Community Care Needs of Highly Complex Chronic Patients: An Epidemiological Study in a Healthcare Area

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

From an epidemiological point of view, the article is original and brings into discussion the importance of characterizing populations through the clinical perspective of nurses, as it refers to the set of human responses of their clients associated with life and disease processes and not, only, the epidemiological characterization of diseases.

However, it has weaknesses that make it difficult to read and that could generate bias that affects the discussion of the results and the conclusions to be drawn for clinical practice.

Please, review the following items:

2.3.8 - Dysfunctionality, per HP – The 11 areas assessed are mentioned, but not how they are assessed and classified to give rise to the table values.

2.3.9 Nursing diagnoses – It is mentioned that a set of nursing diagnoses to be monitored in the study were chosen, by consensus, but the criteria used for their choice were not mentioned. It would be important to know the authors' reasons for choosing these and to know those who were left out

Table 1 – Maybe I'm misreading the table, but from the point of view of the person reading the article, there are variables presented in the form of mean and standard deviation or median that do not allow us to interpret their real size. For example: Number of inhabitants

Table 3 – Maybe I'm reading it wrong, but with the information provided in the article, it is not possible to interpret this table, as nothing is explained about what those values mean concerning Gordon's health patterns.

Discussion:

Taking into account that part of the study is based on nursing records and the ease of access, in the various areas, to nursing care is not documented, the question remains whether the asymmetries are real or whether, as is documented in many parts of the world, in areas where there is less medical care, nursing records are richer in nursing care and in portraying human responses to illness (such as in the northern region) and, in areas where there is easier access to differentiated medical care, nursing records tend in translating the entire expression of the interdependence of care resulting from its prescriptions. In other words, as we are analyzing previously made records, and not reliable assessments of people, carried out by trained teams of health professionals, it is necessary to understand whether the distribution of nursing care is homogeneous across these populations, otherwise, whoever has more access nursing care will have more records and their health situation will be more characterized.

“The southern area has a younger HCCP profile, but a higher frequency of hospital admissions, which could be indicative of poorer management of disease processes by primary care or poorer adherence to treatments.” – Nothing is said in the article about the emigrant population's access to primary health care. As happens in other countries, sometimes the difficulty for immigrants to access primary health care and/or health resources available in the country leads them to resort to differentiated hospital care already in an advanced state of dysfunction and having greater difficulty in managing their treatment regime (which requires close monitoring). It cannot be the reason why there are fewer documented nursing diagnoses... For example: People dependent on self-care are more likely to be guided towards nursing care rather than medical care and are therefore more likely to have more active Nursing Diagnoses.

Regarding pain, it is often responsible for people who do not have follow-up care to resort to emergency services, so it is not surprising that in the south the consumption of painkillers is higher. It is also common for the consumption of painkillers to decrease as psychotropic drugs are added, either due to people's inability to present complaints or to come to terms with them, which may justify the lower consumption in the north.

“In our research, we found that a lower mean income indicated a higher prevalence of the ND Readiness for enhanced health management [00162], which might suggest that, despite inequalities, the willingness of these individuals works in their favor despite the health-related difficulties encountered”. - Taking into account the available evidence, this conclusion may be somewhat controversial. It was hypothesized that this behavior may be associated with limited access to health resources? That is, those who need and have limited access to health resources develop adherence behaviors so as not to lose those who still have access.

"It is also important to note the higher prevalence of several NDs in populations with a higher frequency of prescribed drugs". - We advise further reading about potentially inappropriate medications prescribed for older people and medication reconciliation associated with complex chronic patients to provide a reasoned discussion of these results.

Author Response

Reviewer 1.

Comments and Suggestions for Authors:

From an epidemiological point of view, the article is original and brings into discussion the importance of characterizing populations through the clinical perspective of nurses, as it refers to the set of human responses of their clients associated with life and disease processes and not, only, the epidemiological characterization of diseases.

However, it has weaknesses that make it difficult to read and that could generate bias that affects the discussion of the results and the conclusions to be drawn for clinical practice.

Please, review the following items:

- 2.3.8 - Dysfunctionality, per HP – The 11 areas assessed are mentioned, but not how they are assessed and classified to give rise to the table values.

- Thank you very much for your comment. We have added a sentence in the Study setting section about how nurses document the functionality or dysfunctionality of each health pattern within the context of the Drago-AP electronic health record system. This also addresses another comment made by the second reviewer.

