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Newnham HH. Acting on better data for general medical care will help solve our acute hospital access crisis. Med J Aust 2022; 216:116-118. [PMID: 35073599 PMCID: PMC9306513 DOI: 10.5694/mja2.51385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 11/17/2022]
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Nicolaus S, Crelier B, Donzé JD, Aubert CE. Definition of patient complexity in adults: A narrative review. JOURNAL OF MULTIMORBIDITY AND COMORBIDITY 2022; 12:26335565221081288. [PMID: 35586038 PMCID: PMC9106317 DOI: 10.1177/26335565221081288] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 01/31/2022] [Indexed: 11/17/2022]
Abstract
Background Better identification of complex patients could help to improve their care. However, the definition of patient complexity itself is far from obvious. We conducted a narrative review to identify, describe, and synthesize the definitions of patient complexity used in the last 25 years. Methods We searched PubMed for articles published in English between January 1995 and September 2020, defining patient complexity. We extended the search to the references of the included articles. We assessed the domains presented in the definitions, and classified the definitions as based on (1) medical aspects (e.g., number of conditions) or (2) medical and/or non-medical aspects (e.g., socio-economic status). We assessed whether the definition was based on a tool (e.g., index) or conceptual model. Results Among 83 articles, there was marked heterogeneity in the patient complexity definitions. Domains contributing to complexity included health, demographics, behavior, socio-economic factors, healthcare system, medical decision-making, and environment. Patient complexity was defined according to medical aspects in 30 (36.1%) articles, and to medical and/or non-medical aspects in 53 (63.9%) articles. A tool was used in 36 (43.4%) articles, and a conceptual model in seven (8.4%) articles. Conclusion A consensus concerning the definition of patient complexity was lacking. Most definitions incorporated non-medical factors in the definition, underlining the importance of accounting not only for medical but also for non-medical aspects, as well as for their interrelationship.
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Affiliation(s)
- Stefanie Nicolaus
- Department of General Internal Medicine, Biel Hospital, Biel, Switzerland
| | - Baptiste Crelier
- Department of General Internal Medicine, Bern University Hospital, Inselspital, University of Bern, Inselspital, Bern, Switzerland
| | - Jacques D Donzé
- Department of Medicine, Neuchâtel Hospital Network, Neuchâtel, Switzerland
- Division of General Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Carole E Aubert
- Department of General Internal Medicine, Bern University Hospital, Inselspital, University of Bern, Inselspital, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Tirrell AR, Kim KG, Rashid W, Attinger CE, Fan KL, Evans KK. Patient-reported Outcome Measures following Traumatic Lower Extremity Amputation: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3920. [PMID: 35028257 PMCID: PMC8751770 DOI: 10.1097/gox.0000000000003920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Outcomes after traumatic major lower extremity amputation (MLEA) have focused on surgical complications, despite the life-altering impact on patients. With advances in the surgical management of MLEA, a heightened need for consistent reporting of patient-centered outcomes (PCO) remains. This meta-analysis assesses articles for the prevalence and methods of PCO reporting among traumatic MLEA studies. METHODS An electronic database search was completed using Ovid MEDLINE for studies published between 2000 and 2020. Studies were included that reported any outcome of traumatic MLEA. Weighted means of outcomes were calculated when data were available. The prevalence of PCO was assessed in the categories of physical function, quality of life (QOL), psychosocial, and pain. Trends in PCO reporting were analyzed using Pearson's chi-squared test and analysis of variance when appropriate. RESULTS In total, 7001 studies were screened, yielding 156 articles for inclusion. PCO were evaluated in 94 (60.3%) studies; 83 (53.2%) reported physical function and mobility outcomes, 33 (21.2%) reported QOL and satisfaction measures, 38 (24.4%) reported psychosocial data, and 43 (27.6%) reported pain outcomes. There was no change in prevalence of PCO reporting when comparing 5-year intervals between 2000 and 2020 (P = 0.557). CONCLUSIONS Optimization of function and QOL following traumatic MLEA has become a cornerstone of surgical success; however, only 60% of studies report PCO, with no trend over the last two decades suggesting improvement. As healthcare progresses toward patient-centered care, this inconsistent means of reporting PCO calls for improved inclusion and standardization of instruments to assess function, QOL, and other patient-focused measures.
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Affiliation(s)
| | - Kevin G. Kim
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Waleed Rashid
- George Washington University School of Medicine, Washington, D.C
| | - Christopher E. Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Karen K. Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
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Kim KG, Tirrell AR, Dekker PK, Haffner Z, Attinger CE, Fan KL, Evans KK. The Need to Improve Patient-Centered Outcome Reporting Following Lower Extremity Flap Reconstruction: A Systematic Review and Meta-analysis. J Reconstr Microsurg 2021; 37:764-773. [PMID: 33853126 DOI: 10.1055/s-0041-1726398] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Research in lower extremity (LE) wound management involving flap reconstruction has primarily focused on surgeon-driven metrics. There has been a paucity in research that evaluates patient-centered outcomes (PCO). This systematic review and meta-analysis examines articles published between 2012 and 2020 to assess whether reporting of functional and quality of life (QOL) outcomes have increased in frequency and cohesiveness, compared with the previous two decades. METHODS PubMed and Ovid were queried with appropriate Medical Subject Heading (MeSH) terms for studies published between June 2012 and July 2020. For inclusion, each study had to report any outcome of any tissue transfer procedure to the LE in comorbid patients, including complication rates, ambulation rates, flap success rates, and/or QOL measures. The PCO reporting prevalence was compared with a previous systematic review by Economides et al which analyzed papers published between 1990 and June 2012, using a Pearson's Chi-squared test. RESULTS The literature search yielded 40 articles for inclusion. The proportion of studies reporting PCO was greater for literature published between 1990 and 2012 compared with literature published between 2012 and 2020 (86.0 vs. 50.0%, p < 0.001). Functional outcomes were more commonly reported between 1990 and 2012 (78.0 vs. 47.5%, p = 0.003); similarly, ambulatory status was reported more often in the previous review (70.0 vs. 40.0%, p = 0.004). This study solely examined the rate at which PCO were reported in the literature; the individual importance and effect on medical outcomes of each PCO was not evaluated. CONCLUSION Less than 50% of the literature report functional outcomes in comorbid patients undergoing LE flap reconstruction. Surprisingly, PCO reporting has seen a downward trend in the past 8 years relative to the preceding two decades. Standardized inclusion of PCO in research regarding this patient population should be established, especially as health care and governmental priorities shift toward patient-centered care.
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Affiliation(s)
- Kevin G Kim
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Abigail R Tirrell
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Paige K Dekker
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Zoe Haffner
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
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Huang CJ, Hsieh HM, Tu HP, Jiang HJ, Wang PW, Lin CH. Generalized anxiety disorder in type 2 diabetes mellitus: prevalence and clinical characteristics. ACTA ACUST UNITED AC 2020; 42:621-629. [PMID: 32321059 PMCID: PMC7678902 DOI: 10.1590/1516-4446-2019-0605] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 01/06/2020] [Indexed: 11/25/2022]
Abstract
Objective: This study investigated the prevalence of generalized anxiety disorder (GAD) in Taiwanese patients with type 2 diabetes mellitus (T2DM). Methods: This retrospective observational study was conducted with a random sample of patients from the entire population of National Health Insurance enrollees during 2000-2010 and used ICD-9-CM diagnostic codes to identify T2DM patients and GAD. The prevalence of GAD was compared between T2DM patients and the general population. Results: Between 2000 and 2010, the prevalence of GAD was significantly greater in the T2DM patients than the general population, while the increase of GAD was higher in the general population (from 0.25 to 0.63%) than among T2DM patients (from 0.81 to 1.03%). In T2DM patients, GAD was associated with female gender, a Charlson Comorbidity Index ≥ 1, diabetes mellitus duration > 9 years, and the following comorbidities: congestive heart failure, peripheral vascular disease, and depressive disorder. The prevalence of GAD among T2DM patients was negatively associated with rapid-acting insulin injection therapy and with the use of metformin and sulfonylureas. Conclusion: Since the prevalence of GAD was greater among T2DM patients than the general population, public health initiatives are needed to prevent and treat GAD in T2DM patients, specifically those with the above mentioned risk factors.
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Affiliation(s)
- Chun-Jen Huang
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Pin Tu
- Department of Public Health and Environmental Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - He-Jiun Jiang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Peng-Wei Wang
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Hua Lin
- Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Adult Psychiatry, Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
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VanNess R, Swanson K, Robertson V, Koenig M, Crossey M. The Value of Laboratory Information Augmenting a Managed Care Organization's Comprehensive Diabetes Care Efforts in New Mexico. J Appl Lab Med 2020; 5:978-986. [PMID: 32916713 DOI: 10.1093/jalm/jfaa118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/29/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set on Comprehensive Diabetes Care requires patients with diabetes obtain a hemoglobin A1c (Hb A1c) and urine albumin-to-creatinine ratio (ACR) test every year. To improve these measures, managed care organizations (MCOs) rely on claim and prescription data to identify members for care management. TriCore Reference Laboratories collaborated with Blue Cross Blue Shield of New Mexico (BCBSNM) to determine if laboratory information would augment BCBSNM's diabetes care management services. METHOD In January 2018, BCBSNM provided its Medicaid enrollment file to TriCore for identifying members and determining their diabetes status by evaluating their recent Hb A1c results. Of the 6,138 members with diabetes, a random sample of 600 was extracted, and half were provided to BCBSNM to perform care management from January 18 to May 1, 2018. Completion of Hb A1c and ACR were measured. RESULTS Significantly more (P = 0.03) study group members (25%) than control group members (18%) received an Hb A1c test. The study group (14%) also received more ACR tests than the control group (9%; P = 0.07). We then calculated the monetary penalty to which New Mexico Medicaid MCOs are subject, leading to the identification of additional value ($3,693,000) that clinical laboratories provide beyond the cost per test. CONCLUSION Clinical laboratories play a critical role in healthcare, and this article demonstrates an approach for laboratories to collaborate with MCOs in their care management efforts. In addition, we calculate the value of this novel collaboration, which may play an integral role in laboratories' pursuit of value-based care.
