Are co-morbidities associated with guideline adherence? The MI-Plus study of Medicare patients

Doctors' adherence to guidelines recommendations and glycaemic control in diabetic patients in Quetta, Pakistan: Findings from an observational study

BACKGROUND

Poor control of diabetes mellitus (DM) is partly attributed to doctors' poor adherence to guidelines.

OBJECTIVE

To evaluate doctors' adherence to pharmacotherapeutic recommendations of DM management guidelines and factors associated with guidelines adherence and glycaemic control.

METHODS

This prospective observational study included 30 doctors who were treating DM patients in their private clinics in Quetta, Pakistan. On visit 1, a total of 600 prescriptions written by 30 enrolled doctors (20 patients per doctor) were noted along with patients' sociodemographic and clinical characteristics. American Diabetes Association guidelines was used as a reference. The prescriptions noted were judged for guidelines compliance. Of 600 enrolled patients, 450 patients (15 patients per doctor) were followed for one more visit and included in final analysis. Glycated hemoglobin (HbA1c) level noted one visit 2 was related with the respective prescription on visit 1. Data were analyzed by SPSS (version 23). A p-value <0.05 was considered statistically significant.

RESULTS

Patients received a median of two antidiabetic drugs (range: 1-5). A total of 73.1% patients were on polytherapy. Metformin was the most frequently prescribed (88.4%) antidiabetic followed by gliptins (46.2%). A total of 41.6% prescriptions were judged guidelines compliant. In multivariate binary logistic regressions (MVBLR) analysis, chronic kidney disease (CKD) (OR = 0.422) and polytherapy (OR = 0.367) had statistically significant negative associations (p-value <0.05) with guidelines' compliant prescriptions. The group of doctors comprised of specialists and consultants wrote significantly (p-value = 0.004) high number of guidelines adherent prescriptions (mean rank = 20.25) than the group comprised of medical officers (mean rank = 11.34). On visit 2, only 39.5% patients were on goal glycemic levels. In MVBLR analysis, suffering from dyslipidemia (OR = 0.134) and CKD (OR = 0.111), receiving sulfonylurea (OR = 0.156) and guidelines' compliant prescription (OR = 4.195) were significantly (p-value <0 .05) associated with glycemic control.

CONCLUSION

Although guidelines compliant prescriptions produced better glycemic control, but doctors' adherence to guidelines and glycemic control were poor. Polytherapy and CKD emerged as risk factors for guidelines divergent prescriptions. Dyslipidemia, CKD and reception of sulfonylureas had negative association with glycemic control.

A Scoping Review of Methods Used to Assess Medication Adherence in Patients with Chronic Conditions

BACKGROUND

Medication nonadherence of patients with chronic conditions is a complex phenomenon contributing to increased economic burden and decreased quality of life. Intervention development relies on accurately assessing adherence but no "gold standard" method currently exists.

PURPOSE

The present scoping review aimed to: (a) review and describe current methods of assessing medication adherence (MA) in patients with chronic conditions with the highest nonadherence rates (asthma, cancer, diabetes, epilepsy, HIV/AIDS, hypertension), (b) outline and compare the evidence on the quality indicators between assessment methods (e.g., sensitivity), and (c) provide evidence-based recommendations.

METHODS

PubMed, PsycINFO and Scopus databases were screened, resulting in 62,592 studies of which 71 met criteria and were included.

RESULTS

Twenty-seven self-report and 10 nonself-report measures were identified. The Medication Adherence Report Scale (MARS-5) was found to be the most accurate self-report, whereas electronic monitoring devices such as Medication Event Monitoring System (MEMS) corresponded to the most accurate nonself-report. Higher MA rates were reported when assessed using self-reports compared to nonself-reports, except from pill counts.

CONCLUSIONS

Professionals are advised to use a combination of self-report (like MARS-5) and nonself-report measures (like MEMS) as these were found to be the most accurate and reliable measures. This is the first review examining self and nonself-report methods for MA, across chronic conditions with the highest nonadherence rates and provides evidence-based recommendations. It highlights that MA assessment methods are understudied in certain conditions, like epilepsy. Before selecting a MA measure, professionals are advised to inspect its quality indicators. Feasibility of measures should be explored in future studies as there is presently a lack of evidence.

Can an mhealth clinical decision-making support system improve adherence to neonatal healthcare protocols in a low-resource setting?

Background

This study assessed health workers’ adherence to neonatal health protocols before and during the implementation of a mobile health (mHealth) clinical decision-making support system (mCDMSS) that sought to bridge access to neonatal health protocol gap in a low-resource setting.

Methods

We performed a cross-sectional document review within two purposively selected clusters (one poorly-resourced and one well-resourced), from each arm of a cluster-randomized trial at two different time points: before and during the trial. The total trial consisted of 16 clusters randomized into 8 intervention and 8 control clusters to assess the impact of an mCDMSS on neonatal mortality in Ghana. We evaluated health workers’ adherence (expressed as percentages) to birth asphyxia, neonatal jaundice and cord sepsis protocols by reviewing medical records of neonatal in-patients using a checklist. Differences in adherence to neonatal health protocols within and between the study arms were assessed using Wilcoxon rank-sum and permutation tests for each morbidity type. In addition, we tracked concurrent neonatal health improvement activities in the clusters during the 18-month intervention period.

Results

In the intervention arm, mean adherence was 35.2% (SD = 5.8%) and 43.6% (SD = 27.5%) for asphyxia; 25.0% (SD = 14.8%) and 39.3% (SD = 27.7%) for jaundice; 52.0% (SD = 11.0%) and 75.0% (SD = 21.2%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. In the control arm, mean adherence was 52.9% (SD = 16.4%) and 74.5% (SD = 14.7%) for asphyxia; 45.1% (SD = 12.8%) and 64.6% (SD = 8.2%) for jaundice; 53.8% (SD = 16.0%) and 60.8% (SD = 11.7%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. We observed nonsignificant improvement in protocol adherence in the intervention clusters but significant improvement in protocol adherence in the control clusters. There were 2 concurrent neonatal health improvement activities in the intervention clusters and over 12 in the control clusters during the intervention period.

