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Современные подходы к оценке коморбидности у пациентов
Современные подходы к оценке коморбидности у пациентов
Сарсенбаева Г.И., Турсынбекова А.Е. Современные подходы к оценке коморбидности у пациентов. CardioСоматика. 2019; 10 (1): 19–23. DOI: 10.26442/22217185.2019.1.180073
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Аннотация
Цель. Представить современные данные о преимуществах и недостатках существующих международных шкал и индексов коморбидности.
Материалы и методы. Рассмотрены данные 29 научных источников, опубликованных в российской и зарубежной печати в 1973–2018 гг.
Результаты. Наличие коморбидности у пациента является проблемой современной медицины. В большинстве случаев ряд сопутствующей патологии при своевременной диагностике и соблюдении алгоритмов оказания медицинской помощи поддается коррекции и лечению. Для управления рисками развития осложнений и назначения эффективной терапии при наличии сопутствующих заболеваний созданы международные и национальные клинические рекомендации, в которых изложены алгоритмы клинической и инструментальной оценки развития осложнений, предложены шкалы и индексы, такие как система Cumulative lllness Rating Scale (CIRS), индексы коморбидности Charlson, Kaplan–Feinstein, сосуществующих болезней (Index of Co-Existent Disease – ICED), Гериатрический индекс коморбидности (Geriatric Index of Comorbidity – GIC), Functional Comorbidity Index (FCI), показатель функциональной коморбидности и др. Результаты исследовательской работы канадских ученых по сравнительной характеристике 5 международных шкал коморбидности у пациентов с онкологическими заболеваниями головы и шеи показали значимое влияние коморбидности на выживаемость пациентов с разными стадиями новообразований, было подчеркнуто, что индекс оценки коморбидности необходим для контроля за влиянием сопутствующих заболеваний на состояние пациентов в отдаленный период. Шкала Kaplan–Feinstein явилась лучшим индексом для оценки выживаемости пациентов с онкологическими заболеваниями в области головы и шеи. По данным работ V.de Groot, наиболее широко изученным показателем коморбидности для прогнозирования смертности является индекс Charlson. Каждый из индексов имеет свои преимущества и недостатки и используется в разных клинических ситуациях.
Заключение. Общий индекс коморбидности – это комплексная сводная оценка сочетания или тяжести заболевания, которая объединяет все условия, проблемы и болезни пациентов, взвешивая их по степени тяжести, и значимо влияет на тактику лечения и исход в дальнейшем.
Ключевые слова: коморбидность, полиморбидность, сопутствующие заболевания.
Materials and methods. Data of 29 scientific sources published in Russian and foreign literature press within 1973–2018 are considered.
Results. The presence of comorbidity in a patient is an issue of modern medicine. In most cases some comorbid diseases if timely diagnosed and managed in accordance with algorithms for medical care can be corrected and treated. In order to control risks of development of complications and to prescribe an effective therapy for comorbidity the international and national clinical guidelines have been created. They include algorithms for clinical and instrumental assessment of complications and provide scales and indices, such as Cumulative lllness Rating Scale (CIRS), Charlson comorbidity index, Kaplan–Feinstein index, Index of Co-Existent Disease (ICED), Geriatric Index of Comorbidity (GIC), Functional Comorbidity Index (FCI) et al. Data of Canadian comparative study of 5 international scales of comorbidity in patients with head and neck cancers showed a significant impact of comorbidity on survival of patients with different stages of neoplasms. It was emphasized that the index of comorbidity is necessary to control an impact of comorbid diseases on the patients' status in the long-term period. The Kaplan–Feinstein scale was the best index for assessing a survival of patients with head and neck cancer. According to V.de Groot, the most widely studied comorbidity index for predicting mortality is the Charlson index. Each index has its advantages and disadvantages and is used in different clinical situations.
Conclusion. General comorbidity index is a comprehensive summary score of a disease combination or severity, which combines all conditions, problems and illnesses of patients, weights them by severity, and it significantly affects treatment tactics and outcome in a future.
Key words: comorbidity, polymorbidity, associated diseases.
Материалы и методы. Рассмотрены данные 29 научных источников, опубликованных в российской и зарубежной печати в 1973–2018 гг.