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Affiliation(s)
| | | | | | - Mark Koenig
- TriCore Reference Laboratories, Albuquerque, NM
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Abstract
BACKGROUND There are numerous definitions of multimorbidity (MM). None systematically examines specific comorbidity combinations accounting for multiple testing when exploring large datasets. OBJECTIVES Develop and validate a list of all single, double, and triple comorbidity combinations, with each individual qualifying comorbidity set (QCS) more than doubling the odds of mortality versus its reference population. Patients with at least 1 QCS were defined as having MM. RESEARCH DESIGN Cohort-based study with a matching validation study. SUBJECTS All fee-for-service Medicare patients between age 65 and 85 without dementia or metastatic solid tumors undergoing general surgery in 2009-2010, and an additional 2011-2013 dataset. MEASURES 30-day all-location mortality. RESULTS There were 576 QCSs (2 singles, 63 doubles, and 511 triples), each set more than doubling the odds of dying. In 2011, 36% of eligible patients had MM. As a group, multimorbid patients (mortality rate=7.0%) had a mortality Mantel-Haenszel odds ratio=1.90 (1.77-2.04) versus a reference that included both multimorbid and nonmultimorbid patients (mortality rate=3.3%), and Mantel-Haenszel odds ratio=3.72 (3.51-3.94) versus only nonmultimorbid patients (mortality rate=1.6%). When matching 3151 pairs of multimorbid patients from low-volume hospitals to similar patients in high-volume hospitals, the mortality rates were 6.7% versus 5.2%, respectively (P=0.006). CONCLUSIONS A list of QCSs identified a third of older patients undergoing general surgery that had greatly elevated mortality. These sets can be used to identify vulnerable patients and the specific combinations of comorbidities that make them susceptible to poor outcomes.
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Huang CJ, Hsieh HM, Chiu HC, Wang PW, Lee MH, Li CY, Lin CH. Health Care Utilization and Expenditures of Patients with Diabetes Comorbid with Depression Disorder: A National Population-Based Cohort Study. Psychiatry Investig 2017; 14:770-778. [PMID: 29209380 PMCID: PMC5714718 DOI: 10.4306/pi.2017.14.6.770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 01/14/2017] [Accepted: 03/31/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The study investigated to compare health care utilization and expenditures between diabetic patients with and without depression in Taiwan. METHODS Health care utilization and expenditure among diabetic patients with and without depression disorder during 2000 and 2004 were examined using Taiwan's population-based National Health Insurance claims database. Health care utilization included outpatient visits and the use of inpatient services, and health expenditures were outpatient, inpatient, and total medical expenditures. Moreover, general estimation equation models were used for analyzing the factors associated with outpatient visits and expenditures. Multiple logistic regression analysis was applied for identifying the factors associated with hospitalization. RESULTS The average annual outpatient visits and annual total medical expenditures in the study period were 44.23-52.20; NT$87,496-133,077 and 30.75-32.92; NT$64,411-80,955 for diabetic patients with and without depression. After adjustment for covariates, our results revealed that gender and complication were associated with out-patient visits. Moreover, the time factor was associated with the total medical expenditure, and residential urbanization and complication factors were associated with hospitalization. CONCLUSION Health care utilization and expenditures for diabetic patients with depression were significantly higher than those without depression. Sex, complications, time, and urbanization are the factors associated with health care utilization and expenditures.
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Affiliation(s)
- Chun-Jen Huang
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Herng-Chia Chiu
- Department of Healthcare Administration and Medical Informatics, College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Peng-Wei Wang
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Hsuan Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Yi Li
- Division of Secretary, Kaohsiung Medical University Hospital, Kaohsiung Medical, Kaohsiung, Taiwan
| | - Ching-Hua Lin
- Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
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Zullig LL, Liang Y, Vale Arismendez S, Trevino A, Bosworth HB, Turner BJ. Trajectory of systolic blood pressure in a low-income, racial-ethnic minority cohort with diabetes and baseline uncontrolled hypertension. J Clin Hypertens (Greenwich) 2017; 19:722-730. [PMID: 28371157 PMCID: PMC5503763 DOI: 10.1111/jch.12984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 12/14/2016] [Accepted: 12/25/2016] [Indexed: 12/13/2022]
Abstract
In two primary care clinics in Texas serving low-income patients, systolic blood pressure (SBP) trajectory was examined during 2 years in patients with diabetes mellitus (mean SBP ≥140 mm Hg: 152 mm Hg±11.2 in the baseline year). Among 860 eligible patients, 62.0% were women, 78.8% were Hispanic, and 41.2% were uninsured. Overall, SBP dropped 0.56 mm Hg per month or 13.4 mm Hg by 24 months. For patients with mean glycated hemoglobin ≥9% in year 1, SBP declined 4.8 mm Hg less by 24 months vs those with glycated hemoglobin <7% (P=.03). Compared with white women, SPB declined 7.2 mm Hg less by 24 months in Hispanic women (P=.03) and 9.6 mm Hg less by 24 months in black men (P=.04). SBP also declined 9.1 mm Hg less by 24 months for patients taking four or more blood pressure drug classes at baseline vs one drug class. In this low-income cohort, clinically complex patients and racial-ethnic minorities had clinically significantly smaller declines in SBP.
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Affiliation(s)
- Leah L. Zullig
- Division of General Internal MedicineDuke UniversityDurhamNCUSA
- Durham Center for Health Services Research and Development in Primary Care, Durham Veterans Affairs Health Care SystemDurhamNCUSA
| | - Yuanyuan Liang
- Center for Research to Advance Community HealthUniversity of Texas Health Science CenterSan AntonioTXUSA
- Department of Epidemiology and BiostatisticsUniversity of Texas Health Science CenterSan AntonioTXUSA
| | - Shruthi Vale Arismendez
- Center for Research to Advance Community HealthUniversity of Texas Health Science CenterSan AntonioTXUSA
| | - Aron Trevino
- Center for Research to Advance Community HealthUniversity of Texas Health Science CenterSan AntonioTXUSA
- Department of Epidemiology and BiostatisticsUniversity of Texas Health Science CenterSan AntonioTXUSA
| | - Hayden B. Bosworth
- Division of General Internal MedicineDuke UniversityDurhamNCUSA
- Durham Center for Health Services Research and Development in Primary Care, Durham Veterans Affairs Health Care SystemDurhamNCUSA
- Department of Psychiatry and Behavioral Sciences and School of NursingDuke UniversityDurhamNCUSA
| | - Barbara J. Turner
- Center for Research to Advance Community HealthUniversity of Texas Health Science CenterSan AntonioTXUSA
- Department of MedicineUniversity of Texas Health San AntonioSan AntonioTXUSA
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Katerndahl D, Wood R, Jaen CR. Measuring interdependence in ambulatory care. J Eval Clin Pract 2017; 23:453-459. [PMID: 26663144 DOI: 10.1111/jep.12491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2015] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Complex systems differ from complicated systems in that they are nonlinear, unpredictable and lacking clear cause-and-effect relationships, largely due to the interdependence of their components (effects of interconnectedness on system behaviour and consequences). The purpose of this study was to demonstrate the potential for network density to serve as a measure of interdependence, assess its concurrent validity and test whether the use of valued or binary ties yields better results. METHOD This secondary analysis used the 2010 National Ambulatory Care Medical Survey to assess interdependence of 'top 20' diagnoses seen and medications prescribed for 14 specialties. The degree of interdependence was measured as the level of association between diagnoses and drug interactions among medications. Both valued and binary network densities were computed for each specialty. To assess concurrent validity, these measures were correlated with previously-derived valid measures of complexity of care using the same database, adjusting for diagnosis and medication diversity. RESULTS Partial correlations between diagnosis density, and both diagnosis and total input complexity, were significant, as were those between medication density and both medication and total output complexity; for both diagnosis and medication densities, adjusted correlations were higher for binary rather than valued densities. CONCLUSION This study demonstrated the feasibility and validity of using network density as a measure of interdependence. When adjusted for measure diversity, density-complexity correlations were significant and higher for binary than valued density. This approach complements other methods of estimating complexity of care and may be applicable to unique settings.
