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

Patterns of Telemedicine Use and Glycemic Outcomes of Endocrinology Care for Patients With Type 2 Diabetes

Importance

Telemedicine can increase access to endocrinology care for people with type 2 diabetes (T2D), but patterns of use and outcomes of telemedicine specialty care for adults with T2D beyond initial uptake in 2020 are not known.

Objective

To evaluate patterns of telemedicine use and their association with glycemic control among adults with varying clinical complexity receiving endocrinology care for T2D.

Design, Setting, and Participants

Retrospective cohort study in a single large integrated US health system. Participants were adults who had a telemedicine endocrinology visit for T2D from May to October 2020. Data were analyzed from June 2022 to October 2023.

Exposure

Patients were followed up through May 2022 and assigned to telemedicine-only, in-person, or mixed care (both telemedicine and in-person) cohorts according to visit modality.

Main Outcomes and Measures

Multivariable regression models were used to estimate hemoglobin A1c (HbA1c) change at 12 months within each cohort and the association of factors indicating clinical complexity (insulin regimen and cardiovascular and psychological comorbidities) with HbA1c change across cohorts. Subgroup analysis was performed for patients with baseline HbA1c of 8% or higher.

Results

Of 11 498 potentially eligible patients, 3778 were included in the final cohort (81 Asian participants [2%], 300 Black participants [8%], and 3332 White participants [88%]); 1182 used telemedicine only (mean [SD] age 57.4 [12.9] years; 743 female participants [63%]), 1049 used in-person care (mean [SD] age 63.0 [12.2] years; 577 female participants [55%]), and 1547 used mixed care (mean [SD] age 60.7 [12.5] years; 881 female participants [57%]). Among telemedicine-only patients, there was no significant change in adjusted HbA1c at 12 months (-0.06%; 95% CI, -0.26% to 0.14%; P = .55) while in-person and mixed cohorts had improvements of 0.37% (95% CI, 0.15% to 0.59%; P < .001) and 0.22% (95% CI, 0.07% to 0.38%; P = .004), respectively. Patients with a baseline HbA1c of 8% or higher had a similar pattern of glycemic outcomes. For patients prescribed multiple daily injections vs no insulin, the 12-month estimated change in HbA1c was 0.25% higher (95% CI, 0.02% to 0.47%; P = .03) for telemedicine vs in-person care. Comorbidities were not associated with HbA1c change in any cohort.

Conclusions and Relevance

In this cohort study of adults with T2D receiving endocrinology care, patients using telemedicine alone had inferior glycemic outcomes compared with patients who used in-person or mixed care. Additional strategies may be needed to support adults with T2D who rely on telemedicine alone to access endocrinology care, especially for those with complex treatment or elevated HbA1c.

Socioeconomic disparities in diabetes-concordant comorbidity: national health interview survey, 1997-2018

OBJECTIVE

Although social disparities in morbidity and mortality are well-documented, little is known how socioeconomic status (SES) shapes diabetes-concordant comorbidity (DCC). This study examines socioeconomic inequalities in DCC among adults with diabetes in the United States.

STUDY DESIGN

The study incorporated a cross-sectional nationally representative household health survey.

METHODS

This study used data from the National Health Interview Survey, 1997-2018. The analysis included 56,192 adults aged 30 or above with diabetes. Multinomial logistic regression was used to obtain relative risk ratios in gender-stratified models after adjusting for sociodemographic covariates.

RESULTS

The multivariable-adjusted analyses suggest that across all SES indicators and in both men and women, individuals with lower SES had greater odds of DCC than individuals with higher SES. The associations of SES indicators with DCC were larger in magnitude among women than in men. For example, compared to individuals with a college or higher degree, men with less than a high school degree were 2.06 times (95% confidence interval = 1.76-2.41) and women with less than a high school degree were 3.19 times (95% confidence interval = 2.67-3.82) more likely to have 3 or more DCCs. Similar associations were observed for other indicators of SES.

CONCLUSION

Study findings suggest strong social status and gender-based patterns in DCC. Identifying population groups with poor social status may be useful for informing interventions aiming to improve healthcare services of diabetes-related complications.

Differences in receipt of recommended eye examinations by comorbidity status and healthcare utilization among nonelderly adults with diabetes

BACKGROUND

To evaluate the effect of diabetes comorbidities by baseline healthcare utilization on receipt of recommended eye examinations.

METHODS

Retrospective analysis of 310 691 nonelderly adults with type 2 diabetes in the IBM MarketScan Commercial Database from 2016 to 2019. Patients were grouped based on diabetes-concordant (related) or -discordant (unrelated) comorbidities. Logistic regression was used to estimate the prevalence ratio (PR) for eye examinations by comorbidity status, healthcare utilization, and an interaction between comorbidities and utilization, controlling for age, sex, region, and major eye disease.

RESULTS

Prevalence of biennial eye examinations varied by the four comorbidity groups: 43.5% (diabetes only), 52.7% (concordant + discordant comorbidities), 48.0% (concordant comorbidities only), and 45.3% (discordant comorbidities only). In the lowest healthcare utilization tertile, the concordant-only and concordant + discordant groups had lower prevalence of examinations compared to diabetes only (PR 0.95 [95% CI 0.92-0.98] and PR 0.91 [95% CI 0.88-0.95], respectively). In the medium utilization tertile, the discordant-only and concordant + discordant groups had lower prevalence of examinations (PR 0.89 [0.83-0.95] and PR 0.94 [0.90-0.98], respectively). In the highest utilization tertile, the concordant-only and concordant + discordant groups had higher prevalence of examinations.