Результаты. Наличие коморбидности у пациента является проблемой современной медицины. В большинстве случаев ряд сопутствующей патологии при своевременной диагностике и соблюдении алгоритмов оказания медицинской помощи поддается коррекции и лечению. Для управления рисками развития осложнений и назначения эффективной терапии при наличии сопутствующих заболеваний созданы международные и национальные клинические рекомендации, в которых изложены алгоритмы клинической и инструментальной оценки развития осложнений, предложены шкалы и индексы, такие как система Cumulative lllness Rating Scale (CIRS), индексы коморбидности Charlson, Kaplan–Feinstein, сосуществующих болезней (Index of Co-Existent Disease – ICED), Гериатрический индекс коморбидности (Geriatric Index of Comorbidity – GIC), Functional Comorbidity Index (FCI), показатель функциональной коморбидности и др. Результаты исследовательской работы канадских ученых по сравнительной характеристике 5 международных шкал коморбидности у пациентов с онкологическими заболеваниями головы и шеи показали значимое влияние коморбидности на выживаемость пациентов с разными стадиями новообразований, было подчеркнуто, что индекс оценки коморбидности необходим для контроля за влиянием сопутствующих заболеваний на состояние пациентов в отдаленный период. Шкала Kaplan–Feinstein явилась лучшим индексом для оценки выживаемости пациентов с онкологическими заболеваниями в области головы и шеи. По данным работ V.de Groot, наиболее широко изученным показателем коморбидности для прогнозирования смертности является индекс Charlson. Каждый из индексов имеет свои преимущества и недостатки и используется в разных клинических ситуациях.
Заключение. Общий индекс коморбидности – это комплексная сводная оценка сочетания или тяжести заболевания, которая объединяет все условия, проблемы и болезни пациентов, взвешивая их по степени тяжести, и значимо влияет на тактику лечения и исход в дальнейшем.
Ключевые слова: коморбидность, полиморбидность, сопутствующие заболевания.
________________________________________________
Materials and methods. Data of 29 scientific sources published in Russian and foreign literature press within 1973–2018 are considered.
Results. The presence of comorbidity in a patient is an issue of modern medicine. In most cases some comorbid diseases if timely diagnosed and managed in accordance with algorithms for medical care can be corrected and treated. In order to control risks of development of complications and to prescribe an effective therapy for comorbidity the international and national clinical guidelines have been created. They include algorithms for clinical and instrumental assessment of complications and provide scales and indices, such as Cumulative lllness Rating Scale (CIRS), Charlson comorbidity index, Kaplan–Feinstein index, Index of Co-Existent Disease (ICED), Geriatric Index of Comorbidity (GIC), Functional Comorbidity Index (FCI) et al. Data of Canadian comparative study of 5 international scales of comorbidity in patients with head and neck cancers showed a significant impact of comorbidity on survival of patients with different stages of neoplasms. It was emphasized that the index of comorbidity is necessary to control an impact of comorbid diseases on the patients' status in the long-term period. The Kaplan–Feinstein scale was the best index for assessing a survival of patients with head and neck cancer. According to V.de Groot, the most widely studied comorbidity index for predicting mortality is the Charlson index. Each index has its advantages and disadvantages and is used in different clinical situations.
Conclusion. General comorbidity index is a comprehensive summary score of a disease combination or severity, which combines all conditions, problems and illnesses of patients, weights them by severity, and it significantly affects treatment tactics and outcome in a future.
Key words: comorbidity, polymorbidity, associated diseases.
Полный текст
Список литературы
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[Vertkin A.L., Rumiantsev M.A., Skotnikov A.S. Komorbidnost' v klinicheskoi praktike. Chast' 1. Arkhiv vnutrennei meditsiny. 2011; 1: 9–13 (in Russian).]
4. Нургазизова А.К. Происхождение, развитие и современная трактовка понятий «коморбидность» и «полиморбидность». Казанский мед. журн. 2014; 95 (2): 292–6.
[Nurgazizova A.K. Proiskhozhdenie, razvitie i sovremennaia traktovka poniatii "komorbidnost'' i "polimorbidnost''. Kazanskii med. zhurn. 2014; 95 (2): 292–6 (in Russian).]
5. Торосян Е.А., Торосян А.Ц., Семерджян В.В. «Черная дыра» медицины – полиморбидность. Вестн. новых медицинских технологий. 2008; 15 (1): 202–4.