Conclusion

Whether mHealth interventions can improve adherence to neonatal health protocols in low-resource settings cannot be ascertained by this study. Neonatal health improvement activities are however likely to improve protocol adherence. Future mHealth evaluations of protocol adherence must account for other concurrent interventions in study contexts.

Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States

BACKGROUND

Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking.

METHODS

Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05.

RESULTS

1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location.

CONCLUSIONS

In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors.

Multiple Chronic Conditions in Spousal Caregivers of Older Adults With Functional Disability: Associations With Caregiving Difficulties and Gains

OBJECTIVES

Multiple chronic conditions (MCCs) are common and have harmful consequences in later life. Along with managing their own health, many aging adults care for an impaired partner. Spousal caregiving may be more stressful when caregivers have MCCs, particularly those involving complex management. Yet, little is known about combinations of conditions that are most consequential for caregiving outcomes.

METHOD

Using a U.S. sample of 359 spousal caregivers and care recipients from the 2011 National Aging Trends Study and National Study of Caregiving, we examined three categories of MCCs based on similarity of management strategies (concordant only, discordant only, and both concordant and discordant) and their associations with caregiving difficulties and gains. We also considered gender differences.

RESULTS

Relative to caregivers without MCCs, caregivers with discordant MCCs reported fewer gains, whereas caregivers with both concordant and discordant MCCs reported greater emotional and physical difficulties. Wives with discordant MCCs only reported a trend for greater physical difficulties. Caregivers with concordant MCCs did not report more difficulties or gains.

DISCUSSION

Spousal caregivers with MCCs involving discordant management strategies appear to be at risk for adverse care-related outcomes and may benefit from support in maintaining their own health as well as their caregiving responsibilities.

Loss of Community-Dwelling Status Among Survivors of High-Acuity Emergency General Surgery Disease

OBJECTIVES

To examine loss of community-dwelling status 9 months after hospitalization for high-acuity emergency general surgery (HA-EGS) disease among older Americans.

DESIGN

Retrospective analysis of claims data.

SETTING

US communities with Medicare beneficiaries.

PARTICIPANTS

Medicare beneficiaries age 65 years or older hospitalized urgently/emergently between January 1, 2015, and March 31, 2015, with a principal diagnosis representing potential life or organ threat (necrotizing soft tissue infections, hernias with gangrene, ischemic enteritis, perforated viscus, toxic colitis or gastroenteritis, peritonitis, intra-abdominal hemorrhage) and an operation of interest on hospital days 1 or 2 (N = 3319).

MEASUREMENTS

Demographic characteristics (age, race, and sex), comorbidities, principal diagnosis, complications, and index hospitalization disposition (died; discharged to skilled nursing facility [SNF], long-term acute care [LTAC], rehabilitation, hospice, home (with or without services), or acute care hospital; other) were measured. Survivors of index hospitalization were followed until December 31, 2015, on mortality and community-dwelling status (SNF/LTAC vs not). Descriptive statistics, Kaplan-Meier plots, and χ² tests were used to describe and compare the cohort based on disposition. A multivariable logistic regression model, adjusted for age, sex, comorbidities, complications, and discharge disposition, determined independent predictors of loss of community-dwelling status at 9 months.

RESULTS

A total of 2922 (88%) survived index hospitalization. Likelihood of discharge to home decreased with increasing age, baseline comorbidities, and in-hospital complications. Overall, 418 (14.3%) HA-EGS survivors died during the follow-up period. Among those alive at 9 months, 10.3% were no longer community dwelling. Initial discharge disposition to any location other than home and three or more surgical complications during index hospitalization were independent predictors of residing in a SNF/LTAC 9 months after surviving HA-EGS.

CONCLUSION

Older Americans, known to prioritize living in the community, will experience substantial loss of independence due to HA-EGS. Long-term expectations after surviving HA-EGS must be framed from the perspective of the outcomes that older patients value the most. Further research is needed to examine the quality-of-life burden of EGS survivorship prospectively. J Am Geriatr Soc 67:2289-2297, 2019.

Incidence and Predictors of Sudden Cardiac Death After a Major Non-Fatal Cardiovascular Event

BACKGROUND

Sudden cardiac death (SCD) still accounts for the majority of deaths from the four major cardiovascular events (myocardial infarction (MI), heart failure (HF), atrial fibrillation (AF), and stroke) despite substantial progress on prevention.

METHODS

Four separate cohorts (one for each of the four major cardiovascular conditions) were captured through person-linked hospital morbidity and mortality data collections between 2000 and 2009 and followed-up for 11.5 years. The incidence rate for each cohort was total SCD cases divided by sum of follow-up time for each individual alive. Kaplan-Meier survival curve was used to calculate unadjusted risk of SCD. Predictors of SCD were identified by fitting multivariable adjusted Cox regression models in each of the cohorts.

RESULTS

There were 1,174 cases of SCD from 53,614 total CVD events across the cohorts (35.6% for MI, 15.6% for HF, 22.4% for AF, 26.4% for stroke). The incidence rate and unadjusted risk of SCD were both highest after incident hospitalisation for HF, followed by MI, stroke and AF. The elevated risk of SCD was independently associated with MI, HF, arrhythmias, peripheral artery disease, diabetes, chronic kidney disease, and prior coronary heart disease (hazard ratios ranging from 1.1 to 2.8). Early revascularisation is protective in 28-day survivors after an incident MI event.

CONCLUSIONS

An appreciable incidence of SCD following an incident event of MI, HF, AF and stroke deserves greater prevention efforts. Major medical conditions such as MI, HF, peripheral artery disease, and arrhythmias are risk markers of SCD and coronary revascularisation is protective.