CONCLUSIONS

Among patients with low healthcare utilization, having comorbid conditions is associated with lower prevalence of eye examinations. Among those with medium healthcare utilization, patients with diabetes-discordant comorbidities are particularly vulnerable. This study highlights populations of diabetes patients who would benefit from increased assistance in receiving vision-preserving eye examinations.

Hospital treatment costs associated with incident complications in patients with type 2 diabetes—real-world study based on electronic patient information systems

Background

Type 2 diabetes (T2D) and its complications cause a significant public health and economic challenge. To enable the optimal resource allocation across different prevention and treatment policies for the management of T2D-related complications, detailed cost estimates related to the complications of T2D are needed. Therefore, the objective of the study was to provide reliable and sufficiently detailed real-world estimates of costs associated with different T2D complications in a Finnish university hospital setting.

Methods

A cohort of T2D patients living in the catchment area of a university hospital during 2012 and 2016 was identified from the comprehensive national FinDM diabetes database for longitudinal assessment of T2D associated complication treatment costs. Data on patient-level events were extracted from the FinDM data and complemented with all accountable services and related detailed costing data gathered from the university hospital’s electronic patient information systems by using unique personal identity codes. Patients were screened for their first diagnoses of complications using the same national quality registry definitions as in the FinDM database. Multivariable gamma regression model with a log link function was applied to study the association between baseline factors and complication costs. In addition, an interactive online tool was developed to create predicted costs for complication costs with selected baseline factors.

Results

A total of 27 255 prevalent and incident patients with T2D were identified from the national FinDM register. Finally, a total of 16 148 complication episodes for 7 895 patients were included in the cost analyses. The mean estimated one-year hospital treatment costs of T2D-related complication varied from 6 184 to 24 507 euros per complication. Regression analyses showed that coexisting conditions are significantly associated with initial and recurrent complication costs.

Conclusions

The study shows updated Finnish cost estimates and their main cost drivers for T2D-related complications treated in the university hospital setting. The results of our study highlight the significance of guideline implementation, effective preventive treatments for T2D, as well as the importance of treatment adherence to avoid these costly complications.

Feasibility and Acceptability of Ecological Momentary Assessment of Psychosocial Factors and Self-Management Behaviors Among Veterans With Type 2 Diabetes

Comorbid symptoms such as post-traumatic stress and pain are common barriers to optimal self-management among veterans with type 2 diabetes. Additionally, self-management behaviors occur in the context of veterans' daily routines and social environments. This study evaluated the feasibility and acceptability of ecological momentary assessment (EMA) among veterans with type 2 diabetes. Ten veterans with type 2 diabetes were asked to respond to random EMA surveys during preprogrammed intervals five times per day for 14 days. EMA surveys were delivered via a mobile application and assessed momentary physical location, activities, social interactions, mood, stress, and pain. The last survey of each day included additional items about daily post-traumatic stress symptoms, diabetes distress, social support, physical activity, self-management behaviors, and functioning. Participants completed interviews assessing their experience in the study and barriers to responding and indicated their likelihood of participating in similar studies. The mean survey response rate was 96%, providing 675 observations. The majority of participants completed the five momentary surveys in <1 minute and the daily EMA surveys in <5 minutes. Results revealed substantial individual day-to-day variability across symptoms and self-management behaviors that is not captured by aggregated means across all participants. Participants generally reported enjoying responding to surveys and experiencing few barriers. Nine of 10 participants reported being "extremely likely" to participate in a similar study. These pilot data suggest that intensive EMA designs are feasible and acceptable for veterans with type 2 diabetes and can inform the design of future larger studies.

Emotional Distress is Associated with Lower Health-Related Quality of Life Among Patients with Diabetes Using Antihypertensive and/or Antihyperlipidemic Medications: A Multicenter Study in Indonesia

Objective

To evaluate the associations between different types of diabetes distress and health-related quality of life (HRQOL) among patients with type 2 diabetes (T2DM) using antihypertensive and/or antihyperlipidemic medications in Indonesia and to explore the differences between those using only antihypertensive, only antihyperlipidemic, or both medications.

Methods

A multicenter cross-sectional study was conducted in Community Health Centers in three cities in Indonesia among patients with T2DM aged at least 18 years who were using antihypertensive and/or antihyperlipidemic medications. Diabetes distress subscales (emotional, regimen-related, interpersonal, and physician-related distress) and HRQOL were assessed using a validated diabetes distress scale-17 and EQ-5D-5L scale, respectively. Multiple linear regression models were used to evaluate the associations between different types of diabetes distress and HRQOL adjusting for confounders.

Results

Most of the 503 participants were females (67.6%) and aged 60–69 years (40.8%). Emotional distress was negatively associated with HRQOL among the whole group of patients (β: −0.08; 95% confidence interval (CI): −0.10, −0.05; p < 0.001). This association was similar across all therapeutic subgroups. Regimen-related distress (β: −0.06; 95% CI: −0.09, −0.03; p < 0.001) and interpersonal distress (β: −0.02; 95% CI: −0.05, −0.01; p = 0.022) were negatively associated, whereas physician-related distress (β: 0.04; 95% CI: 0.01, 0.07; p = 0.037) was positively associated with HRQOL among the whole group. These associations were also observed among those using only antihypertensive medication.