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Affiliation(s)
- David Katerndahl
- Family & Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Robert Wood
- Family & Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Carlos R Jaen
- Family & Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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12
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Prevalence of anxiety disorder in patients with type 2 diabetes: a nationwide population-based study in Taiwan 2000-2010. Psychiatr Q 2017; 88:75-91. [PMID: 27155828 DOI: 10.1007/s11126-016-9436-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This study investigates the prevalence of anxiety disorder (AD) in Taiwanese patients with type 2 diabetes (T2D). Study participants were identified based on at least one service claim for ambulatory or inpatient care with a principal diagnosis of AD and at least 2 service claims for ambulatory care or one service claim for inpatient care with a principal diagnosis of T2D, as listed in the National Health Insurance database of Taiwan. The prevalence of AD decreased from 13.75 to 11.00 % in patients with T2D, whereas it increased from 4.17 to 6.09 % in the general population during the 2000-2010 period. A high prevalence of AD in patients with T2D was associated with age >30 years, the female sex, living in the northern region, comorbidities of congestive heart failure, peripheral vascular disease, cerebrovascular disease, and depression disorder, and a Charlson participant comorbidity index of ≥1. A low prevalence of AD in patients with T2D was associated with residency in urban areas, the comorbidity of hemiplegia or paraplegia, the usage of metformin and sulfonylureas, and rapid-acting insulin injection therapy. The prevalence of AD was higher in patients with T2D than in the general population. Therefore, more public health emphasis is required for preventing and treating AD in patients with T2D, specifically those with the mentioned risk factors.
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13
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Manning E, Gagnon M. The complex patient: A concept clarification. Nurs Health Sci 2017; 19:13-21. [PMID: 28054430 DOI: 10.1111/nhs.12320] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/15/2016] [Accepted: 10/19/2016] [Indexed: 01/21/2023]
Abstract
Over the last decade, the concept of the "complex patient" has not only been more widely used in multidisciplinary healthcare teams and across various healthcare disciplines, but it has also become more vacuous in meaning. The uptake of the concept of the "complex patient" spans across disciplines, such as medicine, nursing, and social work, with no consistent definition. We review the chronological evolution of this concept and its surrogate terms, namely "comorbidity," "multimorbidity," "polypathology," "dual diagnosis," and "multiple chronic conditions." Drawing on key principles of concept clarification, we highlight disciplinary usage in the literature published between 2005 and 2015 in health sciences, attending to overlaps and revealing nuances of the complex patient concept. Finally, we discuss the implications of this concept for practice, research, and theory.
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Affiliation(s)
- Eli Manning
- Department of Gender, Sexuality, and Women's Studies, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Marilou Gagnon
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
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Bayliss EA, McQuillan DB, Ellis JL, Maciejewski ML, Zeng C, Barton MB, Boyd CM, Fortin M, Ling SM, Tai-Seale M, Ralston JD, Ritchie CS, Zulman DM. Using Electronic Health Record Data to Measure Care Quality for Individuals with Multiple Chronic Medical Conditions. J Am Geriatr Soc 2016; 64:1839-44. [PMID: 27385077 DOI: 10.1111/jgs.14248] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To inform the development of a data-driven measure of quality care for individuals with multiple chronic conditions (MCCs) derived from an electronic health record (EHR). DESIGN Qualitative study using focus groups, interactive webinars, and a modified Delphi process. SETTING Research department within an integrated delivery system. PARTICIPANTS The webinars and Delphi process included 17 experts in clinical geriatrics and primary care, health policy, quality assessment, health technology, and health system operations. The focus group included 10 individuals aged 70-87 with three to six chronic conditions selected from a random sample of individuals aged 65 and older with three or more chronic medical conditions. MEASUREMENTS Through webinars and the focus group, input was solicited on constructs representing high-quality care for individuals with MCCs. A working list was created of potential measures representing these constructs. Using a modified Delphi process, experts rated the importance of each possible measure and the feasibility of implementing each measure using EHR data. RESULTS High-priority constructs reflected processes rather than outcomes of care. High-priority constructs that were potentially feasible to measure included assessing physical function, depression screening, medication reconciliation, annual influenza vaccination, outreach after hospital admission, and documented advance directives. High-priority constructs that were less feasible to measure included goal setting and shared decision-making, identifying drug-drug interactions, assessing social support, timely communication with patients, and other aspects of good customer service. Lower-priority domains included pain assessment, continuity of care, and overuse of screening or laboratory testing. CONCLUSION High-quality MCC care should be measured using meaningful process measures rather than outcomes. Although some care processes are currently extractable from electronic data, capturing others will require adapting and applying technology to encourage holistic, person-centered care.
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Affiliation(s)
- Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado. .,Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado.
| | - Deanna B McQuillan
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Jennifer L Ellis
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Matthew L Maciejewski
- Health Services Research and Development, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Mary B Barton
- National Committee for Quality Assurance, Washington, District of Columbia
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Martin Fortin
- Department of Family Medicine, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Quebec, Canada
| | - Shari M Ling
- Centers for Medicare and Medicaid Services, Baltimore, Maryland
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
| | - James D Ralston
- Group Health Research Institute, Group Health Cooperative, Seattle, Washington
| | - Christine S Ritchie
- Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Donna M Zulman
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California.,Division of General Medical Disciplines, Stanford University, Stanford, California
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Islam R, Weir C, Del Fiol G. Clinical Complexity in Medicine: A Measurement Model of Task and Patient Complexity. Methods Inf Med 2015; 55:14-22. [PMID: 26404626 DOI: 10.3414/me15-01-0031] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 06/25/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Complexity in medicine needs to be reduced to simple components in a way that is comprehensible to researchers and clinicians. Few studies in the current literature propose a measurement model that addresses both task and patient complexity in medicine. OBJECTIVE The objective of this paper is to develop an integrated approach to understand and measure clinical complexity by incorporating both task and patient complexity components focusing on the infectious disease domain. The measurement model was adapted and modified for the healthcare domain. METHODS Three clinical infectious disease teams were observed, audio-recorded and transcribed. Each team included an infectious diseases expert, one infectious diseases fellow, one physician assistant and one pharmacy resident fellow. The transcripts were parsed and the authors independently coded complexity attributes. This baseline measurement model of clinical complexity was modified in an initial set of coding processes and further validated in a consensus-based iterative process that included several meetings and email discussions by three clinical experts from diverse backgrounds from the Department of Biomedical Informatics at the University of Utah. Inter-rater reliability was calculated using Cohen's kappa. RESULTS The proposed clinical complexity model consists of two separate components. The first is a clinical task complexity model with 13 clinical complexity-contributing factors and 7 dimensions. The second is the patient complexity model with 11 complexity-contributing factors and 5 dimensions. CONCLUSION The measurement model for complexity encompassing both task and patient complexity will be a valuable resource for future researchers and industry to measure and understand complexity in healthcare.
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Affiliation(s)
- R Islam
- Roosan Islam, PharmD, University of Utah, Department of Biomedical Informatics, 421 Wakara Way, Ste 140, Salt Lake City, UT 84108-3514, USA, E-mail:
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Huang CJ, Chiu HC, Hsieh HM, Yen JY, Lee MH, Chang KP, Li CY, Lin CH. Health care utilization and expenditures of persons with diabetes comorbid with anxiety disorder: a national population-based cohort study. Gen Hosp Psychiatry 2015; 37:299-304. [PMID: 25936674 DOI: 10.1016/j.genhosppsych.2015.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 04/12/2015] [Accepted: 04/13/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to investigate and compare health care utilization and expenditures between persons with diabetes comorbid with and without anxiety disorder in Taiwan. METHODS Health care utilization and expenditures among persons with diabetes with and without comorbid anxiety disorder in the period 2000-2004 were examined using the Taiwan's National Health Insurance claims data. Health care utilization included outpatient visits and use of hospital inpatient services, while expenditures included outpatient, inpatient and total medical expenditures. General estimation equation (GEE) models were used to analyze the factors associated with outpatient visits and expenditures, and multiple logistic regression analysis was applied to identify factors associated with hospitalization. RESULTS In the study period, the average number of annual outpatient visits was 43.11-50.37 and 29.82-31.42 for persons with diabetes comorbid with anxiety disorder and for those without anxiety disorder, respectively. The average annual total expenditure was NT$74,875-92,781 and NT$63,764-81,667, respectively. Controlling for covariates, the GEE models revealed that age and time were associated with outpatient visits. Income and time factor were associated with total expenditure. CONCLUSIONS Health care utilization and expenditures for persons with diabetes with comorbid anxiety disorder are significantly higher than those without anxiety disorder. The factors associated with health care utilization and expenditures are age, income and time.
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Affiliation(s)
- Chun-Jen Huang
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Herng-Chia Chiu
- Department of Healthcare Administration and Medical Informatics, College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ju-Yu Yen
- Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Hsuan Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kao-Ping Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Yi Li
- Division of Secretary, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | - Ching-Hua Lin
- Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan.
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Landon BE, O'Malley AJ, McKellar MR, Hadley J, Reschovsky JD. Higher practice intensity is associated with higher quality of care but more avoidable admissions for medicare beneficiaries. J Gen Intern Med 2014; 29:1188-94. [PMID: 24740516 PMCID: PMC4099467 DOI: 10.1007/s11606-014-2840-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 12/19/2013] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The relationship between practice intensity and the quality and outcomes of care has not been studied. OBJECTIVE To examine the relationship between primary care physicians' costliness both for defined episodes of care and for defined patients and the quality and outcomes of care delivered to Medicare beneficiaries. STUDY DESIGN Cross sectional analysis of physician survey data linked to Medicare claims. Physician costliness measures were calculated by comparing the episode specific and overall costs of care for their patients with the care delivered by other physicians. PARTICIPANTS We studied physicians participating in the 2004-2005 Community Tracking Study Physician Survey linked with administrative claims from the Medicare program for the years 2004-2006. MAIN MEASURES Proportion of eligible beneficiaries receiving each of seven preventive services and rates of preventable admissions for acute and chronic conditions. KEY RESULTS The 2,211 primary care physician respondents included 937 internists and 1,274 family or general physicians who were linked to more than 250,000 Medicare enrollees. Patients treated by more costly physicians (whether measured by the overall costliness index or the episode-level index) were more likely to receive recommended preventive services, but were also more likely to experience preventable admissions. For instance, physicians in the lowest quartile of costliness performed appropriate monitoring for hemoglobin A1C for diabetics 72.8% of the time, as compared with 81.9% for physicians in the highest quartile of costliness (p < 0.01). In contrast, patients treated by the physicians in the lowest quartile of episode costliness were admitted at a rate of 1.8/100 for both acute and chronic Prevention Quality Indicators (PQIs), as compared with 2.9/100 for both acute and chronic PQIs for those treated by physicians in the highest quartile of costliness (p < 0.001). CONCLUSIONS Physician practice patterns are associated with the quality of preventive services delivered to Medicare patients. Ongoing efforts to influence physician practice patterns may have differential effects on different aspects of quality.