Comorbidity Type and Health Care Costs in Type 2 Diabetes: A Retrospective Claims Database Analysis

INTRODUCTION

Previous studies suggest that the type and combination of comorbidities may impact diabetes care, but their cost implications are less clear. This study characterized how diabetes patients' health care utilization and costs may vary according to comorbidity type classified on the basis of the Piette and Kerr framework.

METHODS

We conducted a retrospective observational study of privately insured US adults newly diagnosed with type 2 diabetes (n = 138,466) using the 2014-2016 Optum Clinformatics^® Data Mart. Diabetes patients were classified into five mutually exclusive comorbidity groups: concordant only, discordant only, both concordant and discordant, any dominant, and none. We estimated average health care costs of each comorbidity group by using generalized linear models, adjusting for patient demographics, region, insurance type, and prior-year costs.

RESULTS

Most type 2 diabetes patients had discordant conditions only (27%), dominant conditions (25%), or both concordant and discordant conditions (24%); 7% had concordant conditions only. In adjusted analyses, comorbidities were significantly associated with higher health care costs (p < 0.0001) and the magnitude of the association varied with comorbidity type. Diabetes patients with dominant comorbidities incurred substantially higher costs ($38,168) compared with individuals with both concordant and discordant conditions ($20,401), discordant conditions only ($9173), concordant conditions only ($9000), and no comorbidities ($3365). More than half of the total costs in our sample (53%) were attributable to 25% of diabetes patients who had dominant comorbidities.

CONCLUSIONS

Diabetes patients with both concordant and discordant conditions and with clinically dominant conditions incurred substantially higher health costs than other diabetes patients. Our findings suggest that diabetes management programs must explicitly address concordant, discordant, and dominant conditions because patients may have distinctly different health care needs and utilization patterns depending on their comorbidity profiles. The Piette and Kerr framework may serve as a screening tool to identify high-need, high-cost diabetes patients and suggest targets for tailored interventions.

FUNDING

Sanofi.

Exploring the Validity of Developing an Interdisciplinarity Score of a Patient's Needs: Care Coordination, Patient Complexity, and Patient Safety Indicators

Despite the Affordable Care Act's push to improve the coordination of care for patients with multiple chronic conditions, most measures of coordination quality focus on a specific moment in the care process (e.g., medication errors or transfer between facilities), rather than patient outcomes. One possible supplementary way of measuring the care coordination quality of a facility would be to identify the patients needing the most coordination, and to look at outcomes for that group. This paper lays the groundwork for a new measure of care coordination quality by outlining a conceptual framework that considers the interaction between a patient's interdisciplinarity, biological susceptibility, and procedural intensity. Interdisciplinarity captures the degree of specialized medical expertise needed for a patient's care and will be an important measure to estimate the number of specialists a patient might see. We then develop a preliminary measure of interdisciplinarity and run tests linking interdisciplinarity to medical mistakes, as defined by Agency for Healthcare Research and Quality's Patient Safety Indicators. Finally, we use our preliminary measure to verify that interdisciplinarity is likely to be statistically different from existing measures of comorbidity, like the Charlson score. Future research will need to build upon our findings by developing a more statistically validated measure of interdisciplinarity.

Onset of Multiple Chronic Conditions and Depressive Symptoms: A Life Events Perspective

Background

While the association between depressive symptoms and chronic illness has been the subject of many studies, little is known about whether depressive symptoms differ as a function of the illnesses people have as they transition to living with multiple chronic conditions.

Methods

Self-reports of five diagnosed chronic conditions (arthritis, diabetes, heart disease, hypertension, and pulmonary disease) and depressive symptoms were provided by 3,396 people participating in three waves of the ORANJ BOWL^SM research panel. Longitudinal multilevel modeling was used to examine the effects that transitioning to having a diagnosis of multiple chronic conditions has on depressive symptoms.

Results

Between 2006 and 2014, controlling for age, gender, income, race, and a lifetime diagnosis of depression, people who transitioned to having a diagnosis of multiple chronic conditions had significantly higher levels of depressive symptoms than people who did not make this transition. The diagnosis of arthritis, diabetes, heart disease, and pulmonary disease, but not hypertension had independent effects, increasing depressive symptoms.

Conclusions

Having a diagnosis of multiple chronic conditions leads to increases in depressive symptoms, but not all illnesses have the same effect. Findings highlight the need for clinicians to be aware of mental health risks in patients diagnosed with multiple chronic conditions, particularly those with a diagnosis of arthritis, diabetes, heart disease, and pulmonary disease. Clinical care providers should take account of these findings, encouraging psychosocial supports for older adults who develop multiple chronic conditions to minimize the negative psychological impact of illness diagnosis.

Provider adherence to first antenatal care guidelines and risk of pregnancy complications in public sector facilities: a Ghanaian cohort study

BACKGROUND

Guideline utilization aims at improvement in quality of care and better health outcomes. The objective of the current study was to determine the effect of provider complete adherence to the first antenatal care guidelines on the risk of maternal and neonatal complications in a low resource setting.

METHODS

Women delivering in 11 health facilities in the Greater Accra region of Ghana were recruited into a cohort study. Their first antenatal visit records were reviewed to assess providers' adherence to the guidelines, using a thirteen-point checklist. Information on their socio-demographic characteristics and previous pregnancy history was collected. Participants were followed up for 6 weeks post-partum to complete data collection on outcomes. The incidence of maternal and neonatal complications was estimated. The effects of complete adherence on risk of maternal and neonatal complications were estimated and expressed as relative risks (RRs) with their 95% confidence intervals (CI) adjusted for a potential clustering effect of health facilities.

