How do healthcare providers construe patient complexity? A qualitative study of multimorbidity in HIV outpatient clinical practice

INTRODUCTION: Patient complexity is an increasingly used concept in clinical practice, policy debates and medical research. Yet the literature lacks a clear definition of its meaning and drivers from the health provider’s perspective. This shortcoming is problematic for clinical practice and medical education in the light of a rising number of multimorbid patients and the need for future healthcare providers that are adequately trained in treating complex patients. OBJECTIVES: To develop an empirically grounded framework of healthcare providers’ perceptions of patient complexity and to characterise the relationship between case complexity, care complexity and provider experience as complexity-contributing factors. DESIGN: Qualitative study based on semistructured in-depth interviews with healthcare practitioners. SETTING: A Swiss hospital-based HIV outpatient clinic. PARTICIPANTS: A total of 31 healthcare providers participated. Participants volunteered to take part and comprised 17 nurses, 8 junior physicians (interns) and 6 senior physicians (residents, fellows and attendings). RESULTS: Perceived patient complexity arises from the combination of case complexity drivers, the provider’s perceived controllability, and a set of complexity moderators at the levels of the patient, the care provider and the broader care context. We develop a conceptual framework that outlines key relationships among these complexity-contributing factors and present 10 key questions to help guide medical professionals in making complexity more explicit and more manageable in daily practice. CONCLUSIONS: The framework presented in this study helps to advance a shared understanding of patient complexity. Our findings inform curriculum design and the teaching of essential skills to medical students in areas characterised by high patient complexity such as general internal medicine and geriatrics. From a policy perspective, our findings have important implications for the design of more effective healthcare interventions for complex patients.