INTERMED Score Research Articles

Complexity in palliative care inpatients: Prevalence and relationship with the provision of care—a retrospective study

Context End-of-life palliative care aims to provide comprehensive care and can be marked by somatic, psychosocial, and spiritual distresses, requiring interdisciplinary care. However, interdisciplinary care is costly, and palliative care services, similar to all other medical services, are pressurized to be as cost-effective as possible. Objectives To describe the case complexity of palliative care inpatients, we evaluated possible correlations between complexity and the provision of care and identified complexity subgroups. Methods Patients (N = 222) hospitalized in a specialist palliative care unit in Switzerland were assessed for biopsychosocial complexity using INTERMED. Based on a chart review, INTERMED scores were determined at admission and at the end of hospitalization or at death. Descriptive statistics and Pearson’s correlation coefficients were used to estimate the association between biopsychosocial complexity and the amount and type of care provided. Principal component analysis (PCA) was conducted to explain variance and identify patient subgroups. Results Almost all patients (98.7%) qualified as complex, as indicated by INTERMED. Provision of care was positively correlated (r = 0.23, p = 0.0008) with INTERMED scores upon admission. The change in the INTERMED score during the stay correlated negatively with the provision of care (r = −0.27, p = 0.0001). PCA performed with two factors explained 49% of the total variance and identified two subgroups that differed in the INTERMED psychosocial-item scores. Conclusion Inpatients receiving specialist palliative care showed the highest complexity score of all populations assessed to date using INTERMED. Correlations between biopsychosocial complexity and care provided, and between care and decrease in complexity scores can be considered indicators of care efficiency. Patient subgroups with specific requirements (psychosocial burden) suggested that palliative care teams require specialist palliative care collaborators. Key message Palliative care provision correlates with case complexity and is effective.

Delirium in COVID-19 and post-liver transplant patients: an observational study

Objective Delirium is a major complication in hospitalised patients. This study aimed to compare the mortality trends of patients with delirium according to the underlying physical condition. Methods Hospitalised patients diagnosed with delirium by the Modena Consultation-Liaison Psychiatry Service (Italy) during 2020 were enrolled. Three groups were identified: COVID; after orthotopic liver transplant (OLT); other conditions. The full medical records were screened to retrieve socio-demographic and clinical data. INTERMED score and Delirium Rating Scale were used to retrospectively rate bio-social-complexity and delirium severity. Early (20 days) and end of study (31st January 2021) mortality were ascertained for each subject. Results A total of 103 patients were enrolled. Patients hospitalised for COVID showed higher INTERMED scores (two-tailed t-test, p = 0.019) and higher 20-day mortality (HR = 3.68, p = 0.014). When considering a 1-year follow-up, the main predictor of mortality was patients’ age in all three subgroups (HR = 1.06; p = 0.003). Conclusion Our results suggest that patients hospitalised for COVID-19 with delirium showed higher bio-psycho-social complexity and higher short-term mortality, regardless of the severity of delirium. OLT patients showed lower mortality and bio-psycho-social complexity, despite being still considered as ‘complex’, according to the INTERMED score. Future research should focus on understanding the underlying mechanisms in the relationship between delirium and mortality. Key points Patients hospitalised for COVID-19 with delirium were found at risk of higher short-term mortality and higher bio-psycho-social complexity. OLT patients showed lower overall mortality and lower bio-psycho-social complexity than the other two groups, despite being still in the ‘complex’ range according to the INTERMED score. Future research should assess the areas of impact of delirium in patients affected by COVID-19, considering short- and long-term outcomes.

