Cumulative complexity: A functional, patient-centered model of patient complexity can improve research and practice

Nathan D. Shippee, Nilay D. Shah, Carl R. May, Frances S. Mair, Victor M. Montori

Research output: Contribution to journalArticlepeer-review

267 Scopus citations


Objective: To design a functional, patient-centered model of patient complexity with practical applicability to analytic design and clinical practice. Existing literature on patient complexity has mainly identified its components descriptively and in isolation, lacking clarity as to their combined functions in disrupting care or to how complexity changes over time. Study Design and Setting: The authors developed a cumulative complexity model, which integrates existing literature and emphasizes how clinical and social factors accumulate and interact to complicate patient care. A narrative literature review is used to explicate the model. Results: The model emphasizes a core, patient-level mechanism whereby complicating factors impact care and outcomes: the balance between patient workload of demands and patient capacity to address demands. Workload encompasses the demands on the patient's time and energy, including demands of treatment, self-care, and life in general. Capacity concerns ability to handle work (e.g., functional morbidity, financial/social resources, literacy). Workload-capacity imbalances comprise the mechanism driving patient complexity. Treatment and illness burdens serve as feedback loops, linking negative outcomes to further imbalances, such that complexity may accumulate over time. Conclusion: With its components largely supported by existing literature, the model has implications for analytic design, clinical epidemiology, and clinical practice.

Original languageEnglish (US)
Pages (from-to)1041-1051
Number of pages11
JournalJournal of Clinical Epidemiology
Issue number10
StatePublished - Oct 2012


  • Access barriers
  • Adherence
  • Burden
  • Chronic conditions
  • Comorbidity
  • Outcomes
  • Patient complexity

ASJC Scopus subject areas

  • Epidemiology


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