IPCHS. Integrated People-Centred Health Services


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April 19, 2021 Europe

Clustering Complex Chronic Patients: A Cross-Sectional Community Study From the General Practitioner’s Perspective

In public health services, aging and a high prevalence of multiple diseases as age increases are currently the norm rather than the exception, and challenge the single-disease model that prevails in medical education, research and hospital care. Individuals with multimorbidity do not show dominant combinations of conditions, and most clinical programs or guidelines for chronic disease management still focus on specific and single conditions. For these reasons, there is a growing concern that these programs may be less effective and even harmful for individuals with multimorbidity when compared to person-centred approaches.

In recent years, a new concept has been introduced, which is becoming increasingly common in primary care: the “complex chronic patient (CCP)”

The aim of this cross-sectional, population-based observational study is to identify sub-populations of complex chronic patients who could benefit from targeted care management approaches.


International Journal of Integrated Care