Case complexity in outpatients in a centre of excellence for somatic symptom disorder -a cross-sectional study-

Background: At the Clinical Centre of Excellence for Body, Mind and Health, integrated care models are used to provide treatment to patients with Somatic Symptom and Related Disorders (SSD). The aim of this study is to describe complexity of SSD patients using the INTERMED. This instrument has been developed for patients with chronic medical conditions. So far, it has not been used in a population with medically (un-)explained symptoms. Method: The INTERMED indicates case complexity according to the biopsychosocial model of health. It was used to measure case complexity in outpatients with SSD. In this cross-sectional study, data was collected retrospectively from patient files. A quantitative description of complexity will be provided with descriptive statistics and Pearson correlations of complexity scores and demographic variables. Results: Of the total sample (N = 262), 37.7% was male, mean (SD) age was 41.7 (13.2), with an average educational level. The mean INTERMED score was 24.1, indicating high overall complexity in this SSD population. More specifically, 72.6% of the scores indicated complexity to high complexity. The total score correlated significantly with high age (r = .20). Conclusion: The current study demonstrated that SSD patients are complex on multiple levels, indicating the need of individual case management and multi-disciplinary involvement. Compared to other studies, SSD patients were more complex compared to patients with rheumatoid arthritis (Mean < 20), complex regional pain syndrome (Mean = 19) and liver pre-transplant patients (Mean = 20). Patients with a combination of substance abuse, a medical condition and psychiatric illness were more complex than our SSD sample (Mean = 37). The results indicate that patients with SSD in a centre of excellence are highly complex. The INTERMED provides a comprehensive overview of patient functioning and can be used in clinical practice to investigate patient complexity. Further research should focus on its clinical use in psychiatric settings, its implementation, and its use in long-term monitoring of patient outcomes. Early examination of case complexity will contribute to improved case management, treatment selection, and multidisciplinary involvement. The current study emphasizes the need for integrated patient care for SSD patients, exceeding normal medical and psychiatric procedures.

Evaluation of an integrated multidisciplinary approach in multiple sclerosis care: A prospective, randomized, controlled study.

BackgroundDisabled multiple sclerosis (MS) patients often need intervention of multiple specialists, resulting in a complex organization of care. How this multidisciplinary care should be organized and structured has not been studied.ObjectiveThe objective of this article is to address the effectiveness of an integrated multidisciplinary approach versus usual care in MS patients.MethodsThis is a prospective, randomized, controlled, monocentric clinical trial in MS patients. Two treatment strategies were compared: (i) an integrated multidisciplinary (IMD) approach, consisting of a half-day individually tailored comprehensive assessment in the MS clinic; and (ii) a standard care. The primary outcome was the impact of the strategy on quality of life (QoL) measured using the MSIS-29 scale at inclusion and after six months.ResultsFifty MS patients were included. Median MSIS 29 score decreased over six months in the control group (−4.89) and increased in the IMD group (+2.00), with a significant difference between the two groups (p = 0.03). However, in the multivariate analysis, after adjustment of HAD-D and INTERMED score, this difference was no longer significant.ConclusionsThis prospective, randomized study is the first attempt to evaluate the multidisciplinary approach in MS patients. The results show that, contrary to our expectations, an integrated multidisciplinary approach is not superior to usual care on QoL.

Biopsychosocial Health Care Needs at the Emergency Room: Challenge of Complexity

BackgroundIn an emergency room of internal medicine, triage and treatment of patients deserve first priority. However, biopsychosocial case complexity may also affect patient health outcome but has not yet been explored in this setting. Therefore, the aims of the study are (1) to estimate prevalence rates of complex patients in the emergency room (ER), (2) to describe biopsychosocial complexity in this population and (3) to evaluate possible correlations between patient profiles regarding case complexity and further clinical treatment.MethodsDuring a study period of one week, all patients of an emergency room of internal medicine who were triaged to Manchester levels three to five were invited to participate in the study. Biopsychosocial case complexity was assessed by the INTERMED method. Psychosocial interventions were evaluated based on all documented interventions and recommendations given at the emergency room and during inpatient treatment.ResultsStudy participants consisted of 167 patients with a subgroup of 19% (n = 32) receiving subsequent inpatient-treatment at the department. High biopsychosocial case complexity was found in 12% (n = 20) of the total sample (INTERMED score >20). This finding was paralleled by a cluster analysis suggesting three clusters with one highly complex patient group of 14%. These highly complex patients differed significantly from the other clusters as they had visited the emergency room more often within the last year and lived alone more frequently. In addition, admission rates were highest in this group. During ER treatment and subsequent inpatient treatment, 21% of highly complex patients received interventions addressing psychosocial factors as compared to 6% and 7%, respectively, in the other clusters.ConclusionsA standardized screening of biopsychosocial case complexity among ‘frequent utilizers’ of the ER would be helpful to detect specific multidisciplinary health care needs among this particularly burdened patient group.