The sentence added reads as follows: “Thus, after collecting the information available on each HP assessment area, each nurse determines whether a given HP is functional or dysfunctional according to their clinical judgement and, on that basis, establishes the NDs that they deem to be priorities to establish the most suitable care plan while using the NIC and NOC terminologies.”

We have also added “by each nurse” to subsection 2.3.8. to clarify that this information is recorded by each nurse in the electronic health record: “Percentages of HCCP population with a dysfunction recorded in the EHR by each nurse in any of the following eleven assessment areas…”

- 2.3.9 Nursing diagnoses – It is mentioned that a set of nursing diagnoses to be monitored in the study were chosen, by consensus, but the criteria used for their choice were not mentioned. It would be important to know the authors' reasons for choosing these and to know those who were left out.

- We have added a sentence to that paragraph explaining why those 70 nursing diagnoses were included. A previous study conducted with the same sample of participants (which is included in the reference list) identified these diagnoses as the most prevalent. To address the objectives of our current study, we grouped the outcomes of the patients, who also participated in the previous study, by municipality of origin.

“The 70 NDs considered in this research were those identified as most prevalent in a previous study conducted on the same sample in this healthcare area [15].”

- Table 1 – Maybe I'm misreading the table, but from the point of view of the person reading the article, there are variables presented in the form of mean and standard deviation or median that do not allow us to interpret their real size. For example: Number of inhabitants.

- The values shown in the table are the mean number of, for instance, inhabitants per municipality in the entire health area (14,987) with respect to the number of inhabitants (24,626). In other words, the ‘typical’ municipality in the area would have that mean number of inhabitants. The following columns show the mean number of inhabitants in the municipalities of each sector (Metropolitan, North, and South). As shown in those columns, the mean number of inhabitants is higher in the set of municipalities in the Metropolitan area, followed by those in the South and then the North, where the number of inhabitants is smaller. Perhaps the confusion was caused by mistaking municipalities for cases; however, the data provided are either means or medians for these populations. We hope we have been able to clarify this issue. We are very grateful for your comments.

- Table 3 – Maybe I'm reading it wrong, but with the information provided in the article, it is not possible to interpret this table, as nothing is explained about what those values mean concerning Gordon's health patterns.

- Thank you very much again for your comment. We have added the relevant clarifications to the reviewer’s first recommendation on this issue, seeking to explain how (dys)functionality is documented (by each nurse and in the electronic health record system). This would facilitate the calculation of the percentages of dysfunctionality among these patients (grouped by municipalities and by areas: Metropolitan, North, and South) and their mean values, which are shown in Table 3. We hope that these modifications will help to clarify the matter.

• Discussion:

• Taking into account that part of the study is based on nursing records and the ease of access, in the various areas, to nursing care is not documented, the question remains whether the asymmetries are real or whether, as is documented in many parts of the world, in areas where there is less medical care, nursing records are richer in nursing care and in portraying human responses to illness (such as in the northern region) and, in areas where there is easier access to differentiated medical care, nursing records tend in translating the entire expression of the interdependence of care resulting from its prescriptions. In other words, as we are analyzing previously made records, and not reliable assessments of people, carried out by trained teams of health professionals, it is necessary to understand whether the distribution of nursing care is homogeneous across these populations, otherwise, whoever has more access nursing care will have more records and their health situation will be more characterized.

• The entire health area of Tenerife comprises 42 basic healthcare districts (ZBSs) that provide healthcare services to the population as a whole. Each district has a number of primary care teams consisting of at least administrative staff, physicians, nurses, and social workers. The number of primary care teams depends on the size of the population served. Therefore, the organisation of these services caters equitably to the needs of the population, regardless of their place of residence. In addition, each district has an emergency referral point and two tertiary referral hospitals, one covering the South and part of the Metropolitan area and another covering the North and the rest of the Metropolitan area. We did not include this information in the Study setting subsection, as it would have made the text excessively longer. We hope to have clarified that nursing care is indeed distributed homogeneously across the study populations. However, to ensure that there is no confusion, we have added in the Study setting subsection some additional information about the primary care teams, as this subsection also contains a description of the network of care resources and professionals in the study area:

“There are a total of 103 primary care facilities staffed by 795 nurses and 797 family physicians. The primary care teams are distributed evenly throughout the healthcare area based on the number of inhabitants, so that access to healthcare resources can be ensured for everyone”.