RESULTS

Overall, 926 women were followed up to 6 weeks post-partum. Mean age (SD) of participants was 28.2 (5.4) years. Complete adherence to guidelines pertained to the care of 48.5% of women. Incidence of preterm deliveries, low birth weight, stillbirths and neonatal mortality were 5.3, 6.1, 0.4 and 1.4% respectively. Complete adherence to the guidelines decreased risk of any neonatal complication [0.72 (0.65-0.93); p = 0.01] and delivery complication [0.66 (0.44-0.99), p = 0.04].

CONCLUSION

Complete provider adherence to antenatal care guidelines at first antenatal visit influences delivery and neonatal outcomes. While there is the need to explore and understand explanatory mechanisms for these observations, programs that promote complete adherence to guidelines will improve the pregnancy outcomes.

Client Factors Affect Provider Adherence to Clinical Guidelines during First Antenatal Care

Background

The first antenatal clinic (ANC) visit helps to distinguish pregnant women who require standard care, from those with specific problems and so require special attention. There are protocols to guide care providers to provide optimal care to women during ANC. Our objectives were to determine the level of provider adherence to first antenatal visit guidelines in the Safe Motherhood Protocol (SMP), and assess patient factors that determine complete provider adherence.

Methods

This cross-sectional study is part of a cohort study that recruited women who delivered in eleven health facilities and who had utilized antenatal care services during their pregnancy in the Greater Accra region of Ghana. A record review of the first antenatal visit of participants was carried out to assess the level of adherence to the SMP, using a thirteen-point checklist. Information on their socio-demographic characteristics and previous pregnancy history was collected using a questionnaire. Percentages of adherence levels and baseline characteristics were estimated and cluster-adjusted odds ratios (OR) calculated to identify determinants.

Results

A total of 948 women who had delivered in eleven public facilities were recruited with a mean age (SD) of 28.2 (5.4) years. Overall, complete adherence to guidelines pertained to only 48.1% of pregnant women. Providers were significantly more likely to completely adhere to guidelines when caring for multiparous women [OR = 5.43 (1.69–17.44), p<0.01] but less likely to do so when attending to women with history of previous pregnancy complications [OR = 0.50 (0.33–0.75), p<0.01].

Conclusion

Complete provider adherence to first antenatal visit guidelines is low across different facility types in the Greater Accra region of Ghana and is determined by parity and history of previous pregnancy complication. Providers should be trained and supported to adhere to the guidelines during provision of care to all pregnant women.

[Key messages for the initial management of the elderly patient with acute heart failure]

Acute heart failure is a high prevalence geriatric syndrome that has become one of the most frequent causes of visits to emergency departments, as well as hospital admission, and is associated with high morbidity, mortality and functional impairment. There has been an increasing amount of information published in recent years on the initial management of acute heart failure and the results of the short-term outcomes, as well as the natural history of the disease. The objective of this study is to provide several recommendations that should be taken into account in the initial management of the elderly patient with acute heart failure in the emergency departments, and to review the most interesting currently on-going clinical trials.

Evidence-to-practice gaps in the management of community-dwelling Australian patients with ischaemic heart disease

WHAT IS KNOWN AND OBJECTIVE

Ischaemic heart disease (IHD) is a major cause of death in developed countries. Patients with IHD are at greater risk of subsequent myocardial infarction (MI). International studies suggest that guideline recommended therapies proven to reduce this risk are underutilised. The objectives of this study were to review the use of guideline-recommended medications for the secondary prevention of IHD in Australians and identify patient characteristics influencing use of these medications.

METHODS

The medication regimens of community dwelling Australians with documented IHD who received a Home Medicines Review (HMR) between January 2010 and September 2012 were extracted from a pharmacist decision support software database and retrospectively reviewed. Each patient's use of antithrombotics; angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs); statins; and β-blockers (BBs) or non-dihydropyridine calcium channel blockers (CCBs) was evaluated in conjunction with documented contraindications. Guideline concordance in all four categories was classified as 'Optimal Medical Therapy' (OMT). Univariate and multivariate analyses identified patient characteristics influencing OMT use.

RESULTS AND DISCUSSION

Of the 5396 patient medication regimens reviewed, 24·3% demonstrated OMT. Guideline concordance was observed in 91·6%, 75·6%, 74·8%, and 42·4% of patients for antithrombotics, statins, ACEI/ARBs, and BB/CCBs, respectively. The independent predictors of not receiving OMT were age 75 years or over (adjusted odds ratio [AOR] 0·76; 95% confidence interval [CI] 0·67-0·87), asthma (AOR 0·69; 95% CI 0·57-0·84), and depression or anxiety (AOR 0·84; 95% CI 0·71-0·99). Diabetes (AOR 1·20; 95% CI 1·04-1·38), hypertension (AOR 1·56; 95% CI 1·36-1·79) and a high Charlson Comorbidity Index score (AOR 1·37; 95% CI 1·15-1·64) independently predicted receipt of OMT.

WHAT IS NEW AND CONCLUSION

Only one quarter of community dwelling Australian patients with IHD receive antithrombotics, ACEI/ARBs, BB/CCBs and statins. The potential consequences of these evidence-to-practice gaps are exacerbated by Australia's increasing prevalence of IHD. Healthcare professionals must work to ensure that recommended therapies are prescribed and adhered to long-term, especially in the elderly and patients with asthma and mental health problems, to reduce IHD-related mortality and morbidity and the consequent healthcare and financial impact.

The impact of a patient's concordant and discordant chronic conditions on diabetes care quality measures

AIMS

Most patients with diabetes have comorbid chronic conditions that could support (concordant) or compete with (discordant) diabetes care. We sought to determine the impact of the number of concordant and discordant chronic conditions on diabetes care quality.

METHODS

Logistic regression analysis of electronic health record data from 7 health systems on 24,430 patients with diabetes aged 18-75 years. Diabetes testing and control quality care goals were the outcome variables. The number of diabetes-concordant and the number of diabetes-discordant conditions were the main explanatory variables. Analysis was adjusted for health care utilization, health system and patient demographics.

