The number of patients with comorbidities will continue to rise in developing countries as the population ages, life expectancy increases, and lifestyles change (11,12). Compared with a single chronic disease, comorbid patients have complex causes, high medical expenses, and poor quality of life, resulting in a heavy burden of disease to the country, society and family (13-16). In view of this, in December 2016, NICE released the United Kingdom "Comorbidity: Clinical Evaluation and Management", stating that the clinical guidelines for a single disease are not applicable to patients with comorbidities. Medical staff should formulate effective management plans for comorbid patients as part of their overall strategy (17). At present, China and many developing countries have not issued special clinical treatment guidelines for comorbidity. The diagnosis and treatment of comorbidities is still based on specialist diagnosis. The advantages of general medicine in the field of comorbidity prevention and treatment have not been systematically studied. This article comprehensively analyzes the clinical epidemiological characteristics and influencing factors of comorbidities in general medicine inpatients in a provincial tertiary hospital in Henan Province, and provides representative evidence for effective prevention and control of comorbidities.
4.1 Establishing a GP-PCIC comorbidity prevention and control model
"The Mortality, Morbidity, and Risk Factors in China and Its Provinces from 1990 to 2017" published by The Lancet showed that the prevalence of hypertension and diabetes was 25.2% and 9.7% respectively. The overall prevalence of chronic diseases is gradually increasing, indicating that the current situation of chronic disease management is still severe (18). Due to the combined effects of multiple chronic diseases, patients with comorbidities face reduced quality of life, heavy psychological burden, prolonged hospital stay, increased number of readmissions, increased emergency visit rate, high incidence of multiple medications and adverse drug events and waste of medical resources (19-21). This study shows that the prevalence of comorbidities among inpatients in the general medicine department of provincial-level tertiary hospitals is extremely high, reaching 93.1%, which is close to the results reported by Feng Mei et al.(22), but higher than that of foreign Ge L et al.(23), Gupta S et al.(24) and Carolina IC et al. (25). This may be due to the fact that the study participants were enrolled from provincial medical center where the overall complexity and likelihood of the cases admitted is relatively high. It can be seen that the prevention and control of comorbid condition should be the key content of the prevention and control of chronic diseases.
Based on the experience of developed countries, the establishment of a patient-centered integrated service system (Patient Centered Integrated Care, PCIC) provides comprehensive, continuous, and proactive services for patients with comorbidities, and raises their awareness on disease risk factors. A healthy lifestyle can prolong the life of patients, improve the quality of life, reduce the economic burden of patients, and reduce medical expenses. General hospitals in China are of large-scale, with many departments, high-quality medical teams, high-tech equipment, and strong first aid capabilities. However, the cost of diagnosis and treatment is relatively high, characterized with longer waiting times. In addition, primary medical institutions have better access to services and lower cost advantages. Therefore, there should be a link between general medicine department in general hospitals and general practitioners in primary medical institutions to build a general practitioner-based patient centered integrated service system (General Practitioner Based Patient Centered Integrated Care, GP-PCIC). It is hence expected to play an important role in the clinical diagnosis and treatment and comprehensive prevention and control of comorbid diseases.
4.2 Building the integrated two-way referral model between tertiary hospitals and primary hospitals
As the general medicine department of the provincial tertiary hospitals support hierarchical diagnosis and treatment and maintains close contact with the grass-roots community health service centers, thereby building a bridge linking grass-roots medical institutions and comprehensive clinical specialties is important. There should be an establishment of chronic disease management system so as to realize the effective sharing of electronic medical records between hospitals and community health services. The general medicine department of a tertiary hospital should be transferred to a ward or to a lower-level hospital or community health service center for treatment according to the patient's condition and needs. Through chronic disease management platforms, comprehensive, coordinated and continuous medical services should be provided to patients. Constructing a hierarchical diagnosis and treatment system is an important measure for the allocation of medical resources and the promotion of the equalization of basic medical and health services. This can be achieved through the integration and sharing of medical and health resources in the medical consortium, innovative health management, medical consortium operation management, hierarchical diagnosis and treatment, and medical insurance payment models.
4.3 Strengthening comprehensive interventions for comorbidity in elderly and obese patients from both clinical and healthy lifestyle levels
This study found that old age and obesity are risk factors for comorbidity. As age increases, the prevalence of comorbidities increases significantly, which is consistent with the findings of SCHRAM et al (26). The increase in age causes the body's metabolic rate to slow down, the body and organs gradually decline in function, and the possibility of chronic diseases in various body systems increases. Obesity is another major factor that increases the risk of chronic diseases. Obesity will increase the risk of heart disease, hypertension, diabetes and other diseases. The "Report on the Status of Nutrition and Chronic Diseases of Chinese Residents (2020)" issued by the National Health and Family Planning Commission shows that more than 50% of adult residents in China are overweight and obese (27). As a result, treating comorbidities is more complicated than simply diagnosing and treating a single disease. Hence, it is necessary to effectively cope with multiple risk factors at the same time. According to the clinical characteristics of patients with comorbidities, there is a need to explore the connection between clinical treatment and healthy lifestyle. From a practical standpoint, a clinical diagnosis and treatment plan for comorbid patients is established based on general practitioners, with "patient-centered, clinical, and healthy lifestyle integration" to achieve a hospital-community-family trinity health management model (28).
Relevant studies point out that lifestyle medicine plays an irreplaceable role in improving the health outcomes of most chronic diseases and hence significantly reduces medical expenses. Main interventions include weight control, reasonable diet, adequate exercise, adequate sleep, smoking cessation and alcohol restriction (29-32) (see Table 4). In the future general practice diagnosis and treatment, general practitioners should explore healthy lifestyle intervention programs suitable for hospitalized patients with comorbidities as one of the core contents of clinical treatment programs.
4.4 Improving general practitioners' ability to diagnose and treat diseases in key systems and their comprehensive prevention and control capabilities.
This study found that the most commonly affected systems of comorbidities are the circulatory system, endocrine, nutrition and metabolism, digestive system, and respiratory system. Therefore, general practitioners in provincial-level tertiary hospitals should be targeted to improve the clinical treatment of common diseases and frequently-occurring diseases in the corresponding system. At the same time, given that patients with comorbidities often have multiple health risk factors, general practitioners also need to have the ability to identify, mitigate and control the main system-specific health risk factors. Therefore, the ability of general practitioners to effectively prevent and control comorbidities should have the following capabilities: (1) Diagnosis and processing capabilities of diseases and disorders Rapid diagnosis of the circulatory, endocrine, nutrition, and metabolism systems, as well as the digestive, respiratory, and other systems; (2) Ability to respond effectively to patients’ family problems (33) and (3) To Detect, control, and propose healthy lifestyle intervention programs suitable for the residents.
Correspondingly, the education and training system of general practitioners in China should be updated so as to better meet the needs of residents for the diagnosis and treatment capabilities of the practitioners. To be specific, there is a need to scale up the residency training model (5+3) and rapidly increase the number of general practitioners familiar with general medicine concepts, all of which can serve as a foundation for establishing a GP-PCIC comorbidity prevention and control model. Secondly, on the basis of harmonizing national audit standards and training quality monitoring systems for general practitioner transfer training (34, 35), specific capacity improvement training for specific chronic disease epidemic trends in specific regions should be provided to address the problem of general practitioners in the circulatory system. Thirdly, there is a need to provide more trainings to the general practitioners, and the focus to establish and improve the mechanism for the comprehensive prevention and control of diseases and comorbidities.