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Affiliation(s)
- Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA, 02115, USA,
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Lazzeri C, Valente S, Chiostri M, D'Alfonso MG, Gensini GF. Clinical significance of glycated hemoglobin in the acute phase of ST elevation myocardial infarction. World J Cardiol 2014; 6:140-7. [PMID: 24772254 PMCID: PMC3999334 DOI: 10.4330/wjc.v6.i4.140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 03/05/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
In population-based studies, including diabetic and nondiabetic cohorts, glycated hemoglobin A1c (HbA1c) has been reported as an independent predictor of all-cause and cardiovascular disease mortality. Data on the prognostic role of HbA1c in patients with acute myocardial infarction (MI) are not univocal since they stem from studies which mainly differ in patients' selection criteria, therapy (thrombolysis vs mechanical revascularization) and number consistency. The present review is focused on available evidence on the prognostic significance of HbA1c measured in the acute phase in patients with ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI). We furthermore highlighted the role of HbA1c as a screening tool for glucose intolerance in patients with STEMI. According to available evidence, in contemporary cohorts of STEMI patients submitted to mechanical revascularization, HbA1c does not seem to be associated with short and long term mortality rates. However, HbA1c may represent a screening tool for glucose intolerance from the early phase on in STEMI patients. On a pragmatic ground, an HbA1c test has several advantages over fasting plasma glucose or an oral glucose tolerance test in an acute setting. The test can be performed in the non-fasting state and reflects average glucose concentration over the preceding 2-3 mo. We therefore proposed an algorithm based on pragmatic grounds which could be applied in STEMI patients without known diabetes in order to detect glucose intolerance abnormalities from the early phase. The main advantage of this algorithm is that it may help in tailoring the follow-up program, by helping in identifying patients at risk for the development of glucose intolerance after MI. Further validation of this algorithm in prospective studies may be required in the contemporary STEMI population to resolve some of these uncertainties around HbA1c screening cutoff points.
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Affiliation(s)
- Chiara Lazzeri
- Chiara Lazzeri, Serafina Valente, Marco Chiostri, Maria Grazia D'Alfonso, Gian Franco Gensini, Intensive Cardiac Care Unit, Heart and Vessel Department, Azienda Ospedaliero, Universitaria Careggi, 50134 Florence, Italy
| | - Serafina Valente
- Chiara Lazzeri, Serafina Valente, Marco Chiostri, Maria Grazia D'Alfonso, Gian Franco Gensini, Intensive Cardiac Care Unit, Heart and Vessel Department, Azienda Ospedaliero, Universitaria Careggi, 50134 Florence, Italy
| | - Marco Chiostri
- Chiara Lazzeri, Serafina Valente, Marco Chiostri, Maria Grazia D'Alfonso, Gian Franco Gensini, Intensive Cardiac Care Unit, Heart and Vessel Department, Azienda Ospedaliero, Universitaria Careggi, 50134 Florence, Italy
| | - Maria Grazia D'Alfonso
- Chiara Lazzeri, Serafina Valente, Marco Chiostri, Maria Grazia D'Alfonso, Gian Franco Gensini, Intensive Cardiac Care Unit, Heart and Vessel Department, Azienda Ospedaliero, Universitaria Careggi, 50134 Florence, Italy
| | - Gian Franco Gensini
- Chiara Lazzeri, Serafina Valente, Marco Chiostri, Maria Grazia D'Alfonso, Gian Franco Gensini, Intensive Cardiac Care Unit, Heart and Vessel Department, Azienda Ospedaliero, Universitaria Careggi, 50134 Florence, Italy
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Abstract
BACKGROUND Applying disease-specific guidelines to people with multimorbidity may result in complex regimens that impose treatment burden. OBJECTIVES To describe and validate a measure of healthcare task difficulty (HCTD) in a sample of older adults with multimorbidity. RESEARCH DESIGN Cross-sectional and longitudinal secondary data analysis. SUBJECTS Multimorbid adults aged 65 years or older from primary care clinics. MEASURES We generated a scale (0-16) of self-reported difficulty with 8 HCTD and conducted factor analysis to assess its dimensionality and internal consistency. To assess predictive ability, cross-sectional associations of HCTD and number of chronic diseases, and conditions that add to health status complexity (falls, visual, and hearing impairment), patient activation, patient-reported quality of chronic illness care (Patient Assessment of Chronic Illness Care), mental and physical health (SF-36) were tested using statistical tests for trend (n=904). Longitudinal analyses of the effects of change in HCTD on changes in the outcomes were conducted among a subset (n=370) with ≥1 follow-up at 6 and/or 18 months. All models were adjusted for age, education, sex, race, and time. RESULTS Greater HCTD was associated with worse mental and physical health [Cuzick test for trend (P<0.05)], and patient-reported quality of chronic illness care (P<0.05). In longitudinal analysis, increasing patient activation was associated with declining HCTD over time (P<0.01). Increasing HCTD over time was associated with declining mental (P<0.001) and physical health (P=0.001) and patient-reported quality of chronic illness care (P<0.05). CONCLUSIONS The findings of this study establish the construct validity of the HCTD scale.
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Weiss CO, Varadhan R, Puhan MA, Vickers A, Bandeen-Roche K, Boyd CM, Kent DM. Multimorbidity and evidence generation. J Gen Intern Med 2014; 29:653-60. [PMID: 24442333 PMCID: PMC3965759 DOI: 10.1007/s11606-013-2660-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 04/10/2013] [Accepted: 09/04/2013] [Indexed: 10/25/2022]
Abstract
Most people with a chronic disease actually have more than one, a condition known as multimorbidity. Despite this, the evidence base to prevent adverse disease outcomes has taken a disease-specific approach. Drawing on a conference, Improving Guidelines for Multimorbid Patients, the goal of this paper is to identify challenges to the generation of evidence to support the care of people with multimorbidity and to make recommendations for improvement. We identified three broad categories of challenges: 1) challenges to defining and measuring multimorbidity; 2) challenges related to the effects of multimorbidity on study design, implementation and analysis; and 3) challenges inherent in studying heterogeneity of treatment effects in patients with differing comorbid conditions. We propose a set of recommendations for consideration by investigators and others (reviewers, editors, funding agencies, policymaking organizations) involved in the creation of evidence for this common type of person that address each of these challenges. The recommendations reflect a general approach that emphasizes broader inclusion (recruitment and retention) of patients with multimorbidity, coupled with more rigorous efforts to measure comorbidity and comorbidity burden and the influence of multimorbidity on outcomes and the effects of therapy. More rigorous examination of heterogeneity of treatment effects requires careful attention to prioritizing the most important comorbid-related questions, and also requires studies that provide greater statistical power than conventional trials have provided. Relatively modest changes in the orientation of current research along these lines can be helpful in pointing to and partially addressing selected knowledge gaps. However, producing a robust evidence base to support patient-centered decision making in complex individuals with multimorbidity, exposed to many different combinations of potentially interacting factors that can modify the risks and benefits of therapies, is likely to require a clinical research enterprise fundamentally restructured to be more fully integrated with routine clinical practice.
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Affiliation(s)
- Carlos O Weiss
- Department of Family Medicine, College of Human Medicine, Michigan State University, East Lansing, USA
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Zulman DM, Asch SM, Martins SB, Kerr EA, Hoffman BB, Goldstein MK. Quality of care for patients with multiple chronic conditions: the role of comorbidity interrelatedness. J Gen Intern Med 2014; 29:529-37. [PMID: 24081443 PMCID: PMC3930789 DOI: 10.1007/s11606-013-2616-9] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/30/2013] [Accepted: 08/26/2013] [Indexed: 12/21/2022]
Abstract
Multimorbidity--the presence of multiple chronic conditions in a patient--has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient's number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relationship between multimorbidity and quality of care, and discuss how this relationship may be mediated by the degree to which conditions interact with one another to generate clinical complexity (comorbidity interrelatedness). Drawing on established theoretical frameworks from cognitive engineering and biomedical informatics, we describe how interactions among conditions result in clinical complexity and may affect quality of care. We discuss how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics, and describe opportunities to quantify this construct using data widely available through electronic health records. Incorporating comorbidity interrelatedness into conceptualizations of multimorbidity has the potential to enhance clinical and research efforts that aim to improve care for patients with multiple chronic conditions.