• “The southern area has a younger HCCP profile, but a higher frequency of hospital admissions, which could be indicative of poorer management of disease processes by primary care or poorer adherence to treatments.” – Nothing is said in the article about the emigrant population's access to primary health care. As happens in other countries, sometimes the difficulty for immigrants to access primary health care and/or health resources available in the country leads them to resort to differentiated hospital care already in an advanced state of dysfunction and having greater difficulty in managing their treatment regime (which requires close monitoring). It cannot be the reason why there are fewer documented nursing diagnoses... For example: People dependent on self-care are more likely to be guided towards nursing care rather than medical care and are therefore more likely to have more active Nursing Diagnoses.

• Thank you very much for your valuable input. There seems to be an interpretation problem regarding the information we provided. In our study, we refer to non-Spanish nationals who live as residents on the island of Tenerife (the healthcare area at hand). These inhabitants were born in other countries, changed their place of residence, and are full citizens. On the other hand, and as the reviewer points out, there is no mention at all of immigrants without legal status who, as is the case in the Canary Islands, may experience more difficulties in accessing the healthcare services. In fact, the media are reporting extensively on this issue, but in no case are these individuals considered as part of our study sample. When we speak of non-Spanish nationals, we are not referring to this population group of immigrants, but to the other groups mentioned above, which are also numerous in some municipalities in the south and have the same rights to access and receive services from primary care teams as anyone else born on the islands.

In the Discussion section, we are referring to the idea that non-Spanish nationals residing in the health area under study make less use of primary care services when it comes to managing their chronic conditions, and therefore do not have care plans recorded by their primary care nurses. They visit healthcare facilities less often and are referred to hospitals more often, which probably reflects poorer self-care management and/or poorer adherence to treatment.

• Regarding pain, it is often responsible for people who do not have follow-up care to resort to emergency services, so it is not surprising that in the south the consumption of painkillers is higher. It is also common for the consumption of painkillers to decrease as psychotropic drugs are added, either due to people's inability to present complaints or to come to terms with them, which may justify the lower consumption in the north.

• Thank you very much for your very interesting comment. Indeed, these could very well be the reasons for the higher consumption of analgesics observed in the south versus the north. However, we did not mention this in the Discussion section to avoid increasing its length and because we did not observe a significant difference between the percentages regarding this difference.

• “In our research, we found that a lower mean income indicated a higher prevalence of the ND Readiness for enhanced health management [00162], which might suggest that, despite inequalities, the willingness of these individuals works in their favor despite the health-related difficulties encountered”. - Taking into account the available evidence, this conclusion may be somewhat controversial. It was hypothesized that this behavior may be associated with limited access to health resources? That is, those who need and have limited access to health resources develop adherence behaviors so as not to lose those who still have access.

• Thank you very much for your feedback; however, we do not fully understand your last point. In our study, as previously mentioned, the network of healthcare facilities on the island has sufficient and accessible primary care teams and equipment to meet the care needs of the inhabitants in each municipality, which means that patients can visit their closest referral facility in a relatively short time (in less than 30 minutes by car, i.e. an isochronous time of arrival). This is why we explained this finding on the basis of the willingness to improve one’s health among individuals on lower incomes who use public primary care services (“we found that a lower mean income indicated a higher prevalence of the ND Readiness for enhanced health management”).

• "It is also important to note the higher prevalence of several NDs in populations with a higher frequency of prescribed drugs". - We advise further reading about potentially inappropriate medications prescribed for older people and medication reconciliation associated with complex chronic patients to provide a reasoned discussion of these results.

• Thank you very much for your advice. We fully agree that some information was missing in this part of the Discussion. We have reviewed the relevant literature, read further on the topic, and identified some references that we have included in our study to support this crucial idea. We have also added the following paragraph to the Discussion section to clearly state the idea put forward by the reviewer:

“It is well known that in the management of HCCPs, especially in the case of elderly individuals, professionals must pay special attention to medicines reconciliation by reviewing potentially inappropriate prescription drugs and their impact on the health and quality of life of these patients [43]”.

Reviewer 2 Report

Comments and Suggestions for Authors

Community care needs of highly complex chronic patients: an epidemiological study in a healthcare area

Dear authors,

Thank you for the opportunity to review your interesting and well written manuscript. I will give my feedback following the structure of the manuscript. 