[Torosian E.A., Torosian A.Ts., Semerdzhian V.V. "Chernaia dyra" meditsiny – polimorbidnost'. Vestn. novykh meditsinskikh tekhnologii. 2008; 15 (1): 202–4 (in Russian).]
6. Wittchen HU. What is comorbidity – fact or artifact? Br J Psychiatry 1996; 168 (Suppl.): 9–16.
7. De Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure comorbidity: a critical review of available methods. J Clin Epidemiol 2003; 56 (3): 221–9.
8. Linn BS. Linn MW. Gurel L. Cumulative illness rating scale. J Am Geriatr Soc 1968; 16: 622–6.
9. Mark D, Miller MD, Towers A. Manual of Guidelines for Scoring the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Pittsburg, Pa: University of Pittsburgh, 1991; p. 31.
10. Charlson ME, Pompei P, Ales KL et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 1987; 40: 373–83.
11. Van Manen JG, Korevaar JC, Dekker FW et al. How to adjust for comorbidity in survival studies in ESRD patients: a comparison of different indices. Am J Kidney Dis 2002; 40: 82–9.
12. Fried L, Bernardini J, Piraino B. Charlson comorbidity index as a predictor of outcomes in incident peritoneal dialysis patients. Am J Kidney Dis 2001; 37: 337–42.
13. Hemmelgarn BR, Manns BJ, Quan H et al. Adapting the Charlson Comorbidity Index for use in patients with ESRD. Am J Kidney Dis 2003; 42: 125–32.
14. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45 (6): 613–9.
15. Kaplan MH, Feinstein AR. Acritique of methods in reported studies of long-term vascular complications in patients with diabetes mellitus. Diabetes 1973; 22 (3): 160–74.
16. Greenfield S, Apolone G. The importance of coexistent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacement: Comorbidity and outcomes after hip replacement. Med Care 1993; 31: 141–54.
17. Rozzini R, Frisoni GB, Ferrucci L et al. GeriatricIndex of Comorbidity: validation and comparisonwith other measures of comorbidity. Age Ageing 2002; 31 (4): 277–85.
18. Grolla DL, Tob T, Bombardierc C, Wright JG. The development of a comorbidity index with physical function as the outcome . J Clin Epidemiol 2005; 58 (6): 595–602.
19. Preedy VR, Watson RR. Handbook of Diseases and a Measure of Quality of Life. New York: Springer, 2010. DOI: https:// doi.org/10.1007/978-0-387-78665-0
20. Litwin MS, Greenfield S, Elkin EP et al Assessment of Prognosis With the Total Illness Burden Index for Prostate Cancer. Cancer 2007; 109 (9): 1777–83.
21. Hall SF. What is best comorbidity index for retrospective survival studies in head and neck oncology. Canada 2001; p. 135.
22. De Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure comorbidity: a critical review of available methods. J Clin Epidemiol 2003; 56 (3): 221–9.
23. Rhee DS, Salazar JH, Zhang Y et al. New multispecial surgical risk assessment for children. Pediatrics 2013; 131 (3): 829–36.
24. Tai D, Dick P, To T, Wright JG. Development of a children's comorbidity prediction model. Arch Pediatr Adolesc Med 2006; 160 (3): 293–9. DOI: 10.1001/archpedi.160.3.293
25. Jiang R, Wolf S, Alkazemi MH et al. The evaluation of three comorbidity indices in predicting postoperative complications and readmissions in pediatric urology. J Pediatr Urol 2018; 14 (3): 244. DOI: 10.1016/j.jpurol.2017.12.019
26. Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality (PRISM) score. Crit Care Med 1988; 16 (11): 1110–6.
27. Губанова Г.В., Беляева Ю.Н., Шеметова Г.Н. Коморбидный пациент: этапы формирования, факторы риска и тактика ведения. Современные проблемы науки и образования. 2015; 6. http://www.science-education.ru/ru/article/ view?id=23986
[Gubanova G.V., Beliaeva Iu.N., Shemetova G.N. Komorbidnyi patsient: etapy formirovaniia, faktory riska i taktika vedeniia. Sovremennye problemy nauki i obrazovaniia. 2015; 6. http://www.science-education.ru/ru/article/view?id =23986 (in Russian).
28. Белялов Ф.И. Двенадцать тезисов коморбидности. Клин. медицина. 2009; 87 (12): 69–71.
