10.12114/j.issn.1007-9572.2019.00.629.
吴婷婷,路云,艾丹丹等. 基于复杂性科学理论的中国老年人共病护理管理模式研究[J]. 中国全科医学, 2019, 22(34): 4197-4201. DOI: 10.12114/j.issn.1007-9572.2019.00.629.

References

［1］赵明中，胡大一，彭晓霞.老年患者共病及其管理［J］．中华老年医学杂志，2015，34（12）：1364-1367．DOI：10.3760/cma.j.issn.0254-9026.2015.12.023.
ZHAO M Z，HU D Y，PENG X X．Multimorbidity and its management in older adults［J］．Chinese Journal of Geriatrics，2015，34（12）：1364-1367．DOI：10.3760/cma.j.issn.0254-9026.2015.12.023.
［2］WANG H H，WANG J J，WONG S Y，et al．Epidemiology of multimorbidity in China and implications for the healthcare system：cross-sectional survey among 162 464 community household residents in southern China［J］．BMC Med，2014，12：188．DOI：10.1186/s12916-014-0188-0.
［3］王安麟.复杂系统的分析与建模［M］．上海：上海交通大学出版社，2004.
［4］冯志华，何学秋.复杂性理论在煤矿安全管理中的应用［J］．煤矿安全，2006，37（7）：61-64．DOI：10.3969/j.issn.1003-496X.2006.07.025.
FENG Z H，HE X Q．Application of complexity theory in coal mine safety management［J］．Safety in Coal Mines，2006，37（7）：61-64．DOI：10.3969/j.issn.1003-496X.2006.07.025.
［5］袁冰.复杂性科学视野下的精准医学［J］．医学与哲学，2015，36（12）：3-6.
YUAN B．Percision medicine：a perspective of complexity science［J］．Medicine and Philosophy，2015，36（12）：3-6.
［6］美国医疗保险和医疗补助服务中心.Centers for medicare and medicaid services（CMS）［EB/OL］．［2019-08-14］．https：//www.cms.gov/.
［7］BOYD C M，DARER J，BOULT C，et al．Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases：implications for pay for performance［J］．JAMA，2005，294（6）：716-724．DOI：10.1001/jama.294.6.716．
［8］FARMER C，FENU E，O'FLYNN N，et al．Clinical assessment and management of multimorbidity：summary of NICE guidance［J］．BMJ，2016，354：i4843．DOI：10.1136/bmj.i4843.
［9］PAREKH A K，GOODMAN R A，GORDON C，et al．Managing multiple chronic conditions：a strategic framework for improving health outcomes and quality of life［J］．Public Health Reports，2011，126（4）：460-471．DOI：10.2307/41639389.
［10］MOFFAT K，MERCER S W.医疗系统管理共病患者遇到的挑战［J］．中国全科医学，2016，19（23）：2745-2746．DOI：10.1186/s12875-015-0344-4.
MOFFAT K，MERCER S W.Medical system management challenges for comorbid patients［J］．Chinese General Practice，2016，19（23）：2745-2746．DOI：10.1186/s12875-015-0344-4.
［11］PETROSYAN Y.The quality of care among older adults with diabetes comorbid with other chronic conditions［D］．London：University of London，2017.
［12］SAFFORD M M，ALLISON J J，KIEFE C I.Patient complexity：more than comorbidity.The vector model of complexity［J］．J Gen Intern Med，2007，22（s3）：382-390.
［13］SHIPPEE N D，SHAH N D，MAY C R，et al．Cumulative complexity：a functional，patient-centered model of patient complexity can improve research and practice［J］．J Clin Epidemiol，2012，65（10）：1041-1051．DOI：10.1016/j.jclinepi.2012.05.005.
［14］GREMBOWSKI D，SCHAEFER J，JOHNSON K E，et al．A conceptual model of the role of complexity in the care of patients with multiple chronic conditions［J］．Med Care，2014，52（suppl 3）：s7-14．DOI：10.1097/MLR.0000000000000045.
［15］DE G V，BECKERMAN H，LANKHORST G J，et al．How to measure comorbidity？A critical review of available methods［J］．Journal of Clinical Epidemiology，2003，56（3）：221．DOI：10.1016/S0895-4356（02）00585-1.