The INTERMED questionnaire for predicting return to work after a multidisciplinary rehabilitation program for chronic low back pain

ObjectivesTo evaluate the performance of the INTERMED questionnaire score, alone or combined with other criteria, in predicting return to work after a multidisciplinary rehabilitation program in patients with non-specific chronic low back pain. MethodsThe INTERMED questionnaire is a biopsychosocial assessment and clinical classification tool that separates heterogeneous populations into subgroups according to case complexity. We studied 88 patients with chronic low back pain who followed an intensive multidisciplinary rehabilitation program on an outpatient basis. Before the program, we recorded the INTERMED score, radiological abnormalities, subjective pain severity, and sick leave duration. Associations between these variables and return to full-time work within 3 months after the end of the program were evaluated using one-sided Fisher tests and univariate logistic regression followed by multivariate logistic regression. ResultsThe univariate analysis showed a significant association between the INTERMED score and return to work (P<0.001; odds ratio, 0.90; 95% confidence interval, 0.86–0.96). In the multivariate analysis, prediction was best when the INTERMED score and sick leave duration were used in combination (P=0.03; odds ratio, 0.48; 95% confidence interval, 0.25–0.93). ConclusionThe INTERMED questionnaire is useful for evaluating patients with chronic low back pain. It could be used to improve the selection of patients for intensive multidisciplinary programs, thereby improving the quality of care, while reducing healthcare costs.

A simple risk score predicts poor quality of life and non-survival at 1 year follow-up in dialysis patients.

Quality of life (QoL) in end-stage renal disease patients has become an important focus of attention in evaluating dialysis. We studied risk factors of poor QoL at 1 year follow-up. Of a baseline sample of 80 dialysis patients, we contacted 60 patients who were alive at 1 year follow-up. QoL data were obtained for 46 (76.7%) of these patients. QoL measured with the SF-36 [physical health component score (PCS) and mental health component score (MCS)] at 1 year-follow-up was predicted by means of multivariate regression analysis by data collected at baseline using INTERMED-an observer-rated method to assess biopsychosocial care needs-and several indicators for disease severity and comorbidity. The regression models explained 32% of the variance in PCS and 40% in MCS. INTERMED score (P < 0.01) was the only independent risk factor for low MCS, while for low PCS, diabetic comorbidity (P = 0.02) and age (P = 0.03) were independent risk factors. A simple risk score consisting of INTERMED > or =21, diabetic comorbidity and age > or =65 was significantly correlated with non-survival (P = 0.02) and with PCS (P < 0.01) and MCS (P < 0.01) in surviving patients, although not with hospital admissions during follow-up. A simple risk score based on INTERMED, age (> or =65) and comorbid diabetes (yes/no) can be used to detect patients at risk of poor QoL and non-survival at an early stage of treatment.

Assessing Health Care Needs and Clinical Outcome With Urological Case Complexity: A Study Using INTERMED

Urinary tract symptoms and, particularly, urinary incontinence are often chronic and complex conditions that cause diagnosis, treatment, and management problems. In many cases, psychosocial factors contribute to the development of a chronic condition. The authors investigated whether INTERMED, an instrument for assessing case complexity and health care needs, was able to identify such complex cases, to estimate the amount of comorbidity, and to predict clinical outcome for 31 consecutive patients suffering from urinary tract symptoms. To assess clinical outcome, the authors used the American Urologic Association Symptom Score, the Brief Symptom Inventory, and the Hospital Anxiety and Depression Scale. On the basis of the patients' INTERMED scores, the authors distinguished between low-complexity patients (INTERMED score <21, N=25, 80.6%) and high-complexity patients (INTERMED score >or=21, N=6; 19.4%). Low-complexity patients had fewer depressive and anxiety symptoms, less distress, and better clinical outcome at their 3-month follow-up than high-complexity patients. The data confirmed the ability of the instrument to detect patients at risk of complex urinary tract symptoms and to predict clinical outcome.