RESULTS

A higher number of concordant conditions were associated with higher odds of achieving testing and control goals for all outcomes except blood pressure control. There was no to minimal positive association between the number of discordant conditions and outcomes, except for cholesterol testing which was less likely with 4+ discordant conditions.

CONCLUSIONS

Having more concordant conditions makes diabetes care goal achievement more likely. The number of discordant conditions has a smaller, inconsistently significant impact on diabetes goal achievement. Interventions to improve diabetes care need to align with a patient's comorbidities, including the absence of comorbidities, especially concordant comorbidities.

Multi-drug therapy in chronic condition multimorbidity: a systematic review

BACKGROUND

Older populations often suffer from multimorbidity and guidelines for each condition are often associated with recommended drug therapy management. Yet, how different and specific multimorbidity is associated with number and type of multi-drug therapies in general populations is unknown.

AIM

The aim of this systematic review was to synthesize the current evidence on patterns of multi-drug prescribing in family practice.

METHODS

A systematic review on six common chronic conditions: diabetes mellitus, cardiovascular disease, cerebrovascular disease, chronic obstructive pulmonary disease (COPD), osteoarthritis and depression was conducted, with a focus on studies which looked at any potential combination of two or more multimorbidity. Studies were identified from searches of MEDLINE, EMBASE, PsychINFO, the Allied and Complementary Medicine Database (AMED) and the Health Management Information Consortium (HMIC) databases from 1960 to 2013.

RESULTS

A total of eleven articles were selected based on study criteria. Our review identified very few specific studies which had explicitly investigated the association between multimorbidity and multi-drug therapy. Relevant chronic conditions literature showed nine observational studies and two reviews of comorbid depression drug treatment. Most (seven) of the articles had focused on the chronic condition and comorbid depression and whether antidepressant management had been optimal or not, while four studies focused on other multimorbidities mainly heart failure, COPD and diabetes.

CONCLUSIONS

Very few studies have investigated associations between specific multimorbidity and multi-drug therapy, and most currently focus on chronic disease comorbid depression outcomes. Further research needs to identify this area as key priority for older populations who are prescribed high levels of multiple drug therapy.

Negative affect differentiation and adherence during treatment for thalassemia

BACKGROUND

Although research has demonstrated the detrimental effects of excessive negative affect on treatment adherence and morbidity in chronic illness, rarely have researchers investigated the benefits of awareness of negative emotional experiences during treatment.

PURPOSE

In this investigation, we examined the association of negative affect differentiation (the ability to report negative emotional experiences as separate and distinct from each other,) to treatment adherence in adult patients with the congenital blood disorder thalassemia.

METHOD

Negative affect differentiation was assessed during a 12-16-week treatment-based diary and adherence was operationalized as attendance at routine screenings over 12 months. Participants were adult patients (n = 32; age M = 31.63, SD = 7.72; 72 % female) with transfusion-dependent thalassemia in treatment in a large metropolitan hospital in the Northeastern USA.

RESULTS

The results indicate that negative affect differentiation is significantly associated with greater adherence to treatment, even when controlling for disease burden and level of psychological distress.

CONCLUSION

Although preliminary, this investigation suggests that differentiated processing of negative emotional experiences during illness can lead to adaptive treatment-related behavior. As such, it may present a new avenue for research and intervention targeting the improvement of adherence during treatment for chronic illness.

Contextually appropriate emotional word use predicts adaptive health behavior: Emotion context sensitivity and treatment adherence

Emotion context sensitivity is the ability to respond emotionally in a manner that is functionally appropriate for the context in which the emotion arises. This study examined the relationship between emotion context sensitivity and treatment adherence in adults with the chronic illness Thalassemia. Emotional responses were measured by examining the frequency of positive and negative emotional words used to answer two interview questions that created two different emotional contexts. Consistent with previous research on adaptive and contextually appropriate emotions, negative emotion words were related to adherence in the context of the disease itself, while positive emotion words were related to adherence in the context of coping.

Effectiveness and efficiency of a practice accreditation program on cardiovascular risk management in primary care: study protocol of a clustered randomized trial

BACKGROUND

Cardiovascular risk management is largely provided in primary healthcare, but not all patients with established cardiovascular diseases receive preventive treatment as recommended. Accreditation of healthcare organizations has been introduced across the world with a range of aims, including the improvement of clinical processes and outcomes. The Dutch College of General Practitioners has launched a program for accreditation of primary care practices, which focuses on chronic illness care. This study aims to determine the effectiveness and efficiency of a practice accreditation program, focusing on patients with established cardiovascular diseases.

METHODS/DESIGN

We have planned a two-arm cluster randomized trial with a block design. Seventy primary care practices will be recruited from those who volunteer to participate in the practice accreditation program. Primary care practices will be the unit of randomization. A computer list of random numbers will be generated by an independent statistician. The intervention group (n = 35 practices) will be instructed to focus improvement on cardiovascular risk management. The control group will be instructed to focus improvement on other domains in the first year of the program. Baseline and follow-up measurements at 12 months after receiving the accreditation certificate are based on a standardized version of the audit in the practice accreditation program. Primary outcomes include controlled blood pressure, serum cholesterol, and prescription of recommended preventive medication. Secondary outcomes are 15 process indicators and two outcome indicators of cardiovascular risk management, self-reported achievement of improvement goals and perceived unintended consequences. The intention to treat analysis is statistically powered to detect a difference of 10% on primary outcomes. The economic evaluation aims to determine the efficiency of the program and investigates the relationship between costs, performance indicators, and accreditation.

DISCUSSION

It is important to gain more information about the effectiveness and efficiency of the practice accreditation program to assess if participation is worthwhile regarding the quality of cardiovascular risk management. The results of this study will help to develop the practice accreditation program for primary care practices.