-The title and abstract are informative and clear. Nothing to add. 

-Introduction 

In my opinion this section is very clear and well written. I'm just suggesting the authors put the two paragraphs on NANDA-I together, because how it's presented now seems repetitive to me.In addition, it would also be important to note that other communities in Spain use nursing languages other than NANDA. The ATIC language is an example. 

-Material and Methods

-Design and sampling, is informative and clear. Nothing to add. 

-Study setting is informative and clear. I only have one suggestion. Would it be possible to add more information about the drago-AP EHR system in this section?

-Study variables and municipality, I would like to congratulate authors for this section. In my opinion it is very clear. 

-Data collection. Previously, the authors explained that they collected information through different sources such as: the Drago-AP EHR system, the National Institute of Statistics and the Statistical Institute of the Canary Islands. However, with this information it is difficult to identify which sources have been used for each variable. Is it possible to clarify this point in the section? 

In addition, it seems difficult to collect some information especially regarding social or financial aspects without contact directly with the participants. Could the authors clarify how they obtained this information?

-Data analysis is informative and clear. Nothing to add. 

-Ethical considerations’s section is informative and clear. Nothing to add. 

-Results

I would like to congratulate the authors for this section. In my opinion it is very interesting, clear, well-organized and well-written. Moreover, they give us a lot of extra information throughout the supplementary files.  Nothing to add. 

-Discussion

The section is well presented, clear and discusses the main results. However, in my opinion it is a little too long for what I suggest authors make an effort to synthesize it. 

-Conclusions

This point is clear and points out the main conclusions of the research. I only suggest the authors remove the first sentence. In my opinion it refers to the investigation’s objectives and should not appear in the conclusion section. 

Good luck,

Sincerely, 

Author Response

Reviewer 2.

Comments and Suggestions for Authors:

Community care needs of highly complex chronic patients: an epidemiological study in a healthcare area.

Dear authors,

Thank you for the opportunity to review your interesting and well written manuscript. I will give my feedback following the structure of the manuscript.

- The title and abstract are informative and clear. Nothing to add.

-Introduction: In my opinion this section is very clear and well written. I'm just suggesting the authors put the two paragraphs on NANDA-I together, because how it's presented now seems repetitive to me.

- Your comments are very much appreciated. However, we decided to keep the original order of those paragraphs for the following reasons. Firstly, there is another paragraph between those two paragraphs. Secondly, in the first paragraph we mentioned NANDA-I nursing diagnoses because we wanted to provide context for the reader, as this taxonomy, together with the NIC and NOC classifications, are the standardised nursing languages used by nurses to unify their records worldwide, including Spain. Thirdly, this is followed by that other paragraph which addresses the epidemiological use of these language systems by analysing variables related to geographical distribution, which is why, in the third paragraph, the NANDA-I nursing diagnoses are mentioned once again, but in terms of their use and application regarding families and communities, as per axis two of the multi-axial system. Finally, this paragraph leads us to the purpose of our study and the hypothesis we put forward. Therefore, in our opinion, if the order of these paragraphs is altered, it is very likely that the sense of what has been explained thus far and the main thread of this last part of the Introduction, which points out the purpose of the study, will be lost.

In addition, it would also be important to note that other communities in Spain use nursing languages other than NANDA. The ATIC language is an example.

• Thank you very much for your comment. Certainly, in some areas, such as the autonomous community of Catalonia, the ATIC language is widely used to describe and record the care needs observed and the care provided by nurses. This interface language has been described as extremely useful in practice and easy for clinicians to understand and use. In Spain we also have the intervention standardisation language for nursing practice or the lenguaje de Normalización de Intervención para la Práctica Enfermera (known as NIPE), which is endorsed by the International Council of Nurses. However, in our manuscript we refer only to the NNN languages, since these are the ones used in the entries observed in the electronic health records used and are included in the minimum data set established for the Spanish National Health System in the Royal Decree RD1093/2010 of 3 September [included in the reference list as reference no. 9].

-Material and Methods:

-Design and sampling, is informative and clear. Nothing to add.

-Study setting is informative and clear. I only have one suggestion. Would it be possible to add more information about the Drago-AP EHR system in this section?