Conclusion

Emotional distress affects HRQOL in T2DM patients treated for cardiovascular comorbidities, independent of antihypertensive and/or antihyperlipidemic medication use.

Primary care physician volume and quality of care for older adults with dementia: a retrospective cohort study

Background

Some jurisdictions restrict primary care physicians’ daily patient volume to safeguard quality of care for complex patients. Our objective was to determine whether people with dementia receive lower-quality care if their primary care physician sees many patients daily.

Methods

Population-based retrospective cohort study using health administrative data from 100,256 community-living adults with dementia aged 66 years or older, and the 8,368 primary care physicians who cared for them in Ontario, Canada. Multivariable Poisson GEE regression models tested whether physicians’ daily patient volume was associated with the adjusted likelihood of people with dementia receiving vaccinations, prescriptions for cholinesterase inhibitors, benzodiazepines, and antipsychotics from their primary care physician.

Results

People with dementia whose primary care physicians saw ≥ 30 patients daily were 32% (95% CI: 23% to 41%, p < 0.0001) and 25% (95% CI: 17% to 33%, p < 0.0001) more likely to be prescribed benzodiazepines and antipsychotic medications, respectively, than patients of primary care physicians who saw < 20 patients daily. Patients were 3% (95% CI: 0.4% to 6%, p = 0.02) less likely to receive influenza vaccination and 8% (95% CI: 4% to 13%, p = 0.0001) more likely to be prescribed cholinesterase inhibitors if their primary care physician saw ≥ 30 versus < 20 patients daily.

Conclusions

People with dementia were more likely to receive both potentially harmful and potentially beneficial medications, and slightly less likely to be vaccinated by high-volume primary care physicians.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01398-9.

Clustering 5-Year Multidimensional Health Care Trajectory Patterns in Alzheimer's Disease and Related Syndromes

OBJECTIVE

After diagnosis of Alzheimer's disease and related syndromes (ADRS), personalized care adapted to each patient's needs is recommended to provide a care plan and start symptomatic treatments according to guidelines. Over the past decade, dedicated structures and care have been implemented in various settings. Equal access to ADRS care, health care providers and services is crucial to ensure potential health benefits for everyone. However, the extent of use of recommended services and favorable health care utilization trajectories (HUT) may vary according to individual and contextual characteristics. The aim of this article was to (1) describe HUT patterns after multidimensional clustering of similar trajectories, (2) assess the proportion of individuals presenting favorable HUTs, and (3) identify factors associated with favorable HUTs.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

A cohort of 103,317 people newly diagnosed with ADRS identified in the French health reimbursement system (SNDS) was followed for 5 years with their monthly utilization on 11 health care dimensions.

METHODS

For 3 age groups (65-74, 75-84, ≥85 years), 15 clusters of patients were identified using partitioning around medoids applied to Levenshtein distances. They were qualitatively assessed by pluridisciplinary experts. Individual and contextual determinants of clusters denoting favorable trajectories were identified using mixed random effects multivariable logistic regression models.

RESULTS

Clusters with favorable HUTs denoting slow, progressive trajectories centered on at-home care, represented approximatively 25% of the patients. Determinants of favorable HUTs were mostly individual (age, female gender, absence of certain comorbidities, circumstances of ADRS identification, lower deprivation). Contextual determinants were also identified, in particular accessibility to nurses and nursing homes. Inter-territories variance was small but significant in all age groups (from 0.9% to 1.8%).

CONCLUSION AND IMPLICATIONS

Favorable HUTs remain the minority and many efforts can still be made to improve HUTs. Qualitative studies could help understanding underlying barriers to favorable HUTs.

Assessment of Physician Priorities in Delivery of Preventive Care

IMPORTANCE

Primary care physicians have limited time to discuss preventive care, but it is unknown how they prioritize recommended services.

OBJECTIVE

To understand primary care physicians' prioritization of preventive services.

DESIGN, SETTING, AND PARTICIPANTS

This online survey was administered to primary care physicians in a large health care system from March 17 to May 12, 2017. Physicians were asked whether they prioritize preventive services and which factors contribute to their choice (5-point Likert scale). Results were analyzed from July 8, 2017, to September 19, 2019.

EXPOSURES

A 2 × 2 factorial design of 2 hypothetical patients: (1) a 50-year-old white woman with hypertension, type 2 diabetes, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of breast cancer; and (2) a 45-year-old black man with hypertension, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of colorectal cancer. Two visit lengths (40 minutes vs 20 minutes) were given. Each patient was eligible for at least 11 preventive services.

MAIN OUTCOMES AND MEASURES

Physicians rated their likelihood of discussing each service during the visit and reported their top 3 priorities for patients 1 and 2. Physician choices were compared with the preventive services most likely to improve life expectancy, using a previously published mathematical model.

