INTEGRATED OUTPATIENT CARE MODELS FOR PATIENTS WITH COMPLEX CHRONIC MULTIMORBIDITY

To:
The World Health Organization (WHO),
The Organisation for Economic Co-operation and Development (OECD),
Organizations and scientists interested in integrated outpatient care models for patients with complex chronic multimorbidity, currently lying outside the operational coverage of single-disease clinical guidelines.

My name is Nguyen Dinh Quang, an independent medical researcher and the founder of Vien Gut, a medical center based in Ho Chi Minh City, Vietnam. For nearly two decades, we have conducted research, developed, and implemented in clinical practice an integrated outpatient care model for complex chronic multimorbidity. Our initial focus was on patients with severely complicated gout. Since 2018, we have expanded the model’s capacity to other life-threatening chronic conditions, including stage 4–5 chronic kidney disease prior to dialysis, chronic heart failure with preserved ejection fraction and selected cases with reduced ejection fraction, and decompensated cirrhosis (Child–Pugh A and selected Child–Pugh B cases).

The foundation of this model did not begin with a new medication, but with a reference-shifting discovery: despite the evolution of medicine toward living guidelines, a clinical blind zone persists for patients with complex multimorbidity, and a guideline paradox emerges whereby strictly adhering to multiple single-disease guidelines may lead to incorrect reference-frame decisions for the same patient. On this basis, Vien Gut developed a breakthrough solution: constructing a “map of the blind zone” through longitudinal patient data, combined with an integrated outpatient operational layer that shifts care from individual-dependent decision-making to system-level capability. This system includes risk stratification, polypharmacy governance, trend-based monitoring, action-threshold alert mechanisms, and a bidirectional referral safety valve with reintegration after inpatient care.

The value of the Vien Gut Model has been demonstrated through measurable and verifiable clinical outcomes across four core disease groups. Moreover, the blind zone map enables the identification and preservation of windows of opportunity—timely intervention before crossing the “point of no return”—to reduce adverse events, lower readmission rates, safely delay end-stage progression, and move toward controlled stabilization or recovery.

Recognizing this as a global gap in medicine, since 2014 Vien Gut has collaborated in research with numerous French professors and physicians—world-leading experts across multiple specialties—to both align the model with existing guidelines and rigorously evaluate its therapeutic effectiveness.

At a time when the global medical community is strongly advancing integrated care for patients with complex chronic multimorbidity—with cross-cutting priorities including outpatient safety, readmission reduction, polypharmacy control, and longitudinal risk governance—I am writing this letter with a single purpose: to share a practice-validated experience on how to build system-level capacity to care for patients lying outside the operational scope of single-disease guidelines.

I particularly hope that this shared experience may serve as a practical reference for low- and middle-income countries, where the burden of complex chronic multimorbidity is rapidly increasing while resources, longitudinal monitoring infrastructure, and specialized workforce remain limited—thereby supporting the development of a safe, structured, and scalable outpatient operational layer.

Vien Gut is prepared to organize online meetings, conduct thematic professional exchanges, and host expert delegations for on-site observation of the operational model, longitudinal monitoring processes, and outpatient risk-control mechanisms. We are also ready to share data and participate in international collaborative research programs.

Respectfully,

Nguyen Dinh Quang
Independent Medical Researcher – Chairman of Vien Gut
Ho Chi Minh City, Vietnam