[Belialov F.I. Dvenadtsat' tezisov komorbidnosti. Klin. meditsina. 2009; 87 (12): 69–71 (in Russian).]
29. Gijsen R, Hoeymans N, Schellevis FG et al. Causes and consequences of comorbidity: a review. J Clin Epidemiol 2001; 54 (7): 661–74.
2. Campbell-Scherer D. Multimorbidity challenge ofevidence-based medicine. Evid Based Med 2010; 15: 165–6.
3. Vertkin A.L., Rumiantsev M.A., Skotnikov A.S. Komorbidnost' v klinicheskoi praktike. Chast' 1. Arkhiv vnutrennei meditsiny. 2011; 1: 9–13 (in Russian).
4. Nurgazizova A.K. Proiskhozhdenie, razvitie i sovremennaia traktovka poniatii "komorbidnost'' i "polimorbidnost''. Kazanskii med. zhurn. 2014; 95 (2): 292–6 (in Russian).
5. Torosian E.A., Torosian A.Ts., Semerdzhian V.V. "Chernaia dyra" meditsiny – polimorbidnost'. Vestn. novykh meditsinskikh tekhnologii. 2008; 15 (1): 202–4 (in Russian).
6. Wittchen HU. What is comorbidity – fact or artifact? Br J Psychiatry 1996; 168 (Suppl.): 9–16.
7. De Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure comorbidity: a critical review of available methods. J Clin Epidemiol 2003; 56 (3): 221–9.
8. Linn BS. Linn MW. Gurel L. Cumulative illness rating scale. J Am Geriatr Soc 1968; 16: 622–6.
9. Mark D, Miller MD, Towers A. Manual of Guidelines for Scoring the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Pittsburg, Pa: University of Pittsburgh, 1991; p. 31.
10. Charlson ME, Pompei P, Ales KL et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 1987; 40: 373–83.
11. Van Manen JG, Korevaar JC, Dekker FW et al. How to adjust for comorbidity in survival studies in ESRD patients: a comparison of different indices. Am J Kidney Dis 2002; 40: 82–9.
12. Fried L, Bernardini J, Piraino B. Charlson comorbidity index as a predictor of outcomes in incident peritoneal dialysis patients. Am J Kidney Dis 2001; 37: 337–42.
13. Hemmelgarn BR, Manns BJ, Quan H et al. Adapting the Charlson Comorbidity Index for use in patients with ESRD. Am J Kidney Dis 2003; 42: 125–32.
14. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45 (6): 613–9.
15. Kaplan MH, Feinstein AR. Acritique of methods in reported studies of long-term vascular complications in patients with diabetes mellitus. Diabetes 1973; 22 (3): 160–74.
16. Greenfield S, Apolone G. The importance of coexistent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacement: Comorbidity and outcomes after hip replacement. Med Care 1993; 31: 141–54.
17. Rozzini R, Frisoni GB, Ferrucci L et al. GeriatricIndex of Comorbidity: validation and comparisonwith other measures of comorbidity. Age Ageing 2002; 31 (4): 277–85.
18. Grolla DL, Tob T, Bombardierc C, Wright JG. The development of a comorbidity index with physical function as the outcome . J Clin Epidemiol 2005; 58 (6): 595–602.
19. Preedy VR, Watson RR. Handbook of Diseases and a Measure of Quality of Life. New York: Springer, 2010. DOI: https:// doi.org/10.1007/978-0-387-78665-0
20. Litwin MS, Greenfield S, Elkin EP et al Assessment of Prognosis With the Total Illness Burden Index for Prostate Cancer. Cancer 2007; 109 (9): 1777–83.
21. Hall SF. What is best comorbidity index for retrospective survival studies in head and neck oncology. Canada 2001; p. 135.
22. De Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure comorbidity: a critical review of available methods. J Clin Epidemiol 2003; 56 (3): 221–9.
23. Rhee DS, Salazar JH, Zhang Y et al. New multispecial surgical risk assessment for children. Pediatrics 2013; 131 (3): 829–36.
24. Tai D, Dick P, To T, Wright JG. Development of a children's comorbidity prediction model. Arch Pediatr Adolesc Med 2006; 160 (3): 293–9. DOI: 10.1001/archpedi.160.3.293
25. Jiang R, Wolf S, Alkazemi MH et al. The evaluation of three comorbidity indices in predicting postoperative complications and readmissions in pediatric urology. J Pediatr Urol 2018; 14 (3): 244. DOI: 10.1016/j.jpurol.2017.12.019
26. Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality (PRISM) score. Crit Care Med 1988; 16 (11): 1110–6.