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Affiliation(s)
- Donna M Zulman
- Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, CA, USA,
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Tevis SE, Kennedy GD. Postoperative complications and implications on patient-centered outcomes. J Surg Res 2013; 181:106-13. [PMID: 23465392 DOI: 10.1016/j.jss.2013.01.032] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 11/23/2012] [Accepted: 01/17/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative complications increase patient morbidity and mortality and are a target for quality improvement programs. The goal of this study was to review the world's literature on postoperative complications in general surgery patients and try to examine the effect of these complications on patient-centered outcomes. METHODS A comprehensive search of the current literature identified 18 studies on the topic of postoperative complications in general surgery patients. RESULTS Postoperative complications are common in general surgery patients and contribute to increased mortality, length of stay, and need for an increased level of care at discharge (decline in disposition). CONCLUSIONS Although the concept of patient-centered outcomes is not new, it has not been applied to postoperative complications. It is likely that the effect of complications on length of hospital stay and postoperative discharge reflects an impact of complications on these patient-centered outcomes. Future studies should consider the effect of complications on those outcomes that are most important to the individual patient.
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Affiliation(s)
- Sarah E Tevis
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
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Abstract
The primary focus of this review is on the cost-effectiveness of critical care. The rapid growth in health care expenditures has engendered careful scrutiny of the practice of medicine with regard not only to effectiveness but also to efficiency. This shift necessitates that physicians understand the effectiveness of their interventions and the cost at which this effectiveness is obtained. Cost-effectiveness and cost-utility analyses have become crucial evaluative tools in medicine. Explicit articulation of comparative cost-effectiveness facilitates the allocation of limited resources. Physicians and policy-makers must evaluate such studies with caution, skepticism, and attention to the methods used.
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Steinman MA, Lee SJ, John Boscardin W, Miao Y, Fung KZ, Moore KL, Schwartz JB. Patterns of multimorbidity in elderly veterans. J Am Geriatr Soc 2012; 60:1872-80. [PMID: 23035702 DOI: 10.1111/j.1532-5415.2012.04158.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To determine patterns of co-occurring diseases in older adults and the extent to which these patterns vary between the young-old and the old-old. DESIGN Observational study. SETTING Department of Veterans Affairs. PARTICIPANTS Veterans aged 65 years and older (1.9 million male, mean age 76 ± 7; 39,000 female, mean age 77 ± 8) with two or more visits to Department of Veterans Affairs (VA) or Medicare settings in 2007 and 2008. MEASUREMENTS The presence of 23 common conditions was assessed using hospital discharge diagnoses and outpatient encounter diagnoses from the VA and Medicare. RESULTS The mean number of chronic conditions (out of 23 possible) was 5.5 ± 2.6 for men and 5.1 ± 2.6 for women. The prevalence of most conditions increased with advancing age, although diabetes mellitus and hyperlipidemia were 11% to 13% less prevalent in men and women aged 85 and older than in those aged 65 to 74 (P < .001 for each). In men, the most common three-way combination of conditions was hypertension, hyperlipidemia, and coronary heart disease, which together were present in 37% of men. For women, the most common combination was hypertension, hyperlipidemia, and arthritis, which co-occurred in 25% of women. Reflecting their high population prevalence, hypertension and hyperlipidemia were both present in 9 of the 15 most common three-way disease combinations in men and in 11 of the 15 most common combinations in women. The prevalence of many disease combinations varied substantially between young-old and old-old adults. CONCLUSIONS Specific combinations of diseases are highly prevalent in older adults and inform the development of guidelines that account for the simultaneous presence of multiple chronic conditions.
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Affiliation(s)
- Michael A Steinman
- Division of Geriatrics, University of California at San Francisco, San Francisco, California, USA.
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Huang CJ, Lin CH, Lee MH, Chang KP, Chiu HC. Prevalence and incidence of diagnosed depression disorders in patients with diabetes: a national population-based cohort study. Gen Hosp Psychiatry 2012; 34:242-8. [PMID: 22325626 DOI: 10.1016/j.genhosppsych.2011.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 12/23/2011] [Accepted: 12/31/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study aimed to investigate the prevalence and incidence of diagnosed depression disorders among patients with diabetes in Taiwan. METHODS Study subjects were identified by at least one service claim for ambulatory or inpatient care with a principal diagnosis of depression disorder, and at least two service claims for ambulatory care or one service claim for inpatient care with a principal diagnosis of diabetes from 2000 to 2004, as found in the National Health Insurance database. RESULTS The 1-year prevalence of diagnosed depression disorders in the general population was 11.22 per 1000 in 2000, while the 5-year cumulative diagnosed prevalence increased to 40.76 per 1000 in 2004. The 1-year prevalence rate of diagnosed depression disorders among patients with diabetes was 33.95 per 1000 in 2000, and the 5-year cumulative prevalence increased to 92.17 per 1000 in 2004. Patients with diabetes had a higher 5-year cumulative prevalence and annual incidence than the general population throughout the observation period. A higher diagnosed prevalence was associated with a monthly income <US*$640 using multiple logistic regression analysis. Cox regression analysis revealed that a lower incidence was associated with male gender. CONCLUSIONS The prevalence and annual incidence density of diagnosed depression disorders in patients with diabetes were significantly higher than those in the general population. The prevalence of diagnosed depression disorder among patients with diabetes in Taiwan was lower than the rate in Western countries.
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Affiliation(s)
- Chun-Jen Huang
- Department of Psychiatry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
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Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The changes involved in patient-centered medical home transformation. Prim Care 2012; 39:241-59. [PMID: 22608865 DOI: 10.1016/j.pop.2012.03.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In 2007, the major primary care professional societies collaboratively introduced a new model of primary care: the patient-centered medical home (PCMH). The published document outlines the basic attributes and expectations of a PCMH but not with the specificity needed to help interested clinicians and administrators make the necessary changes to their practice. To identify the specific changes required to become a medical home, the authors reviewed literature and sought the opinions of two multi-stakeholder groups. This article describes the eight consensus change concepts and 32 key changes that emerged from this process, and the evidence supporting their inclusion.
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Affiliation(s)
- Edward H Wagner
- MacColl Center for Health Care Innovation, Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, USA.
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Bayliss EA, Ellis JL, Shoup JA, Zeng C, McQuillan DB, Steiner JF. Association of patient-centered outcomes with patient-reported and ICD-9-based morbidity measures. Ann Fam Med 2012; 10:126-33. [PMID: 22412004 PMCID: PMC3315135 DOI: 10.1370/afm.1364] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Evaluating patient-centered care for complex patients requires morbidity measurement appropriate for use with a variety of clinical outcomes. We compared the contributions of self-reported morbidity and morbidity measured using administrative diagnosis data for both patient-reported outcomes and utilization outcomes. METHODS Using a cohort of 961 persons aged 65 years or older with 3 or more medical conditions, we explored 9 health outcomes as a function of 4 independent variables representing different types of morbidity measures: International Classification of Diseases, Ninth Revision (ICD-9), a self-reported weighted count of conditions, and self-reported symptoms of depression and of anxiety. Outcomes varied from self-reported health status to utilization. Depending on the outcome measure, we used multivariate linear, negative binomial, or logistic regression, adjusting for demographic characteristics and length of enrollment to assess associations between dependent and all 4 independent variables. RESULTS Higher morbidity measured by ICD-9 diagnoses was independently associated with less favorable levels of 7 of the 9 clinical outcomes. Higher self-reported disease burden was significantly associated with less favorable levels of 8 of the outcomes, controlling for the 3 other morbidity measures. Morbidity measured by diagnosis code was more strongly associated with higher utilization, whereas self-reported disease burden and emotional symptoms were more strongly associated with patient-reported outcomes. CONCLUSIONS A comprehensive assessment of morbidity requires both subjective and objective measurement of disease burden as well as an assessment of emotional symptoms. Such multidimensional morbidity measurement is particularly relevant for research or quality assessments involving the delivery of patient-centered care to complex patient populations.
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Affiliation(s)
- Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente, Denver, Colorado 80231-5968, USA.
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Davis JW, Chung R, Juarez DT. Prevalence of comorbid conditions with aging among patients with diabetes and cardiovascular disease. HAWAII MEDICAL JOURNAL 2011; 70:209-213. [PMID: 22162595 PMCID: PMC3215980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES The objectives were to develop a methodology to understand the prevalence of medically complex patients, and to apply the methodology to examine patients with one or more of hypertension, hyperlipidemia, diabetes, and heart disease. METHODS Prevalence was measured using insurance data by calculating the proportion of days patients in a health state of interest contributed to the total days of enrollment. Graphs summarized the prevalence patterns within age and morbidity categories. Results by age and gender were supplemented with cubic spline curves that closely fit the prevalence data. RESULTS The study provides basic epidemiologic information on changes with aging in the prevalence of patients with one or more comorbid conditions. Patients such as those with hyperlipidemia alone rose in prevalence at younger ages and fell at older ages, whereas the prevalence of other patients, such as patients having hypertension, diabetes, and heart disease, progressively increased with age. With straightforward extensions of the methodology other issues such as the incidence of emergency department visits and hospitalizations might be investigated.
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Affiliation(s)
- James W Davis
- University of Hawai'i John A. Burns School of Medicine, Honolulu, USA.
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Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, Meinow B, Fratiglioni L. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev 2011; 10:430-9. [PMID: 21402176 DOI: 10.1016/j.arr.2011.03.003] [Citation(s) in RCA: 1792] [Impact Index Per Article: 137.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Revised: 03/03/2011] [Accepted: 03/07/2011] [Indexed: 12/12/2022]
Abstract
A literature search was carried out to summarize the existing scientific evidence concerning occurrence, causes, and consequences of multimorbidity (the coexistence of multiple chronic diseases) in the elderly as well as models and quality of care of persons with multimorbidity. According to pre-established inclusion criteria, and using different search strategies, 41 articles were included (four of these were methodological papers only). Prevalence of multimorbidity in older persons ranges from 55 to 98%. In cross-sectional studies, older age, female gender, and low socioeconomic status are factors associated with multimorbidity, confirmed by longitudinal studies as well. Major consequences of multimorbidity are disability and functional decline, poor quality of life, and high health care costs. Controversial results were found on multimorbidity and mortality risk. Methodological issues in evaluating multimorbidity are discussed as well as future research needs, especially concerning etiological factors, combinations and clustering of chronic diseases, and care models for persons affected by multiple disorders. New insights in this field can lead to the identification of preventive strategies and better treatment of multimorbid patients.