Does diabetes care differ by type of chronic comorbidity?: An evaluation of the Piette and Kerr framework

OBJECTIVE

To evaluate the relationship between diabetes care and types of comorbidity, classified by the degree to which their treatment is concordant with that for diabetes.

RESEARCH DESIGN AND METHODS

Retrospective cohort study (fiscal year [FY] 2001 to FY 2004) of 42,826 veterans with new-onset diabetes in FY 2003. Veterans were classified into five chronic comorbid illness groups (CCIGs): none, concordant only, discordant only, both concordant and discordant, and dominant. Five diabetes-related care measures were assessed in FY 2004 (guideline-consistent testing and treatment goals for HbA(1c) and LDL cholesterol and diabetes-related outpatient visits). Analyses included logistic regressions adjusting for age, race, sex, marital status, priority code, and interaction between CCIGs and visit frequency.

RESULTS

Only 20% of patients had no comorbidities. Mean number of visits per year ranged from 7.8 (no CCIG) to 17.5 (dominant CCIG). In unadjusted analyses, presence of any illness was associated with equivalent or better care. In the fully adjusted model, we found interaction between CCIG and visit frequency. When visits were <7 per year, the odds of meeting the goal of HbA(1c) <8% were similar in the concordant (odds ratio 0.96 [95% CI 0.83-1.11]) and lower in the discordant (0.90 [0.81-0.99]) groups compared with the no comorbidity group. Among patients with >24 visits per year, these odds were insignificant. Dominant CCIG was associated with substantially reduced care for glycemic control for all visit categories and for lipid management at all but the highest visit category.

CONCLUSIONS

Our study indicates that diabetes care varies by types of comorbidity. Concordant illnesses result in similar or better care, regardless of visit frequency. Discordant illnesses are associated with diminished care: an effect that decreases as visit frequency increases.

Receipt of monitoring of diabetes mellitus in older adults with comorbid dementia

OBJECTIVES

To examine the extent to which receipt of recommended monitoring of diabetes mellitus (DM) differed for participants with and without comorbid dementia, as well as the effect of other comorbidities on monitoring of DM in individuals with comorbid dementia.

DESIGN

Retrospective cohort study.

SETTING

Secondary analysis of 2005/2006 claims and enrollment data for a 5% national random sample of Medicare beneficiaries.

PARTICIPANTS

Two hundred eighty-eight thousand eight hundred five Medicare fee-for-service beneficiaries with a diagnosis of DM before 2006, 44,717 (16%) of whom had evidence of comorbid dementia in claims.

MEASUREMENTS

Established algorithms were used to determine whether patients received at least one glycosylated hemoglobin (HbA1c) test, one low-density lipoprotein cholesterol (LDL-C) test, and one annual eye examination in 2006 and to construct variables representing comorbidities common in DM, sociodemographic characteristics, and patterns of healthcare utilization.

RESULTS

In unadjusted and fully adjusted models, the presence of dementia reduced the likelihood of receiving HbA1c tests, LDL-C tests, and eye examinations, with effects being smallest for HbA1c tests. The effects of other comorbidities on DM monitoring in participants with dementia varied according to the nature of the comorbidity and the specific test.

CONCLUSION

Dementia reduces the likelihood that individuals with DM will receive recommended annual monitoring for DM. More research is needed to understand reasons for lower monitoring in this subgroup and how this affects functioning, adverse events, and quality of life.

Improving care after myocardial infarction using a 2-year internet-delivered intervention: the Department of Veterans Affairs myocardial infarction-plus cluster-randomized trial

BACKGROUND

Cardiovascular risk reduction in ambulatory patients who survive myocardial infarction (MI) is effective but underused. We sought to evaluate a provider-directed, Internet-delivered intervention to improve cardiovascular management for post-MI outpatients.

METHODS

The Department of Veterans Affairs (VA) MI-Plus study was a cluster-randomized trial involving 168 community-based primary care clinics and 847 providers in 26 states, the Virgin Islands, and Puerto Rico, from January 1, 2002, through December 31, 2008, with the clinic as the randomization unit. We collected administrative data for 15,847 post-MI patients and medical record data for 10,452 of these. A multicomponent, Internet-delivered intervention included quarterly educational modules, practice guidelines, monthly literature summaries, and automated e-mail reminders delivered to providers for 27 months. Main outcome measures included percentage of patients who achieved each of 7 clinical indicators, a composite score of the 7 clinical indicators, and mean low-density lipoprotein cholesterol and hemoglobin A(1c) levels.

RESULTS

Clinics had a median of 3 providers (interquartile range, 2-6), with a median of 50.0% of providers (33.3%-66.7%) participating in the study. Patients in intervention clinics had greater improvements (from 70.0% to 85.5%) in the percentages prescribed β-blockers than patients in control clinics (71.9% to 84.0%; adjusted improvement gain for intervention vs control, 2.6%; 95% CI, 0.1%-4.1%). We found nonsignificant differences in improvements favoring patients in intervention clinics for 5 of 6 remaining clinical indicators and levels of low-density lipoprotein cholesterol and hemoglobin A(1c).

CONCLUSION

A longitudinal, Internet-delivered intervention improved only 1 of 7 clinical indicators of cardiovascular management in ambulatory post-MI patients.

Change in comorbidity prevalence with advancing age among persons with heart failure

BACKGROUND

Comorbidity-a condition that co-exists with a primary illness-is common among older persons with heart failure and can complicate the overall management of this population.

OBJECTIVES

To determine the relationship between advancing age and the prevalence and patterns of comorbidity among older persons with heart failure.

DESIGN

Retrospective longitudinal cohort study

PARTICIPANTS

A total of 201,130 Medicare beneficiaries with heart failure stratified into three age strata in 2001: 66-75, 76-85, and 86+ years, and followed over 5 years.