-We have added one more sentence to supplement the information provided on the Drago-AP EHR system and explained how the outcome of each health pattern is described as either functional or dysfunctional: “Thus, after collecting the information available on each HP assessment area, each nurse determines whether a given HP is functional or dysfunctional according to their clinical judgement and, on that basis, establishes the NDs that they deem to be priorities to devise the most suitable care plan while using the NIC and NOC terminologies.”

In doing so, we also respond to the other reviewer’s point about how the (dys)functionality of a given health pattern is determined, while pointing out that the nursing assessment follows a semi-structured data collection method.

-Study variables and municipality, I would like to congratulate authors for this section. In my opinion it is very clear.

-Data collection. Previously, the authors explained that they collected information through different sources such as: the Drago-AP EHR system, the National Institute of Statistics and the Statistical Institute of the Canary Islands. However, with this information it is difficult to identify which sources have been used for each variable. Is it possible to clarify this point in the section?

- We are grateful for your valuable insights. For clarification, the sources from which each group of variables originates are listed one by one in subsection 2.3 (Study variables per municipality), from 2.3.1. to 2.3.9. inclusive.

In addition, it seems difficult to collect some information especially regarding social or financial aspects without contact directly with the participants. Could the authors clarify how they obtained this information?

- The information provided on the financial variables as well as on the social variables originates from the Spanish National Institute of Statistics and the Statistical Institute of the Canary Islands. This is noted in the body of the manuscript, in subsection 2.3. (Study variables per municipality), in accordance with the recommendations made in the previous comment.

- Data analysis is informative and clear. Nothing to add.

- Ethical considerations’s section is informative and clear. Nothing to add.

- Results:

I would like to congratulate the authors for this section. In my opinion it is very interesting, clear, well-organized and well-written. Moreover, they give us a lot of extra information throughout the supplementary files. Nothing to add.

- Discussion:

The section is well presented, clear and discusses the main results. However, in my opinion it is a little too long for what I suggest authors make an effort to synthesize it.

- The Discussion, as it stands, is already the result of a process of synthesis that has been revised and reviewed several times before. At this point, we believe it is necessary to keep the content as it is, given that the most noteworthy aspects of our study are highlighted in line with the study objectives. We sought to provide a precise and rigorous Discussion section. Consequently, removing parts of its content would not allow us to properly compare and reflect on the findings that we believe are the most relevant, i.e. the ones that were shown to have statistically significant differences.

-Conclusions:

This point is clear and points out the main conclusions of the research. I only suggest the authors remove the first sentence. In my opinion it refers to the investigation’s objectives and should not appear in the conclusion section.

- You are absolutely right; we have deleted the first sentence in the Conclusions section. Thank you very much indeed for the correction and for all your valuable feedback.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for all the clarifications provided that improved my understanding of the study.

In science, we always have several hypotheses to consider when we analyze an exploratory descriptive study. Presenting a single interpretation hypothesis when discussing the results, or not considering many others, continues to be a weakness that I observe in this study. However, the present conclusions also allow scientific discussion to take place around this topic.

For example, clarifying what I meant with the phrase - "Taking into account the available evidence, this conclusion may be somewhat controversial. It was hypothesized that this behavior may be associated with limited access to health resources? That is, those who need and have limited access to health resources develop adherence behaviors so as not to lose those who still have access." - Bearing in mind that, as I am poor, I have no other option than to use public health services, then I will have a greater propensity to comply with what I am told to do, because I don't I have other options left.

Being dependent at home and not being able to get to a medical appointment or choose the healthcare institution also makes me adhere more closely to the recommendations of the healthcare professional who visits me so as not to run the risk of him stopping visiting me.

We will have several hypotheses to discuss a controversial result with scientific evidence - Low-income people have greater adherence to the therapeutic regimen.

What I said has nothing to do with the equal provision of healthcare but with the possibility of choosing, or not, for people who use the healthcare services available.

Congratulations on the study and for emphasizing nursing decision-making in light of the health care needs of populations.

Author Response

Thank you very much for these clarifications. We are glad that we were able to improve the understanding of the study with our explanations. Indeed, we can now better understand this reviewer's positioning and suggestions. They will be very useful to us in new publications on this line of research, although they are not included in this completed work. In fact, we have new funding to continue this work and carry out a follow-up -cohort- with the population profile described as highly complex chronic patients. We will surely take into consideration the proposals of new hypotheses made by the reviewer, which will contribute to improving the quality of the discussion on the possible findings.

Author Response File: Author Response.pdf