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Tinetti ME, McAvay GJ, Chang SS, Newman AB, Fitzpatrick AL, Fried TR, Peduzzi PN. Contribution of multiple chronic conditions to universal health outcomes. J Am Geriatr Soc 2011; 59:1686-91. [PMID: 21883118 PMCID: PMC3622699 DOI: 10.1111/j.1532-5415.2011.03573.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the relative effect of five chronic conditions on four representative universal health outcomes. DESIGN Cross-sectional. SETTING Cardiovascular Health Study. PARTICIPANTS Five thousand two hundred and ninety-eight community-living participants aged 65 and older. MEASUREMENTS Multiple regression and Cox models were used to determine the effect of heart failure (HF), chronic obstructive pulmonary disease (COPD), osteoarthritis, depression, and cognitive impairment on self-rated health, 12 basic and instrumental activities of daily living (ADLs and IADLs), six-item symptom burden scale, and death. RESULTS Each condition adversely affected self-rated health (P < .001) and ADLs and IADLs (P < .001). For example, persons with HF performed 0.70 ± 0.08 fewer ADLs and IADLs than those without; persons with depression and persons with cognitive impairment performed 0.59 ± 0.04 and 0.58 ± 0.06 fewer activities, respectively, than those without these conditions. Depression, HF, COPD, and osteoarthritis were associated with 1.18 ± 0.04, 0.40 ± 0.08, 0.40 ± 0.05, and 0.57 ± 0.03 more symptoms, respectively, in individuals with these conditions than in those without. HF (hazard ratio (HR) = 2.84, 95% confidence interval (CI) = 1.97-4.10), COPD (2.62, 95% CI = 1.94-3.53), cognitive impairment (2.05, 95% CI = 1.47-2.85), and depression (1.47, 95% CI = 1.08-2.01) were each associated with death within 2 years. Several paired combinations of conditions had synergistic effects on ADLs and IADLs. For example, individuals with HF plus depression performed 2.0 fewer activities than persons with neither condition, versus the 1.3 fewer activities expected from adding the effects of the two conditions together. CONCLUSION Universal health outcomes may provide a common metric for measuring the effects of multiple conditions and their treatments. The varying effects of the conditions across universal outcomes could inform care priorities.
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Affiliation(s)
- Mary E Tinetti
- Department of Medicine, School of MedicineSchool of Public Health, Yale University, New Haven, Connecticut 06520, USA.
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Huang CJ, Wang SY, Lee MH, Chiu HC. Prevalence and incidence of mental illness in diabetes: a national population-based cohort study. Diabetes Res Clin Pract 2011; 93:106-14. [PMID: 21514965 DOI: 10.1016/j.diabres.2011.03.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 03/12/2011] [Accepted: 03/28/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND This study aimed to investigate the prevalence and incidence of mental illness among diabetic patients in Taiwan. METHODS Study subjects were identified by at least one service claim for ambulatory or inpatient care with a principal diagnosis of mental illness, and at least two claims for ambulatory care or one claim for inpatient care with a principal diagnosis of diabetes from 2000 to 2004. RESULTS The one-year prevalence of mental illness among diabetic patients was 20.6% in 2000, and the cumulative prevalence increased to 42.2% in 2004. Diabetic patients had a higher cumulative prevalence and annual incidence than the general population throughout the observation period. A higher prevalence was associated with age ≥45 and low income, and a lower prevalence with male gender and residing in rural areas. Cox regression analysis revealed that a higher incidence was associated with female gender, age ≥45, and low income. CONCLUSIONS The prevalence and annual incidence density of mental illness in diabetic patients were significantly higher than in the general population. Females had higher prevalence and incidence density of mental illness among diabetic patients. Mental illness in diabetic patients was more prevalent in elderly females of low income, and less in rural areas.
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Affiliation(s)
- Chun-Jen Huang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Burgers JS, Voerman GE, Grol R, Faber MJ, Schneider EC. Quality and coordination of care for patients with multiple conditions: results from an international survey of patient experience. Eval Health Prof 2011; 33:343-64. [PMID: 20801976 DOI: 10.1177/0163278710375695] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Previous studies using clinical performance measures suggest that quality of care for patients with multiple chronic conditions is not worse than that for others. This article presents patient-reported experiences of health care among 8,973 of chronically ill adults from eight countries, using telephone survey data. We designed a ''morbidity score'' combining the number of conditions and reported health status. Respondents with high morbidity scores reported less favorable experience with coordination of care compared to those with low morbidity scores. They also reported lower ratings of overall quality of care. There were no differences in reported experience with the individual physicians. Comparing type of comorbidity, chronic lung, and mental health problems were associated with lower ratings than hypertension, heart disease, diabetes, arthritis, and cancer. The implications and limitations of this study are discussed in the context of health care reform. Pay-for-performance programs need to account for chronic conditions to avoid penalizing physicians who care for larger shares of such patients.
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Affiliation(s)
- Jako S Burgers
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
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Kelley AS, Ettner SL, Morrison RS, Du Q, Wenger NS, Sarkisian CA. Determinants of medical expenditures in the last 6 months of life. Ann Intern Med 2011; 154:235-42. [PMID: 21320939 PMCID: PMC4126809 DOI: 10.7326/0003-4819-154-4-201102150-00004] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND End-of-life medical expenditures exceed costs of care during other years, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs. OBJECTIVE To identify patient-level determinants of Medicare expenditures at the end of life and to determine the contributions of these factors to expenditure variation while accounting for regional characteristics. It was hypothesized that race or ethnicity, social support, and functional status are independently associated with treatment intensity and controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation. DESIGN Using data from the Health and Retirement Study, Medicare claims, and The Dartmouth Atlas of Health Care, relationships were modeled between expenditures and patient and regional characteristics. SETTING United States, 2000 to 2006. PARTICIPANTS 2394 Health and Retirement Study decedents aged 65.5 years or older. MEASUREMENTS Medicare expenditures in the last 6 months of life were estimated in a series of 2-level multivariable regression models that included patient, regional, and patient and regional characteristics. RESULTS Decline in function (rate ratio [RR], 1.64 [95% CI, 1.46 to 1.83]); Hispanic ethnicity (RR, 1.50 [CI, 1.22 to 1.85]); black race (RR, 1.43 [CI, 1.25 to 1.64]); and certain chronic diseases, including diabetes (RR, 1.16 [CI, 1.06 to 1.27]), were associated with higher expenditures. Nearby family (RR, 0.90 [CI, 0.82 to 0.98]) and dementia (RR, 0.78 CI, 0.71 to 0.87]) were associated with lower expenditures, and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (RR, 1.09 [CI, 1.06 to 1.14]) and hospital beds per capita (RR, 1.01 [CI, 1.00 to 1.02]), were associated with higher expenditures. Patient characteristics explained 10% of overall variance and retained statistically significant relationships with expenditures after regional characteristics were controlled for. LIMITATION The study limitations include the decedent sample, proxy informants, and a large proportion of unexplained variation. CONCLUSION Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics. PRIMARY FUNDING SOURCE The Brookdale Foundation.
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Affiliation(s)
- Amy S Kelley
- Mount Sinai School of Medicine, New York, New York 10029, USA.
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Huang CJ, Chiu HC, Lee MH, Wang SY. Prevalence and incidence of anxiety disorders in diabetic patients: a national population-based cohort study. Gen Hosp Psychiatry 2011; 33:8-15. [PMID: 21353122 DOI: 10.1016/j.genhosppsych.2010.10.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 10/11/2010] [Accepted: 10/11/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study aimed to investigate the prevalence and incidence of anxiety disorders among diabetic patients in Taiwan. METHODS Study subjects were identified by at least one service claim for ambulatory or inpatient care with a principal diagnosis of anxiety disorders and at least two service claims for ambulatory care or one service claim for inpatient care with a principal diagnosis of diabetes from 2000 to 2004 in the National Health Insurance database. RESULTS The 1-year prevalence rate of anxiety disorders among diabetic patients was 128.76 per 1000 in 2000, and the cumulative prevalence increased to 289.89 per 1000 in 2004. Diabetic patients had a higher cumulative prevalence and annual incidence than the general population throughout the observation period. A higher prevalence was associated with age (≥65, 55-64), female sex and low income by multiple logistic regression analysis. Cox regression analysis revealed that a higher incidence was associated with female sex and low income. CONCLUSIONS The prevalence and annual incidence density of anxiety disorders in diabetic patients were significantly higher than in patients with mental illness only in the general population. Female diabetic patients had a higher prevalence and incidence density of anxiety disorders. Anxiety disorders in diabetic patients were more prevalent in elderly women and in those with low income.