RESULTS

Of 241 physicians, 137 responded (57%), of whom 74 (54%) were female and 85 (62%) were younger than 50 years. Physicians agreed they prioritized preventive services (mean score, 4.27 [95% CI, 4.12-4.42] of 5.00), mostly by ability to improve quality (4.56 [95% CI, 4.44-4.68] of 5.00) or length (4.53 [95% CI, 4.40-4.66] of 5.00) of life. Physicians reported more prioritization in the 20- vs 40-minute visit, indicating that they were likely to discuss fewer services during the shorter visit (median, 5 [interquartile range {IQR}, 3-8] vs 11 [IQR, 9-13] preventive services for patient 1, and 4 [IQR, 3-6] vs 9 [IQR, 8-11] for patient 2). Physicians reported similar top 3 priorities for both patients: smoking cessation, hypertension control, and glycemic control for patient 1 and smoking cessation, hypertension control, and colorectal cancer screening for patient 2. Physicians' top 3 priorities did not usually include diet and exercise or weight loss (ranked in their top 3 recommendations for either patient by only 48 physicians [35%]), although these were among the 3 preventive services most likely to improve life expectancy based on the mathematical model.

CONCLUSIONS AND RELEVANCE

In this survey study, physicians prioritized preventive services under time constraints, but priorities did not vary across patients. Physicians did not prioritize lifestyle interventions despite large potential benefits. Future research should consider whether physicians and patients would benefit from guidance on preventive care priorities.

Health literacy, multimorbidity, and patient-perceived treatment burden in individuals with cardiovascular disease. A Danish population-based study

OBJECTIVE

The aim was to investigate the association between: 1) multimorbidity and high treatment burden 2) health literacy and high treatment burden, and 3) the interaction between multimorbidity and health literacy in relation to high treatment burden.

METHODS

We included respondents with cardiovascular disease who participated in a Danish population-based survey from 2017 (N = 2,111). Logistic regression analyses were used to study associations.

RESULTS

The study showed that multimorbid individuals with cardiovascular disease were more likely to experience a high treatment burden than individuals with cardiovascular disease only (2+ additional conditions OR 4.16 [2.80-6.18]). Also, individuals with difficulties in understanding health information were more likely to report a high treatment burden than individuals who found it easy to understand information about health (OR 9.97 [6.23-15.95]). Finally, individuals with multimorbidity and difficulties in understanding health information had markedly higher odds of experiencing a high treatment burden.

CONCLUSION

If individuals find it difficult to understand health information, there is a risk they might feel overwhelmed by the treatment.

PRACTICE IMPLICATIONS

Healthcare professionals should be aware of health literacy challenges in planning medical treatment particularly for patients with both low health literacy levels and multimorbidity.

A population-based study of the association between food insecurity and potentially avoidable hospitalization among persons with diabetes using linked survey and administrative data

Background

Studies have found food insecurity to be more prevalent among persons with diabetes mellitus. Other research using areal-based measures of socioeconomic status have pointed to a social gradient in diabetes hospitalizations, but without accounting for individuals’ health status. Linking person-level data from health surveys to population-based hospital records enables profiling of the role of food insecurity with hospital morbidity, focusing on the high-risk diabetic population.

Objective

This national study aims to assess the association between income-related household food insecurity and potentially avoidable hospital admissions among community-dwelling persons living with diagnosed diabetes.

Methods

We use three cycles of the Canadian Community Health Survey (2007, 2008, and 2011) linked to multiple years of hospital records from the Discharge Abstract Database (2005/06 to 2012/13), covering 12 of Canada’s 13 provinces and territories. We apply multiple logistic regression for testing the association of household food insecurity with the risk of hospitalization for diabetes and common comorbid ambulatory care sensitive conditions among persons aged 12 and over living with diabetes.

Analysis

Data linkage allowed us to analyze inpatient hospital records among 10,260 survey respondents with diabetes; 590 respondents had been hospitalized at least once for diabetes or a common comorbid chronic physical or mental illness. The regression results indicated that the odds of experiencing a preventable hospital admission were significantly higher among persons with diabetes who were food insecure compared to their counterparts who were food secure (OR=1.66 [95%CI=1.24-2.23]), after controlling for age, sex and other characteristics.

Conclusion

We found food insecurity to significantly increase the odds of hospital admission for ambulatory care sensitive conditions among Canadians living with diabetes. These results reinforce the need to consider food insecurity in public health and clinical strategies to reduce the hospital burden of diabetes and other nutrition-related chronic diseases, from primary prevention to post-discharge care.

Assessing Patient Interest in Individualized Preventive Care Recommendations

Background. Few Americans obtain all 41 guideline-recommended preventive services for nonpregnant adults. We assessed patient interest in prioritizing their preventive care needs. Methods. We conducted a mixed-methods study, with 4 focus groups (N = 28) at a single institution and a nationwide survey (N = 2,103). Participants were middle-aged and older adults with preventive care needs. We obtained reactions to written materials describing the magnitude of benefit from major preventive services, including both absolute and relative benefits. Recommendations were individualized for patient risk factors (“individualized preventive care recommendations”). Focus groups assessed patient interest, how patients would want to discuss individualized recommendations with their providers, and potential for individualized recommendations to influence patient decision making. Survey content was based on focus groups and analyzed with logistic regression. Results. Patients expressed strong interest in individualized recommendations. Among survey respondents, an adjusted 88.2% (95% confidence interval [CI] = 86.7% to 89.7%) found individualized recommendations very easy to understand, 77.2% (95% CI = 75.3% to 79.1%) considered them very useful, and 64.9% (95% CI = 62.8% to 67.0%) highly trustworthy (each ≥6/7 on Likert scale). Three quarters of participants wanted to receive their own individualized recommendations in upcoming primary care visits (adjusted proportion = 77.5%, 95% CI = 75.6% to 79.4%). Both focus group and survey participants supported shared decision making and reported that individualized recommendations would improve motivation to obtain preventive care. Half of survey respondents reported that they would be much more likely to visit their doctor if they knew individualized recommendations would be discussed, compared with 4.2% who would not be more likely to visit their doctor. Survey respondents already prioritized preventive services, stating they were most likely to choose quick/easy preventive services and least likely to choose expensive preventive services (adjusted proportions, 63.8% and 8.5%, respectively). Results were consistent in sensitivity analyses. Conclusions. Individualized preventive care recommendations are likely to be well received in primary care and might motivate patients to improve adherence to evidence-based care.

