1. NAPCRG Workshop (Complexity SIG) New York – November 2014 Presenters Joachim Sturmberg, Joanne Reeve, Rick Botelho & Carmel Martin

2. the co-occurrence of multiple chronic or acute diseases and medical conditions within one person Van Den Akker, Buntinx, & Knottnerus

4.  Agent that are linked in a network  Are bounded  Interdependencies  Sensitivity to initial condition  Agents that learn  Emergent behaviours – unpredictable impact resulting in  Unintended negative consequences  Amplified positive effects  Resulting feedback loops  Reinforcing (vicious cycles)  Self-stabilising

5.  Homeostasis/Allostasis vs disease markers  Allostasis is the process of achieving stability, or homeostasis, through physiological or behavioral change. This can be carried out by means of alteration in HPA axis hormones, the autonomic nervous system, cytokines, or a number of other systems, and is generally adaptive in the short term. Allostasis is essential in order to maintain internal viability amid changing conditions.

6.  Can you share some examples where things went wrong due to “clinical complexity”?  Why did it go wrong?

7.  What is clinical complexity?  How might complexity science help with clinical complexity?  How would it help you from a generalist perspective?  Complex Adaptive Systems  Agent that are linked in a network fashion  Are bounded  Interactions between agents drive the system and result in emergent behaviour  Resulting feedback loops can be  Core drivers provide focus for the system  Outcomes are non- deterministic

10.  Definitional Issues  What is multimorbidity?  How does it relate to the notions of co-morbidity and chronic disease?  Multimorbidity is the greatest burden on the health system – yes or no?

11.  Write down  Your definition of MULTIMORBIDITY  Your definition of CO-MORBIDITY  Your definition of CHRONIC DISEASE

12.  Provide a focus for the system  Self-organization of structure and function  Emergent behaviour  Outcome  Non-deterministic, i.e. not precisely predictable

13.  In groups of 4  Discuss your definitions of MULTIMORBIDITY  Discuss your definition of CO-MORBIDITY  Discuss your definition of CHRONIC DISEASE  How are they different from a complex adaptive systems perspective?  Complex Adaptive Systems  Agent that are linked in a network fashion  Are bounded  Interactions between agents drive the system and result in emergent behaviour  Resulting feedback loops can be  Core drivers provide focus for the system  Outcomes are non- deterministic

14. the co-occurrence of multiple chronic or acute diseases and medical conditions within one person Feinstein

15. Chronic diseases are illnesses that are prolonged in duration, do not often resolve spontaneously, and are rarely cured completely. complex causality, with multiple factors leading to their onset long development period, may have no symptoms; a prolonged course of illness, perhaps leading to other health complications; associated functional impairment or disability AIWH

16.  Exclude the patient’s experiential consequences of their diseases  emotional  psychological  existential /spiritual distress  Exclude levels of severity of disease and their impact on daily function  quality of life  changing characteristics over time  Fail to provide  integrated understanding of the underlying mechanisms  meaningful approaches to dealing with them on an individual or population level

17.  Emergence  simple entities (or agents) operate in an environment and form more complex behaviours as a collective  emergent behaviour arises from intricate causal relations across different scales and through feedback  the emergent behaviours or properties are not a property of any single entity NOR can they be predicted or deduced from behaviours in the lower level entities (irreducibility)

18.  are the END RESULT of ongoing perturbations and interconnected activities  of simpler substructures  that collectively constitute the complex adaptive superstructure known as us, the person or patient

19.  Who was in charge of his management?  What was the focus of his management?  What were the limitations of using the disease-specific EBM- guidelines?  What improvements did it achieve?  What were the unintended consequences?  Drug interactions  Deterioration of other morbidities  Loss of physical/social/cognitive function  Other issues  How did the healthcare system fail to adequately deal with the patient’s complex problem?  How did you get around these failures in your practice?

20.  What are the take home messages from your discussion? Consider any of the following complex adaptive system characteristics:  Interconnectedness  Emergent outcomes  Unintended consequences  Disproportioned response of input versus output  Feedback loops (catastrophic outcomes)

21.  How much of the burden of multimorbidity is intrinsically linked to current health system configurations?  How much of the burden could be eliminated by small changes in the provision of care across all domains of healthcare?

22.  are emergent phenomena  resulting from a multitude of interconnected and interdependent variables covering somatic, social, mental and cognitive domains  exhibit different properties to those of its underlying ‘discrete conditions’  responses are emergent phenomena, too  ‘discrete condition-specific’ interventions are highly likely to disturb the patient’s overall function in ways that result in unexpected and unintended consequences

23.  show emergent behaviours to living with multimorbidity and chronic disease  adaptation patterns  temporarily fixed patterns that over time can change unbeknown to the patient  altered/shifting by subtle change in experience and expectation about one’s illness and care needs  fluctuating with changing availability of emotional resources  more stable resulting in somatization

24.  Successful care delivery services  acknowledge emergent behaviours in patients’ responses to their illnesses  allow their delivery structures and functions to emerge with these changing illness dynamics

25. Multimorbidity and chronic disease: an emergent perspective Journal of Evaluation in Clinical Practice (2014) doi:10.1111/jep.12126