MEASUREMENTS

(1) Prevalence of 19 conditions as identified by the Chronic Conditions Warehouse from Medicare claims data, characterized as concordant (related to heart failure) or discordant (unrelated to heart failure), and (2) overall comorbidity burden, defined as count of conditions.

RESULTS

The median number of comorbidities rose from four (IQR: 2-5) to five (IQR: 4-7) among the young-old, and from 4 (IQR: 3-6) to 6 (IQR: 5-8) among the middle-old and oldest-old between 2001 and 2006. In 2001, the majority of concordant conditions were more prevalent among the youngest than oldest beneficiaries (e.g., diabetes 46.2% vs 26.9%; kidney disease 21.8% vs 18.4%), while the majority of discordant conditions were more prevalent among the oldest-old than youngest-old beneficiaries (e.g., dementia 39.6% vs 9.9%; hip fracture 9.5% vs 1.9%). Discordant conditions increased in prevalence faster among the oldest than youngest beneficiaries (e.g., dementia 13% points versus 9% points).

CONCLUSION

Among older Medicare beneficiaries with heart failure, there is a higher overall burden of comorbidity and greater prevalence of discordant comorbidity among the oldest old. Comorbidity prevalence increases over time, with discordant comorbidity increasing at the fastest rate among the oldest old. This comorbidity burden highlights the challenge of effectively treating heart failure while simultaneously managing co-existing and unrelated conditions.

Recruitment activities for a nationwide, population-based, group-randomized trial: the VA MI-Plus study

BACKGROUND

The Veterans Health Administration (VHA) oversees the largest integrated healthcare system in the United States. The feasibility of a large-scale, nationwide, group-randomized implementation trial of VHA outpatient practices has not been reported. We describe the recruitment and enrollment of such a trial testing a clinician-directed, Internet-delivered intervention for improving the care of postmyocardial infarction patients with multiple comorbidities.

METHODS

With a recruitment goal of 200 eligible community-based outpatient clinics, parent VHA facilities (medical centers) were recruited because they oversee their affiliated clinics and the research conducted there. Eligible facilities had at least four VHA-owned and -operated primary care clinics, an affiliated Institutional Review Board (IRB), and no ongoing, potentially overlapping, quality-improvement study. Between December 2003 and December 2005, in two consecutive phases, we used initial and then intensified recruitment strategies.

RESULTS

Overall, 48 of 66 (73%) eligible facilities were recruited. Of the 219 clinics and 957 clinicians associated with the 48 facilities, 168 (78%) clinics and 401 (42%) clinicians participated. The median time from initial facility contact to clinic enrollment was 222 days, which decreased by over one-third from the first to the second recruitment phase (medians: 323 and 195 days, respectively; p < .001), when more structured recruitment with physician recruiters was implemented and a dedicated IRB manager was added to the coordinating center staff.

CONCLUSIONS

Large group-randomized trials benefit from having dedicated physician investigators and IRB personnel involved in recruitment. A large-scale, nationally representative, group-randomized trial of community-based clinics is feasible within the VHA or a similar national healthcare system.

Informing clinical practice guideline development and implementation: prevalence of coexisting conditions among adults with coronary heart disease

OBJECTIVES

To describe the prevalence of coexisting conditions that affect clinical decision-making in adults with coronary heart disease (CHD).

DESIGN

Cross-sectional.

SETTING

National Health and Nutrition Examination Survey, 1999 to 2004.

PARTICIPANTS

Eight thousand six hundred fifty-four people aged 45 and older; 1,259 with CHD.

MEASUREMENTS

Coexisting conditions relevant to clinical decision-making and implementing therapy for CHD across three domains: chronic diseases, self-reported and laboratory-based clinical measures, and health status factors of self-reported and observed function. Prevalence was estimated according to sex and age, mutually exclusive patterns were examined, and the odds ratios (OR) of having incurred repeated hospitalization in the last year of participants with CHD and each complexity pattern versus CHD alone were modeled.

RESULTS

The prevalence of comorbid chronic diseases in subjects with CHD was 56.7% for arthritis, 29.0% for congestive heart failure, 25.5% for chronic lower respiratory tract disease, 24.8% for diabetes mellitus, and 13.8% for stroke. Clinical factors adding to complexity of clinical decision-making for CHD were use of more than four medications (54.5%), urinary incontinence (48.6%), dizziness or falls (34.8%), low glomerular filtration rate (24.4%), anemia (10.1%), high alanine aminotransferase (5.9%), use of warfarin (10.2%), and health status factors were cognitive impairment (29.9%), mobility difficulty (40.4%), frequent mental distress (14.3%), visual impairment (16.7%), and hearing impairment (17.9%). Several comorbidity patterns were associated with high odds of hospitalization.

CONCLUSION

Coexisting conditions that may modify the effectiveness of or interact with CHD therapies, influence the feasibility of CHD therapies, or alter patients' priorities concerning their health care should be considered in the development of trials and guidelines to better inform real-world clinical decision-making.

Physician and patient influences on provider performance: β-blockers in postmyocardial infarction management in the MI-Plus study

BACKGROUND

Efforts to improve the quality of care for patients with cardiovascular disease frequently target the decrease of physician-level performance variability. We assessed how variability in providing β-blockers to ambulatory postmyocardial infarction (MI) patients was influenced by physician and patient level characteristics.