Meeting the needs of multimorbid patients with Type 2 diabetes mellitus - A randomized controlled trial to assess the impact of a care management intervention aiming to improve self-care

AIMS

This study explored the impact of a care management intervention aiming to improve self-care behavior in multimorbid individuals with Type 2 diabetes mellitus on health-related quality of life (HRQoL).

METHODS

A patient-level randomized parallel-group superiority trial with 32 primary care practice teams, 11 care managers and 495 patients was conducted. The intervention was delivered as add-on to an already implemented disease management program and embedded in a network of primary care practices. Hierarchical linear modeling was used to analyze impacts of the care management approach on HRQoL.

RESULTS

Small improvements of HRQoL in the intervention arm were found after nine months (r = 0.024; 95%CI = [0.000, 0.047]). However, compared to standard care no significant differences of HRQoL changes were observed (r = 0.022; 95%CI = [-0.011, 0.054]). Subgroup analyses showed effects for female participants favoring the intervention arm (r = 0.059; 95%CI = [0.010, 0.108]). No significant differences between intervention and control arm for several other subgroups were observed, including subgroups defined by comorbidities.

CONCLUSION

Additional care management did not influence HRQoL over and above standard disease management. Improving diabetes patients' self-care behavior in the context of structured disease management programs may be difficult to achieve. Women might benefit from additional care management, but this finding needs to be confirmed in future research.

Timings for HbA1c testing in people with diabetes are associated with incentive payments: an analysis of UK primary care data

AIMS

Guidelines recommend testing HbA1c every 3-6 months in people with diabetes. In the United Kingdom (UK), primary care clinics are financially incentivized to monitor HbA1c at least annually and report proportions of patients meeting targets on 31 March. We explored the hypothesis that this reporting deadline may be associated with over-frequent or delayed HbA1c testing.

METHODS

This analysis used HbA1c results from 100 000 people with diabetes during 2005-2014 in the Clinical Practice Research Datalink UK primary care database. Logistic regression was used to explore whether the four months prior to the deadline for quality reporting (December to March) or individual's previous HbA1c were aligned with retesting HbA1c within 60 days or > 1 year from the previous test, and identify other factors associated with the timing of HbA1c testing.

RESULTS

Retesting HbA1c within 60 days or > 1 year was more common in December to March compared with other months of the year (odds ratio 1.06, 95% confidence interval 1.04-1.08 for retesting within 60 days). Those with higher HbA1c were more likely to have a repeat test within 60 days and less likely to have a repeat test > 1 year from the previous test.

CONCLUSIONS

We have found that retesting HbA1c within 60 days and > 1 year from the previous test was more common in December to March compared with the other months of the year. This work suggests that both practice-centred administrative factors and patient-centred considerations may be influencing diabetes care in the UK.

Association between different types of comorbidity and disease burden in patients with diabetes

BACKGROUND

This study examined the association between different types of comorbidities and the quality of diabetes care, health-related quality of life (HRQoL), and total health care expenditure.

METHODS

Adult patients with diabetes were identified from the 2011 to 2013 Medical Expenditure Panel Survey, a nationally representative survey of the civilian non-institutionalized US population. Twenty different chronic conditions were captured and categorized as: (i) diabetes only; (ii) diabetes plus concordant (diabetes-related) comorbidity only; and (iii) diabetes plus one or more discordant (non-diabetes-related) comorbidities. Disease burden outcomes included the process of diabetes care (eye and foot examinations, HbA1c and cholesterol tests, influenza vaccination), HRQoL, and total health care expenditure. Multivariable models were used to examine associations between the type of comorbidity and outcomes.

RESULTS

A sample of 8292 patients with diabetes was identified, of which 11.4% had diabetes only, 40.5% had concordant comorbidity only, and 48.1% reported one or more discordant comorbidities. Patients with diabetes and either type of comorbidity received better quality of diabetes care than those without a comorbidity. However, patients with discordant comorbidity showed significantly lower HRQoL measures and higher health care expenditure than those with concordant comorbidity. Adjusted total mean annual expenditure was US$4891, $6326, and $9210 for those with diabetes only and those with diabetes with one concordant or one discordant comorbidity, respectively.

CONCLUSIONS

Higher disease burden in patients with diabetes was associated with discordant rather than concordant comorbidity. Future interventional studies evaluating patient-centered care models addressing different types of comorbidity are necessary to better manage these complex patients.