[1]	WANG Tingting, TANG Yong, ZHANG Wenke, LI Zhigang. Research Progress on Exercise Intervention of Hyperuricemia [J]. Chinese General Practice, 2025, 28(30): 3841-3846.
[2]	CHENG Zhuozhuo, ZHANG Rui, XU Haofeng, HUANG Junting, LIANG Zijing, YAN Ping. Systematic Cluster Analysis of Comorbidity Patterns in Patients with Chronic Obstructive Pulmonary Disease and the Impact on Hospitalization Costs [J]. Chinese General Practice, 2025, 28(17): 2127-2133.
[3]	CAO Chenchen, ZHENG Lyuyun, WANG Lin, LIU Jing. Preference Study on Family Doctor Contract Service among Patients with Hypertension and Type 2 Diabetes Mellitus [J]. Chinese General Practice, 2025, 28(16): 2011-2016.
[4]	Chinese Academy Society of Sleep Medicine, Chinese Medical Doctor Association, Sleep Medicine Group, China Neurologist Association. Chinese Guideline for Diagnosis and Treatment of Co-morbid Insomnia and Obstructive Sleep Apnea (2024) [J]. Chinese General Practice, 2025, 28(11): 1289-1303.
[5]	ZHU Xianshang, ZENG Hongyu, LYU Fengli, WANG Jiancheng. The Current Status and Influencing Factors of Multiple Chronic Conditions among the Elderly Aged 60 and above in Gansu Province [J]. Chinese General Practice, 2025, 28(10): 1193-1199.
[6]	GU Mingyu, QIN Tingting, QIAO Kun, BAI Xinyuan, WANG Yao, YANG Yutong, LI Xingming. A Network Meta-analysis of Primary Hypertension Management Patterns in China [J]. Chinese General Practice, 2025, 28(10): 1265-1272.
[7]	LI Xiaofeng, PEI Xingtong, YANG Chunhui, ZHAO Yang, XU Mingming. Association between Comorbidity Patterns and Disability for the Older Adults: Based on a Sampling Survey in Sichuan Province [J]. Chinese General Practice, 2025, 28(02): 149-158.
[8]	FENG Caixia, WANG Zengshuai, MU Hailin, YANG Hanxuan, TAMIR. Effect of Parkinson's Disease Management Model Dominated by Movement Disorder Specialists and Centered on Community Doctors [J]. Chinese General Practice, 2024, 27(34): 4280-4285.
[9]	SUBINUER Aiwaiduli, GULIBAHAER Kadeer, MUKAIDASI Taxi, LYU Yujuan, KADEERYA Nasier, SUBIDE Alimujiang. Effects of Chronic Disease Prevalence and Comorbidity Patterns on SRH Status in Middle-aged and Elderly Populations in Rural Areas [J]. Chinese General Practice, 2024, 27(28): 3520-3528.
[10]	ZHU Yaming, DU Li, WANG Huanhui, WANG Peipei. Obstructive Sleep Apnea-hypopnea Syndrome and Severe Asthma: Advances and Challenges [J]. Chinese General Practice, 2024, 27(25): 3192-3196.
[11]	WU Taiqin, GAN Xiuni, GAO Yan, ZHANG Huan, YANG Li. Interpretation of the 2023 ESPEN Guideline on Nutritional Support for Polymorbid Medical Inpatients [J]. Chinese General Practice, 2024, 27(21): 2557-2564.
[12]	XU Li, GE Jing, YU Peng, YU Ying. Shifts in Chronic Disease and Comorbidity Patterns among Chinese Older Adults: an Analysis Based on the China Health and Retirement Longitudinal Study [J]. Chinese General Practice, 2024, 27(11): 1296-1302.
[13]	LI Linjin, XIAO Liqin, ZHANG Dan. Study on the Factors Affecting the Number of Chronic Diseases among Elderly Comorbidity Patients in Guangdong Province Based on the Model of Ecological Health [J]. Chinese General Practice, 2024, 27(02): 208-216.
[14]	LI Chanjiao, HE Anning, HUANG Xianhong, NI Ziling. Research Progress of International and Domestic Integrated Health Care of Multimorbidity [J]. Chinese General Practice, 2024, 27(02): 184-191.
[15]	HE Li, ZHANG Yifan, SHEN Xuechun, SUN Yan, ZHAO Yang. Prevalence Trends of Multimorbidity among Residents in Mainland China: a Meta-analysis [J]. Chinese General Practice, 2023, 26(29): 3599-3607.