METHODS AND RESULTS

β-Blocker prescription and patient characteristics were abstracted from charts of post-MI patients treated by 133 primary care physicians between 2003 and 2007 and linked to physician and practice characteristics. Associations of β-blocker prescription with physician- and patient-level characteristics were examined using mixed-effects models, with physician-level effects as random. Mean physician-specific predicted probabilities and the intraclass correlations, which assessed the proportion of variance explainable at the physician level, were estimated. Of 1901 patients without major contraindication, 69.1% (range across physicians, 20% to 100%) were prescribed β-blockers. Prescription varied with comorbidity from 78.3% in patients with chronic kidney disease to 54.7% for patients with stroke. Although physician characteristics such as older physician age, group practice, and rural location were each positively associated with β-blocker prescription, physician factors accounted for only 5% to 8% of the variance in β-blocker prescription; the preponderance of the variance, 92% to 95%, was at the patient level. The mean physician-specific probability of β-blocker prescription (95% confidence interval) in the fully adjusted model was 63% (61% to 65%).

CONCLUSIONS

β-Blocker prescription rates were surprisingly low. The contribution of physician factors to overall variability in β-blocker prescription, however, was limited. Increasing evidence-based use of β-blockers may not be accomplished by focusing mostly on differential performance across physicians.

Influence of comorbidities on therapeutic progression of diabetes treatment in Australian veterans: a cohort study

Background

This study assessed whether the number of comorbid conditions unrelated to diabetes was associated with a delay in therapeutic progression of diabetes treatment in Australian veterans.

Methodology/Principal Findings

A retrospective cohort study was undertaken using data from the Australian Department of Veterans' Affairs (DVA) claims database between July 2000 and June 2008. The study included new users of metformin or sulfonylurea medicines. The outcome was the time to addition or switch to another antidiabetic treatment. The total number of comorbid conditions unrelated to diabetes was identified using the pharmaceutical-based comorbidity index, Rx-Risk-V. Competing risk regression analyses were conducted, with adjustments for a number of covariates that included age, gender, residential status, use of endocrinology service, number of hospitalisation episodes and adherence to diabetes medicines. Overall, 20134 veterans were included in the study. At one year, 23.5% of patients with diabetes had a second medicine added or had switched to another medicine, with 41.4% progressing by 4 years. The number of unrelated comorbidities was significantly associated with the time to addition of an antidiabetic medicine or switch to insulin (subhazard ratio [SHR] 0.87 [95% CI 0.84–0.91], P<0.001). Depression, cancer, chronic obstructive pulmonary disease, dementia, and Parkinson's disease were individually associated with a decreased likelihood of therapeutic progression. Age, residential status, number of hospitalisations and adherence to anti-diabetic medicines delayed therapeutic progression.

Conclusions/Significance

Increasing numbers of unrelated conditions decreased the likelihood of therapeutic progression in veterans with diabetes. These results have implications for the development of quality measures, clinical guidelines and the construction of models of care for management of diabetes in elderly people with comorbidities.

Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions

BACKGROUND

Clinicians are caring for an increasing number of older patients with multiple diseases in the face of uncertainty concerning the benefits and harms associated with guideline-directed interventions. Understanding how primary care clinicians approach treatment decision making for these patients is critical to the design of interventions to improve the decision-making process.

METHODS

Focus groups were conducted with 40 primary care clinicians (physicians, nurse practitioners, and physician assistants) in academic, community, and Veterans Affairs-affiliated primary care practices. Participants were given open-ended questions about their approach to treatment decision making for older persons with multiple medical conditions. Responses were organized into themes using qualitative content analysis.

RESULTS

The participants were concerned about their patients' ability to adhere to complex regimens derived from guideline-directed care. There was variability in beliefs regarding, and approaches to balancing, the benefits and harms of guideline-directed care. There was also variability regarding how the participants involved patients in the process of decision making, with clinicians describing conflicts between their own and their patients' goals. The participants listed a number of barriers to making good treatment decisions, including the lack of outcome data, the role of specialists, patient and family expectations, and insufficient time and reimbursement.

CONCLUSIONS

The experiences of practicing clinicians suggest that they struggle with the uncertainties of applying disease-specific guidelines to their older patients with multiple conditions. To improve decision making, they need more data, alternative guidelines, approaches to reconciling their own and their patients' priorities, the support of their subspecialist colleagues, and an altered reimbursement system.

Multiple uncontrolled conditions and blood pressure medication intensification: an observational study

BACKGROUND

Multiple uncontrolled medical conditions may act as competing demands for clinical decision making. We hypothesized that multiple uncontrolled cardiovascular risk factors would decrease blood pressure (BP) medication intensification among uncontrolled hypertensive patients.

METHODS

We observed 946 encounters at two VA primary care clinics from May through August 2006. After each encounter, clinicians recorded BP medication intensification (BP medication was added or titrated). Demographic, clinical, and laboratory information were collected from the medical record. We examined BP medication intensification by presence and control of diabetes and/or hyperlipidemia. 'Uncontrolled' was defined as hemoglobin A1c >/= for diabetes, BP >/= 140/90 mmHg (>/= 130/80 mmHg if diabetes present) for hypertension, and low density lipoprotein cholesterol (LDL-c) >/= 130 mg/dl (>/= 100 mg/dl if diabetes present) for hyperlipidemia. Hierarchical regression models accounted for patient clustering and adjusted medication intensification for age, systolic BP, and number of medications.

RESULTS

Among 387 patients with uncontrolled hypertension, 51.4% had diabetes (25.3% were uncontrolled) and 73.4% had hyperlipidemia (22.7% were uncontrolled). The BP medication intensification rate was 34.9% overall, but higher in individuals with uncontrolled diabetes and uncontrolled hyperlipidemia: 52.8% overall and 70.6% if systolic BP >/= 10 mmHg above goal. Intensification rates were lowest if diabetes or hyperlipidemia were controlled, lower than if diabetes or hyperlipidemia were not present. Multivariable adjustment yielded similar results.

CONCLUSIONS

The presence of uncontrolled diabetes and hyperlipidemia was associated with more guideline-concordant hypertension care, particularly if BP was far from goal. Efforts to understand and improve BP medication intensification in patients with controlled diabetes and/or hyperlipidemia are warranted.