Multimorbidity and care for hypertension, diabetes and HIV among older adults in rural South Africa

Objective

To examine how multimorbidity might affect progression along the continuum of care among older adults with hypertension, diabetes and human immunodeficiency virus (HIV) infection in rural South Africa.

Methods

We analysed data from 4447 people aged 40 years or older who were enrolled in a longitudinal study in Agincourt sub-district. Household-based interviews were completed between November 2014 and November 2015. For hypertension and diabetes (2813 and 512 people, respectively), we defined concordant conditions as other cardiometabolic conditions, and discordant conditions as mental disorders or HIV infection. For HIV infection (1027 people) we defined any other conditions as discordant. Regression models were fitted to assess the relationship between the type of multimorbidity and progression along the care continuum and the likelihood of patients being in each stage of care for the index condition (four stages from testing to treatment).

Findings

People with hypertension or diabetes plus other cardiometabolic conditions were more like to progress through the care continuum for the index condition than those without cardiometabolic conditions (relative risk, RR: 1.14, 95% confidence interval, CI: 1.09-1.20, and RR: 2.18, 95% CI: 1.52-3.26, respectively). Having discordant comorbidity was associated with greater progression in care for those with hypertension but not diabetes. Those with HIV infection plus cardiometabolic conditions had less progress in the stages of care compared with those without such conditions (RR: 0.86, 95% CI: 0.80-0.92).

Conclusion

Patients with concordant conditions were more likely to progress further along the care continuum, while those with discordant multimorbidity tended not to progress beyond diagnosis.

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.

National Rates of Initiation and Intensification of Antidiabetic Therapy Among Patients With Commercial Insurance

OBJECTIVE

Prompt initiation and intensification of antidiabetic therapy can delay or prevent complications from diabetes. We sought to understand the rates of and factors associated with the initiation and intensification of antidiabetic therapy among commercially insured patients in the U.S.

RESEARCH DESIGN AND METHODS

Using 2008-2015 commercial claims linked with laboratory and pharmacy data, we created an initiation cohort with no prior antidiabetic drug use and an HbA_1c ≥8% (64 mmol/mol) and an intensification cohort of patients with an HbA_1c ≥8% (64 mmol/mol) who were on a stable dose of one noninsulin diabetes drug. Using multivariable logistic regression, we determined the rates of and factors associated with initiation and intensification. In addition, we determined the percent of variation in treatment patterns explained by measurable patient factors.

RESULTS

In the initiation cohort (n = 9,799), 63% of patients received an antidiabetic drug within 6 months of the elevated HbA_1c test. In the intensification cohort (n = 10,941), 82% had their existing antidiabetic therapy intensified within 6 months of the elevated HbA_1c test. Higher HbA_1c levels, lower generic drug copayments, and more frequent office visits were associated with higher rates of both initiation and intensification. Better patient adherence prior to the elevated HbA_1c level, existing therapy with a second-generation antidiabetic drug, and lower doses of existing therapy were also associated with intensification. Patient factors explained 7.96% of the variation in initiation and 7.35% of the variation in intensification.

CONCLUSIONS

Approximately two-thirds of patients were newly initiated on antidiabetic therapy, and four-fifths of those already receiving antidiabetic therapy had it intensified within 6 months of an elevated HbA_1c in a commercially insured population. Patient factors explain 7-8% of the variation in diabetes treatment patterns.

Association Between Number of Preventive Care Guidelines and Preventive Care Utilization by Patients

INTRODUCTION

The number of preventive care guidelines is rapidly increasing. It is unknown whether the number of guideline-recommended preventive services is associated with utilization.

METHODS

The authors used Poisson regression of 390,778 person-years of electronic medical records data from 2008 to 2015, in 80,773 individuals aged 50-75 years. Analyses considered eligibility for 11 preventive services most closely associated with guidelines: tobacco cessation; control of obesity, hypertension, lipids, or blood glucose; influenza vaccination; and screening for breast, cervical, or colorectal cancers, abdominal aortic aneurysm, or osteoporosis. The outcome was the rate of preventive care utilization over the following year. Results were adjusted for demographics and stratified by the number of disease risk factors (smoking, obesity, hypertension, hyperlipidemia, diabetes). Data were collected in 2016 and analyzed in 2017.

RESULTS

Preventive care utilization was lower when the number of guideline-recommended preventive services was higher. The adjusted rate of preventive care utilization decreased from 38.67 per 100 (95% CI=38.16, 39.18) in patients eligible for one guideline-recommended service to 31.59 per 100 (95% CI=31.29, 31.89) in patients eligible for two services and 25.43 per 100 (95% CI=24.68, 26.18) in patients eligible for six or more services (p-trend<0.001). Results were robust to disease risk factors and observed for all but two services (tobacco cessation, obesity reduction). However, for any given number of guideline-recommended services, patients with more disease risk factors had higher utilization rates.

CONCLUSIONS

The rate of preventive care utilization was lower when the number of guideline-recommended services was higher. Prioritizing recommendations might improve utilization of high-value services.

Health-Related Quality of Life in Primary Care: Which Aspects Matter in Multimorbid Patients with Type 2 Diabetes Mellitus in a Community Setting?