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Affiliation(s)
- Chun-Jen Huang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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Boyd CM, Fortin M. Future of Multimorbidity Research: How Should Understanding of Multimorbidity Inform Health System Design? Public Health Rev 2010. [DOI: 10.1007/bf03391611] [Citation(s) in RCA: 362] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Gardner LA, Snow V, Weiss KB, Amundson G, Schneider E, Casey D, Hornbake ER, Manaker S, Pawlson LG, Reynolds P, Sha M, Baker D. Leveraging improvement in quality and value in health care through a clinical performance measure framework: a recommendation of the American College of Physicians. Am J Med Qual 2010; 25:336-42. [PMID: 20498384 DOI: 10.1177/1062860610366589] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Policy maker efforts to evaluate the quality and costs of health care have stimulated a proliferation of disparate performance measures. This cacophony of performance measures creates confusion over which measures are applicable at which level of the health care system, limiting their effective application for accountability and improvements in patient care. The American College of Physicians (ACP) has created a clinical performance measurement framework to provide direction to policy makers and measure developers for future performance measure development and application. The ACP believes that this clinical performance measurement framework is one way to help promote transformational change in patient care through judicious application of performance measures. Recommendation. The ACP recommends that policy makers and measure developers adopt this clinical performance measurement framework to promote transformational change and improve the quality of health care in the United States.
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Stolker JM, Sun D, Conaway DG, Jones PG, Masoudi FA, Peterson PN, Krumholz HM, Kosiborod M, Spertus JA. Importance of measuring glycosylated hemoglobin in patients with myocardial infarction and known diabetes mellitus. Am J Cardiol 2010; 105:1090-4. [PMID: 20381658 DOI: 10.1016/j.amjcard.2009.12.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Revised: 12/01/2009] [Accepted: 12/01/2009] [Indexed: 01/08/2023]
Abstract
Although medical co-morbidities commonly affect clinical outcomes after acute myocardial infarction (AMI), current performance measures of AMI quality focus exclusively on the management of the AMI itself. However, patients with AMIs frequently present with other co-morbidities, such as diabetes mellitus (DM), that also warrant assessment and management. To date, the quality of DM evaluation in patients presenting with AMIs has not been described. From January 2003 to June 2004, the Prospective Registry Evaluating Myocardial Infarction Patients: Events and Recovery-Quality Improvement (PREMIER-QI) enrolled 3,953 patients with AMIs at 19 centers in the United States. The frequency of glycosylated hemoglobin (HbA(1c)) assessment, either during the hospitalization or documented in the chart from the preceding 3 months, was prospectively evaluated. Among 1,168 patients with AMIs with preexisting DM, only 47% had recent HbA(1c) levels available, with marked variability in HbA(1c) assessment among hospitals (range 7% to 81%). Among those with available HbA(1c) levels, 39% had good control (HbA(1c) <7%), 36% had suboptimal control (HbA(1c) 7% to 9%), and 25% had poor control (HbA(1c) >9%). Patients with suboptimal and poor control were more likely to have their DM treatment intensified than those without HbA(1c) assessment (for HbA(1c) 7% to 9%, rate ratio 1.38, 95% confidence interval 1.03 to 1.85; for HbA(1c) >9%, rate ratio 2.20, 95% confidence interval 1.68 to 2.88). Similarly, patients with DM who had HbA(1c) measured were more likely to receive instructions on DM disease management before discharge. In conclusion, the assessment of chronic glycemic control is highly variable among patients with AMIs and DM. Because much of this variability occurs at the hospital level, the evaluation of DM control could represent an additional quality indicator and an opportunity to advance patient-centered AMI care.
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Schmitt EM, Sands LP, Weiss S, Dowling G, Covinsky K. Adult day health center participation and health-related quality of life. THE GERONTOLOGIST 2010; 50:531-40. [PMID: 20106933 DOI: 10.1093/geront/gnp172] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The purpose of this study was to assess the association between Adult Day Health Center (ADHC) participation and health-related quality of life. DESIGN AND METHODS Case-controlled prospective study utilizing the Medical Outcomes Survey Form 36 (SF-36) to compare newly enrolled participants from 16 ADHC programs with comparable community-dwelling older adults who did not attend an ADHC. Assessments were conducted at study enrollment, 6 and 12 months. RESULTS ADHC participants (n = 57) and comparison group subjects (n = 67) were similar at baseline in age, ethnic diversity, medical conditions, depression, cognition, immigration history, education, income, and marital status. Significantly more comparison group subjects lived alone (p = .002). One year after enrollment, the SF-36 domains role physical and role emotional improved significantly. Adjusted role physical scores for ADHC participants improved (23 vs. 36) but declined for the comparison group (38 vs. 26, time by group interaction p = .01), and role emotional scores improved for ADHC participants (62 vs.70) but declined for the comparison group (65 vs. 48, time by group interaction p = .02). Secondary analyses revealed that changes in daily physical functioning, depressed affect, or cognitive functioning did not explain the improvements found in role physical and role emotional scores for ADHC participants. No significant differences in trends for the 2 groups occurred for the SF-36 domains physical functioning, social functioning, and mental health. IMPLICATIONS ADHC participation may enhance older adults' quality of life. Quality of life may be a key measure to inform care planning, program improvement, and policy development of ADHC.
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Affiliation(s)
- Eva M Schmitt
- Institute on Aging, San Francisco, California 94118, USA.
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Millett C, Bottle A, Ng A, Curcin V, Molokhia M, Saxena S, Majeed A. Pay for perfomance and the quality of diabetes management in individuals with and without co-morbid medical conditions. J R Soc Med 2009; 102:369-77. [PMID: 19734534 DOI: 10.1258/jrsm.2009.090171] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To examine the impact of the Quality and Outcomes Framework, a major pay-for-performance incentive introduced in the UK during 2004, on diabetes management in patients with and without co-morbidity. DESIGN Cohort study comparing actual achievement of treatment targets in 2004 and 2005 with that predicted by the underlying (pre-intervention) trend in diabetes patients with and without co-morbid conditions. SETTING A total of 422 general practices participating in the General Practice Research Database. MAIN OUTCOMES MEASURES Achievement of diabetes treatment targets for blood pressure (< 140/80 mm Hg), HbA1c (<or= 7.0%) and cholesterol (<or= 5 mmol/L). RESULTS The percentage of diabetes patients with co-morbidity reaching blood pressure and cholesterol targets exceeded that predicted by the underlying trend during the first two years of pay for perfomance (by 3.1% [95% CI 1.1-5.1] for BP and 4.1% [95% CI 2.2-6.0] for cholesterol among patients with >or= 5 co-morbidities in 2005). Similar improvements were evident in patients without co-morbidity, except for cholesterol control in 2004 (-0.2% [95% CI -1.7-1.4]). The percentage of patients meeting the HbA1c target in the first two years of this program was significantly lower than predicted by the underlying trend in all patients, with the greatest shortfall in patients without co-morbidity (3.8% [95% CI 2.6-5.0] lower in 2005). Patients with co-morbidity remained significantly more likely to meet treatment targets for cholesterol and HbA1c than those without after the introduction of pay for perfomance. CONCLUSIONS Diabetes patients with co-morbid conditions appear to have benefited more from this pay-for-performance program than those without co-morbidity.
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Banerjea R, Pogach LM, Smelson D, Sambamoorthi U. Mental Illness and Substance Use Disorders among Women Veterans with Diabetes. Womens Health Issues 2009; 19:446-56. [DOI: 10.1016/j.whi.2009.07.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2008] [Revised: 07/24/2009] [Accepted: 07/24/2009] [Indexed: 01/22/2023]
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Are co-morbidities associated with guideline adherence? The MI-Plus study of Medicare patients. J Gen Intern Med 2009; 24:1205-10. [PMID: 19727967 PMCID: PMC2771234 DOI: 10.1007/s11606-009-1096-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 06/12/2009] [Accepted: 08/10/2009] [Indexed: 01/22/2023]
Abstract
BACKGROUND/OBJECTIVES The impact of co-morbid illnesses on adherence to guideline recommendations in chronic illness is of growing concern. We tested a framework [Piette and Kerr, Diabetes Care. 29(3):725-31, 2006] of provider adherence to guidelines in the presence of co-morbid conditions, which suggests that the effect of co-morbid conditions depends on treatment recommendations for the co-morbid conditions and how symptomatic they are. METHODS We conducted an exploratory analysis to assess the framework using chart audit data for 1,240 post-acute myocardial infarction (AMI) Medicare beneficiaries in Alabama. We assessed level of guideline-adherent post-AMI care from chart-based quality indicators and constructed scores reflecting how much care for the co-morbid condition was similar to post-AMI care (concordance) and how symptomatic the co-morbid condition is, based on expert opinion. RESULTS Patients had a mean age of 74 years, mean co-morbidities of 2, and 61% were white. Both concordance and symptomatic scores were positively associated with guideline compliance, with correlations of 0.32 and 0.14, respectively (p < 0.001 for each). We found positive correlations between highly concordant co-morbid conditions and post-AMI quality scores and negative correlations between highly symptomatic conditions and post-AMI quality scores; both findings support the framework. However, the framework performed less well for conditions that were not highly concordant or highly symptomatic, and the magnitudes of the associations were not large. CONCLUSIONS The framework was related to the association of co-morbid conditions with adherence by providers to guideline-recommended treatment for post-AMI patients. The framework holds promise for evaluating and possibly predicting guideline adherence.