27. Gubanova G.V., Beliaeva Iu.N., Shemetova G.N. Komorbidnyi patsient: etapy formirovaniia, faktory riska i taktika vedeniia. Sovremennye problemy nauki i obrazovaniia. 2015; 6. http://www.science-education.ru/ru/article/view?id =23986 (in Russian).
28. Belialov F.I. Dvenadtsat' tezisov komorbidnosti. Klin. meditsina. 2009; 87 (12): 69–71 (in Russian).]
29. Gijsen R, Hoeymans N, Schellevis FG et al. Causes and consequences of comorbidity: a review. J Clin Epidemiol 2001; 54 (7): 661–74.
[Belialov F.I. Sochetannye zabolevaniia vnutrennikh organov v terapevticheskoi praktike. Irkutsk, 2009; s. 47–52 (in Russian).]
2. Campbell-Scherer D. Multimorbidity challenge ofevidence-based medicine. Evid Based Med 2010; 15: 165–6.
3. Верткин А.Л., Румянцев М.А., Скотников А.С. Коморбидность в клинической практике. Часть 1. Архив внутренней медицины. 2011; 1: 9–13.
[Vertkin A.L., Rumiantsev M.A., Skotnikov A.S. Komorbidnost' v klinicheskoi praktike. Chast' 1. Arkhiv vnutrennei meditsiny. 2011; 1: 9–13 (in Russian).]
4. Нургазизова А.К. Происхождение, развитие и современная трактовка понятий «коморбидность» и «полиморбидность». Казанский мед. журн. 2014; 95 (2): 292–6.
[Nurgazizova A.K. Proiskhozhdenie, razvitie i sovremennaia traktovka poniatii "komorbidnost'' i "polimorbidnost''. Kazanskii med. zhurn. 2014; 95 (2): 292–6 (in Russian).]
5. Торосян Е.А., Торосян А.Ц., Семерджян В.В. «Черная дыра» медицины – полиморбидность. Вестн. новых медицинских технологий. 2008; 15 (1): 202–4.
[Torosian E.A., Torosian A.Ts., Semerdzhian V.V. "Chernaia dyra" meditsiny – polimorbidnost'. Vestn. novykh meditsinskikh tekhnologii. 2008; 15 (1): 202–4 (in Russian).]
6. Wittchen HU. What is comorbidity – fact or artifact? Br J Psychiatry 1996; 168 (Suppl.): 9–16.
7. De Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure comorbidity: a critical review of available methods. J Clin Epidemiol 2003; 56 (3): 221–9.
8. Linn BS. Linn MW. Gurel L. Cumulative illness rating scale. J Am Geriatr Soc 1968; 16: 622–6.
9. Mark D, Miller MD, Towers A. Manual of Guidelines for Scoring the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Pittsburg, Pa: University of Pittsburgh, 1991; p. 31.
10. Charlson ME, Pompei P, Ales KL et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 1987; 40: 373–83.
11. Van Manen JG, Korevaar JC, Dekker FW et al. How to adjust for comorbidity in survival studies in ESRD patients: a comparison of different indices. Am J Kidney Dis 2002; 40: 82–9.
12. Fried L, Bernardini J, Piraino B. Charlson comorbidity index as a predictor of outcomes in incident peritoneal dialysis patients. Am J Kidney Dis 2001; 37: 337–42.
13. Hemmelgarn BR, Manns BJ, Quan H et al. Adapting the Charlson Comorbidity Index for use in patients with ESRD. Am J Kidney Dis 2003; 42: 125–32.
14. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45 (6): 613–9.
15. Kaplan MH, Feinstein AR. Acritique of methods in reported studies of long-term vascular complications in patients with diabetes mellitus. Diabetes 1973; 22 (3): 160–74.
16. Greenfield S, Apolone G. The importance of coexistent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacement: Comorbidity and outcomes after hip replacement. Med Care 1993; 31: 141–54.
17. Rozzini R, Frisoni GB, Ferrucci L et al. GeriatricIndex of Comorbidity: validation and comparisonwith other measures of comorbidity. Age Ageing 2002; 31 (4): 277–85.
