Complex patient care not uncommon in SG

Complexity exists in primary care, with a few patient encounters deemed as “medically challenging” (MC), reports a study in Singapore.

“Our study identified key areas for improving care for patients with complex care (CC) needs, [namely] adequate consultation time, multidisciplinary teamwork, complexity training in medical education, and refined methods for identifying complexity,” the researchers said.

A total of 4,327 encounters were evaluated, of which 15.0 percent were classified as CC, 18.5 percent as MC, and the rest (66.4 percent) as routine care (RC). [Ann Acad Med Singap 2025;54:87-100]

Polypharmacy was the most common medical challenge in both CC (66.2 percent) and MC (44.9 percent) encounters, followed by poorly controlled chronic conditions (41.3 percent in CC and 24.5 percent in MC) and treatment interactions (34.4 percent in CC and 26.0 percent in MC).

For nonmedical issues, the most common was low health literacy (32.6 percent in CC and 20.8 percent in MC), followed by limited motivation for healthy lifestyle behaviours (27.2 percent in CC and 16.6 percent in MC) and the need for coordinated care with hospital specialists (24.7 percent in CC and 17.1 percent in MC).

Researchers identified mobility limitation requiring assistance (odds ratio [OR] for requiring wheelchair/trolley, 7.14 for CC vs RC, 95 percent confidence interval [CI], 4.74–10.74) as the top independent predictor of complexity in primary care.

Other major predictors included longer consultation times with physicians (OR for taking >20 min for doctor’s consultation, 3.96 for CC vs RC, 95 percent CI, 2.86–5.48) and low socioeconomic status (OR for living in 1- or 2-room government-subsidized flats, 2.98 for CC vs RC, 95 percent CI, 1.74–5.13).

“High care needs, encompassing both CC and MC encounters, were prevalent in primary care interactions,” the researchers said. “These findings highlight that relying solely on chronic disease count is insufficient to capture the full spectrum of patient complexity.”

Asian studies

Earlier studies on complexity in Asia were limited and usually centred on inpatients, specific conditions (eg, alcohol misuse), validation of specific complexity tools, or equated multimorbidity with complexity. [BMJ Open 2017;7:e016175; BMJ Open 2020;10:e034665; Fam Pract 2016;33:112-117; BMC Prim Care 2022;23:258; BMJ Open 2019;9:e025176; BMJ Open 2022;12:e051891]

Among Asian studies on complexity in primary care, two were qualitative in design and focused on primary care physicians’ perceptions of complexity, and one found a medium positive association between patient complexity and healthcare costs. [BMC Prim Care 2024;25:134; BMC Prim Care 2022;23:14; BMJ Open 2023;13:e068497]

“[The current] study adds to the literature describing how the use of an intuitive questionnaire could identify individuals with complex needs—who were more likely to have incurred higher cost and consumed more resources,” the researchers said. 

“This questionnaire could be easily administered in a form suited to any resource setting, integrated seamlessly with electronic medical records systems or filled manually via pen and paper,” they added.

In this qualitative study, researchers developed a patient complexity questionnaire to assess how physicians in Singapore recognize patient complexity. Sixty-nine participants applied this tool to evaluate patient encounters, categorizing each as RC, MC, or CC.

Subsequently, care needs across the above categories were compared. Independent predictors of complexity were also identified using mixed-effects multinomial logistic regression.