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Riegel B, Moser DK, Anker SD, Appel LJ, Dunbar SB, Grady KL, Gurvitz MZ, Havranek EP, Lee CS, Lindenfeld J, Peterson PN, Pressler SJ, Schocken DD, Whellan DJ. State of the Science. Circulation 2009; 120:1141-63. [DOI: 10.1161/circulationaha.109.192628] [Citation(s) in RCA: 638] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Keays S, Wister AV, Gutman GM. Administrators and Quality of Care in Long-Term Care Facilities. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/02763890903035621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Comorbidities, Frailty, and “Pay-off Time”. Med Care 2009; 47:607-9. [DOI: 10.1097/mlr.0b013e3181a5c629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rose AJ, Berlowitz DR, Frayne SM, Hylek EM. Measuring quality of oral anticoagulation care: extending quality measurement to a new field. Jt Comm J Qual Patient Saf 2009; 35:146-55. [PMID: 19326806 DOI: 10.1016/s1553-7250(09)35019-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Oral anticoagulation with warfarin is an increasingly common medical intervention. Despite its efficacy, warfarin is difficult to manage, contributing to potential for patient harm. Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with comparatively little effort in measuring the quality of oral anticoagulation care once therapy has begun. To address this gap in the literature, a MEDLINE search was conducted for all papers relevant to possible quality measures in oral anticoagulation care, including measures of structure, process, and outcomes of care. LIMITATIONS, CONCERNS, AND CHALLENGES OF QUALITY MEASUREMENT IN ORAL ANTICOAGULATION Because they do not have intrinsic significance, measures of structure and process should be strongly related to outcomes that matter to merit our interest. Consensus guidelines may provide useful guidance to practicing clinicians but may not represent valid process measures. Outcome measures must be studied with databases that provide sufficient statistical power to reliably demonstrate real differences between providers or sites of care. CONCLUSION Oral anticoagulation care, a common and serious condition, is in need of a program of quality measurement. This article suggests a research agenda to begin such a program. Previous research has established the evidence for anticoagulant therapy across a broad spectrum of indications and has helped to achieve consensus on the optimal target intensity for various indications. The next task will be to use this body of evidence to develop valid measures of the structure, process, and outcomes of oral anticoagulation care. Quality indicators provide a framework for quality improvement, two goals of which are to maximize the effectiveness of therapy and to minimize harm.
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Affiliation(s)
- Adam J Rose
- Center for Health Quality, Outcomes and Economic Research, Bedford VA Medical Center, Bedford, MA, USA.
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Conrad DA, Perry L. Quality-Based Financial Incentives in Health Care: Can We Improve Quality by Paying for It? Annu Rev Public Health 2009; 30:357-71. [DOI: 10.1146/annurev.publhealth.031308.100243] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Douglas A. Conrad
- Department of Health Services, University of Washington, Seattle, Washington 98195;
| | - Lisa Perry
- Department of Economics, University of Washington, Seattle, Washington 98195;
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Abbo ED, Zhang Q, Zelder M, Huang ES. The increasing number of clinical items addressed during the time of adult primary care visits. J Gen Intern Med 2008; 23:2058-65. [PMID: 18830762 PMCID: PMC2596516 DOI: 10.1007/s11606-008-0805-8] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 08/07/2008] [Accepted: 08/22/2008] [Indexed: 01/22/2023]
Abstract
BACKGROUND Primary care physicians report that there is insufficient time to meet patients' needs during clinical visits, but visit time has increased over the past decade. OBJECTIVE To determine whether the number of clinical items addressed during the primary care visit has increased, and if so, whether this has been associated with changes in visit length and the pace of clinical work. DESIGN Analysis of non-hospital-based adult primary care visits from 1997 to 2005, as reported in the National Ambulatory Medical Care Survey. PARTICIPANTS A total of 46,431 adult primary care visits. MEASUREMENTS We assessed changes over time for the total number of clinical items addressed per visit (including diagnoses, medications, tests ordered, and counseling), visit duration, and average available time per clinical item. In adjusted analyses we controlled for patient and physician characteristics. RESULTS The number of clinical items addressed per visit increased from 5.4 to 7.1 from 1997 to 2005 (p < 0.001). Visit duration concurrently increased from 18.0 to 20.9 min (p < 0.001). The increase in the number of clinical items outpaced the increase in duration, resulting in a decrease in time per clinical item from 4.4 to 3.8 (p = 0.04). These changes occurred across patient age and payer status and were confirmed in adjusted analyses. CONCLUSIONS The volume of work associated with primary care visits has increased to a greater extent than has visit duration, resulting in less available time to address individual items. These findings have important implications for reimbursing physician time and improving the quality of care.
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Affiliation(s)
- Elmer D Abbo
- Section of General Internal Medicine, University of Chicago, Chicago, IL 60637, USA.
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The relationship between measured performance and satisfaction with care among clinically complex patients. J Gen Intern Med 2008; 23:1729-35. [PMID: 18649107 PMCID: PMC2585675 DOI: 10.1007/s11606-008-0734-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 05/14/2008] [Accepted: 07/01/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recent work has shown that clinically complex patients are more likely to receive recommended care, but it is unknown whether higher achievement on individual performance goals results in improved care for complex patients or detracts from other important but unmeasured aspects of care, resulting in unmet needs and lower satisfaction with care. OBJECTIVE To examine the relationship between measured performance and satisfaction with care among clinically complex patients DESIGN AND PARTICIPANTS An observational analysis of a national sample of 35,927 veterans included in the External Peer Review Program in fiscal years 2003 and 2004. MEASUREMENTS First, compliance with individual performance measures (breast cancer screening with mammography, colorectal cancer screening, influenza vaccination, pneumococcal vaccination, lipid monitoring, use of ACE inhibitor in heart failure, and diabetic eye examination), as well as overall receipt of recommended care, was estimated as a function of each patient's clinical complexity. Second, global satisfaction with care was estimated as a function of clinical complexity and compliance with performance measures. MAIN RESULTS Higher clinical complexity was predictive of slightly higher overall performance (OR 1.13, 95% CI 1.09 to 1.18) and higher performance on most individual performance measures, an effect that was mediated by increased visit frequency. High measured performance was associated with higher satisfaction with care among patients with high clinical complexity. In fact, as complexity increased, the effect of achieving high performance on the odds of being satisfied with care also increased CONCLUSIONS Not only was measured performance higher in clinically complex patients, but satisfaction with care was also higher among clinically complex patients with high measured performance, suggesting that compliance with performance measures in clinically complex patients does not crowd out unmeasured care.
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Bayliss EA, Ellis JL, Steiner JF. Seniors' self-reported multimorbidity captured biopsychosocial factors not incorporated into two other data-based morbidity measures. J Clin Epidemiol 2008; 62:550-7.e1. [PMID: 18757178 DOI: 10.1016/j.jclinepi.2008.05.002] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Revised: 03/14/2008] [Accepted: 05/05/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To explore the constructs underlying a self-report assessment of multimorbidity. STUDY DESIGN AND SETTING We conducted a cross-sectional survey of 352 HMO members aged 65 years or more with, at a minimum, diabetes, depression, and osteoarthritis. We assessed self-reported 'disease burden' (a severity-adjusted count of conditions) as a function of biopsychosocial factors, two data-based comorbidity indices, and demographic variables. RESULTS In multivariate regression, age, 'compound effects of conditions' (treatments and symptoms interfering with each other), self-efficacy, financial constraints, and physical functioning were significantly (p<or=0.05) associated with disease burden. An ICD-9-based morbidity index did not significantly contribute to disease burden, and a pharmacy-data-based morbidity index was minimally significant. CONCLUSION This measure of self-reported disease burden represents an amalgamation of functional capabilities, social considerations, and medical conditions that are not captured by two administrative data-based measures of morbidity. This suggests that (a) self-reported descriptions of multimorbidity incorporate biopsychosocial constructs that reflect the perceived burden of multimorbidity, (b) a simple count of diagnoses should be supplemented by an assessment of activity limitations imposed by these conditions, and (c) choice of the morbidity measurement instrument should be based on the outcome of interest rather than on the most convenient method of measurement.
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Affiliation(s)
- Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente, Denver, CO 80237-8066, USA.
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Bayliss EA, Edwards AE, Steiner JF, Main DS. Processes of care desired by elderly patients with multimorbidities. Fam Pract 2008; 25:287-93. [PMID: 18628243 PMCID: PMC2504745 DOI: 10.1093/fampra/cmn040] [Citation(s) in RCA: 231] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Most recommended care for chronic diseases is based on the research of single conditions. There is limited information on 'best' processes of care for persons with multiple morbidities. Our objective was to explore processes of care desired by elderly patients who have multimorbidities that may present competing demands for patients and providers. METHODS Qualitative investigation using one-on-one interviews of 26 community-dwelling HMO members aged 65-84 (50% male) who had, at a minimum, the combined conditions of diabetes, depression and osteoarthritis. Participants were chosen from a stratified random sample to have a range of 4-16 chronic medical conditions. RESULTS Participants' desired processes of care included: the need for convenient access to providers (telephone, internet or in person), clear communication of individualized care plans, support from a single coordinator of care who could help prioritize their competing demands and continuity of relationships. They also desired providers who would listen to and acknowledge their needs, appreciate that these' needs were unique and fluctuating and have a caring attitude. CONCLUSIONS These respondents describe an ideal process of care that is patient centered and individualized and that supports their unique constellations of problems, shifting priorities and multidimensional decision making. Individual and ongoing care coordination managed by a primary contact person may meet some of these needs. Achieving these goals will require developing efficient methods of assessing patient care needs and flexible care management support systems that can respond to patients' needs for different levels of support at different times.
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Affiliation(s)
- Elizabeth A Bayliss
- Kaiser Permanente Institute for Health Research, Denver, CO 80237-8066, USA.
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