18. Grolla DL, Tob T, Bombardierc C, Wright JG. The development of a comorbidity index with physical function as the outcome . J Clin Epidemiol 2005; 58 (6): 595–602.
19. Preedy VR, Watson RR. Handbook of Diseases and a Measure of Quality of Life. New York: Springer, 2010. DOI: https:// doi.org/10.1007/978-0-387-78665-0
20. Litwin MS, Greenfield S, Elkin EP et al Assessment of Prognosis With the Total Illness Burden Index for Prostate Cancer. Cancer 2007; 109 (9): 1777–83.
21. Hall SF. What is best comorbidity index for retrospective survival studies in head and neck oncology. Canada 2001; p. 135.
22. De Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure comorbidity: a critical review of available methods. J Clin Epidemiol 2003; 56 (3): 221–9.
23. Rhee DS, Salazar JH, Zhang Y et al. New multispecial surgical risk assessment for children. Pediatrics 2013; 131 (3): 829–36.
24. Tai D, Dick P, To T, Wright JG. Development of a children's comorbidity prediction model. Arch Pediatr Adolesc Med 2006; 160 (3): 293–9. DOI: 10.1001/archpedi.160.3.293
25. Jiang R, Wolf S, Alkazemi MH et al. The evaluation of three comorbidity indices in predicting postoperative complications and readmissions in pediatric urology. J Pediatr Urol 2018; 14 (3): 244. DOI: 10.1016/j.jpurol.2017.12.019
26. Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality (PRISM) score. Crit Care Med 1988; 16 (11): 1110–6.
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[Gubanova G.V., Beliaeva Iu.N., Shemetova G.N. Komorbidnyi patsient: etapy formirovaniia, faktory riska i taktika vedeniia. Sovremennye problemy nauki i obrazovaniia. 2015; 6. http://www.science-education.ru/ru/article/view?id =23986 (in Russian).
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[Belialov F.I. Dvenadtsat' tezisov komorbidnosti. Klin. meditsina. 2009; 87 (12): 69–71 (in Russian).]
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26. Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality (PRISM) score. Crit Care Med 1988; 16 (11): 1110–6.
27. Gubanova G.V., Beliaeva Iu.N., Shemetova G.N. Komorbidnyi patsient: etapy formirovaniia, faktory riska i taktika vedeniia. Sovremennye problemy nauki i obrazovaniia. 2015; 6. http://www.science-education.ru/ru/article/view?id =23986 (in Russian).
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29. Gijsen R, Hoeymans N, Schellevis FG et al. Causes and consequences of comorbidity: a review. J Clin Epidemiol 2001; 54 (7): 661–74.
Авторы
Г.И.Сарсенбаева*1, А.Е.Турсынбекова2
1 АО «Научный центр педиатрии и детской хирургии» Минздрава Республики Казахстан. 050023, Республика Казахстан, Алматы, пр-т Аль-Фараби, д. 146;
2 Казахский национальный медицинский университет им. С.Д.Асфендиярова. 050012, Республика Казахстан, Алматы, ул. Толе би, д. 88
*gulzhan75@mail.ru
1 Scientific Center of Pediatrics and Pediatric Surgery of the Ministry of Health of the Republic of Kazakhstan. 146, Al-Farabi dr., Almaty, 050023, Republic of Kazakhstan;
2 S.D.Asfendiyarov Kazakh National Medical University. 88, Tole bi st., Almaty, 050012, Republic of Kazakhstan
*gulzhan75@mail.ru
1 АО «Научный центр педиатрии и детской хирургии» Минздрава Республики Казахстан. 050023, Республика Казахстан, Алматы, пр-т Аль-Фараби, д. 146;
2 Казахский национальный медицинский университет им. С.Д.Асфендиярова. 050012, Республика Казахстан, Алматы, ул. Толе би, д. 88
*gulzhan75@mail.ru
________________________________________________
1 Scientific Center of Pediatrics and Pediatric Surgery of the Ministry of Health of the Republic of Kazakhstan. 146, Al-Farabi dr., Almaty, 050023, Republic of Kazakhstan;
2 S.D.Asfendiyarov Kazakh National Medical University. 88, Tole bi st., Almaty, 050012, Republic of Kazakhstan
*gulzhan75@mail.ru
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