BACKGROUND AND OBJECTIVE

Knowledge about predictors of health-related quality of life for multimorbid patients with type 2 diabetes mellitus in primary care could help to improve quality and patient-centeredness of care in this specific group of patients. Thus, the aim of this study was to investigate the impact of several patient characteristics on health-related quality of life of multimorbid patients with type 2 diabetes mellitus in a community setting.

RESEARCH DESIGN AND METHODS

A cross-sectional study with 32 primary care practice teams in Mannheim, Germany, and randomly selected multimorbid patients with type 2 diabetes mellitus (N = 495) was conducted. In order to analyze associations of various patient characteristics with health-related quality of life (EQ-5D index) a multilevel analysis was applied.

RESULTS

After excluding patients with missing data, the cohort consisted of 404 eligible patients. The final multilevel model highlighted six out of 14 explanatory patient variables which were significantly associated with health-related quality of life: female gender (r = -0.0494; p = .0261), school education of nine years or less (r = -0.0609; p = .0006), (physical) mobility restrictions (r = -0.1074; p = .0003), presence of chronic pain (r = -0.0916; p = .0004), diabetes-related distress (r = -0.0133; p < .0001), and BMI (r = -0.0047; p = .0045).

CONCLUSION

The findings of this study suggest that increased diabetes-related distress, chronic pain, restrictions in (physical) mobility, female gender, as well as lower education and, increased BMI have a noteworthy impact on health-related quality of life in multimorbid patients with type 2 diabetes mellitus seen in primary care practices in a community setting. The highlighted aspects should gain much more attention when treating multimorbid patients with type 2 diabetes mellitus.

Association of Multimorbidity with Mortality and Healthcare Utilization in Chronic Kidney Disease

OBJECTIVES

Chronic kidney disease (CKD) almost universally occurs in individuals with other medical problems. However, few studies have described CKD-related multimorbidity using a framework that identifies chronic conditions as concordant (having overlap in treatment goals) versus discordant (having opposing treatment recommendations) and unrelated (having no overlap, but contributing to complexity via different resource requirements).

DESIGN

Retrospective cohort.

SETTING

Veterans Affairs (VA) Medical Centers.

PARTICIPANTS

VA patients (n = 821,334) ages 18-100 years with at least one outpatient visit and incident CKD defined as an estimated glomerular filtration rate <60 mL/min/1.73 m² for at least 3 months between January 1, 2005 and December 31, 2008 after excluding prevalent CKD.

MEASUREMENTS

We determined the associations of number of chronic conditions (1, 2, 3, 4, 5, 6 or more) stratified by the presence of one or more discordant/unrelated conditions with mortality, hospitalizations and emergency department (ED) visits.

RESULTS

There were 381,187 deaths over 6.8 median years of follow-up. Higher risks of death, hospitalization and ED visits were associated with higher number of chronic conditions, among those with and without discordant/unrelated conditions. However, the magnitudes of the associations were consistently larger when at least one discordant/unrelated condition was present. For example, compared to patients with one concordant condition, patients with six or more concordant conditions had an age-, race- and sex-adjusted hazard ratio (HR) for mortality of 1.72 (95% CI 1.64-1.80) whereas those with six or more conditions, at least one of which was discordant/unrelated, had a HR of 2.05 (2.01-2.09) (P-interaction <0.001).

CONCLUSIONS

The presence of one or more discordant/unrelated conditions was associated with increased risk for adverse health outcomes, beyond the effect of multimorbidity.

Role of Patient and Practice Characteristics in Variance of Treatment Quality in Type 2 Diabetes between General Practices

Background

Accounting for justifiable variance is important for fair comparisons of treatment quality. The variance between general practices in treatment quality of type 2 diabetes (T2DM) patients may be attributed to the underlying patient population and practice characteristics. The objective of this study is to describe the between practice differences in treatment, and identify patient and practice level characteristics that may explain these differences.

Methods

The data of 24,607 T2DM patients from 183 general practices in the Netherlands were used. Treatment variance was assessed in a cross-sectional manner for: glucose-lowering drugs/metformin, lipid-lowering drugs/statins, blood pressure-lowering drugs/ACE-inhibitor or ARB. Patient characteristics tested were age, gender, diabetes duration, comorbidity, comedication. Practice characteristics were number of T2DM patients, practice type, diabetes assistant available. Multilevel logistic regression was used to examine the between practice variance in treatment and the effect of characteristics on this variance.

Results

Treatment rates varied considerably between practices (IQR 9.5–13.9). The variance at practice level was 7.5% for glucose-lowering drugs, 3.6% for metformin, 3.1% for lipid-lowering drugs, 10.3% for statins, 8.6% for blood pressure-lowering drugs, and 3.9% for ACE-inhibitor/ARB. Patient and practice characteristics explained 19.0%, 7.5%, 20%, 6%, 9.9%, and 13.4% of the variance respectively. Age, multiple chronic drugs, and ≥3 glucose-lowering drugs were the most relevant patient characteristics. Number of T2DM patients per practice was the most relevant practice characteristic.

Discussion

Considerable differences exist between practices in treatment rates. Patients’ age was identified as characteristic that may account for justifiable differences in especially lipid-lowering treatment. Other patient or practice characteristics either do not explain or do not justify the differences.

The Relationship between Diabetes Care Quality and Diabetes-Related Hospitalizations and the Modifying Role of Comorbidity

OBJECTIVES

To evaluate the impact of comorbidity on diabetes care quality and diabetes-related hospitalizations and to examine whether associations between the likelihood of diabetes-related hospitalizations and compliance with diabetes testing are modified by type of comorbidity.

METHODS

A population-based cohort study of 861 354 adults with diabetes was conducted in Ontario, Canada. The diabetes cohort was categorized into 4 groups defined by their comorbidity statuses: no comorbidity, diabetes-concordant only, diabetes-discordant only, and both concordant and discordant. Outcome variables were defined as having had at least 1 hospitalization for diabetes-related short- or long-term complications between 2009 and 2011. Diabetes-care quality measures included testing for glycated hemoglobin (A1C) and low-density lipoprotein-cholesterol levels and eye examinations between 2007 and 2009. Multivariable logistic regression models were performed to examine the associations between diabetes testing and diabetes-related hospitalizations and the modifying role of comorbidity type.

RESULTS

Compliance with all 3 monitoring tests by patients with diabetes had a strong positive impact on reducing hospitalizations for diabetes-related long-term complications, especially in patients with diabetes-concordant conditions. The highest levels of adherence to all 3 diabetes monitoring tests were observed in patients with diabetes-concordant conditions only and in patients with diabetes-discordant conditions. The highest odds of hospitalizations for diabetes-related short-term complications were observed in patients having both discordant and concordant conditions.

CONCLUSIONS

Meeting diabetes testing goals has the potential to reduce hospitalizations for diabetes-related complications; however, this depends on types of coexisting chronic conditions and diabetes-related complications in patients with diabetes.

Prevalence and co-prevalence of comorbidities among patients with type 2 diabetes mellitus

OBJECTIVE

Patients with type 2 diabetes (T2DM) often have multiple comorbidities which may impact the selection of antihyperglycemic therapies. The purpose of this study was to quantify the prevalence and co-prevalence of common comorbidities.

RESEARCH DESIGN AND METHODS

A retrospective study was conducted using the Quintiles Electronic Medical Record database. Adult patients with T2DM who had ≥1 encounter from July 2014 to June 2015 (index period) with ≥1 year medical history available were included. The index date was defined as the most recent encounter date during the 1 year index period.

MAIN OUTCOME MEASURES

Comorbid conditions were assessed using all data available prior to and including the index date. Patient characteristics, laboratory measures, and comorbidities were summarized via descriptive analyses, overall and by subgroups of age (<65, 65-74, 75+ years) and gender.

RESULTS

Of the 1,389,016 eligible patients, 53% were female and the median age was 65 years. 97.5% of patients had at least one comorbid condition in addition to T2DM and 88.5% had at least two. The comorbidity burden tended to increase in older age groups and was higher in men than women. The most common conditions in patients with T2DM included hypertension (HTN) in 82.1%; overweight/obesity in 78.2%; hyperlipidemia in 77.2%; chronic kidney disease (CKD) in 24.1%; and cardiovascular disease (CVD) in 21.6%. The highest co-prevalence was demonstrated for the combination of HTN and hyperlipidemia (67.5%), followed by overweight/obesity and HTN (66.0%), overweight/obesity and hyperlipidemia (62.5%), HTN and CKD (22.4%), hyperlipidemia and CKD (21.1%), HTN and CVD (20.2%), hyperlipidemia and CVD (20.1%), overweight/obesity and CKD (19.1%) and overweight/obesity and CVD (17.0%).

LIMITATIONS

Limitations include the potential for misclassification/underreporting due to the use of diagnostic codes, drug codes, or laboratory measures for identification of medical conditions.

CONCLUSIONS

The vast majority of patients with T2DM have multiple comorbidities. To ensure a comprehensive approach to patient management, the presence of multimorbidity should be considered in the context of clinical decision making.

How are metabolic control targets of patients with Type 1 diabetes mellitus achieved in daily practice in the area with high diabetes prevalence?

AIMS

We assessed the prevalence of Type 1 diabetes mellitus and determined how the targets established in the guidelines for patients with Type 1 diabetes mellitus were achieved in clinical practice in North Karelia, Finland.

METHODS

All adult Type 1 diabetes mellitus patients (n=1075) were identified from the regional electronic patient database. The data for HbA1c and LDL cholesterol measurements during the years 2013 and 2014 were obtained from medical records.

RESULTS

The prevalence of Type 1 diabetes mellitus in the adult population in North Karelia was 0.8%, which is among the highest worldwide. HbA1c and LDL cholesterol were measured in 93% and 90% of participants, respectively. Nineteen percent of patients reached the HbA1c target of <7.0% (53mmol/mol) and 45% attained LDL cholesterol <2.5mmol/l. Overall, 26% of patients over 60 years old with diabetes achieved glycaemic control targets compared with 13-16% of younger patients with diabetes.

CONCLUSIONS

Glycaemic control was in line with the recommendations in only one-fifth of Type 1 diabetes mellitus patients and less than half of them had LDL cholesterol levels within the target range. Interestingly, older Type 1 diabetes mellitus patients met the glycaemic control target more often than younger patients with diabetes. The targets established for patients with Type 1 diabetes mellitus are not achieved satisfactorily in daily practice.

Health Impact Index. Development and Validation of a Method for Classifying Comorbid Disease Measured against Self-Reported Health

The objective of this study was to develop a method of classifying comorbid conditions that accounts for both the severity and joint effects of the diseases. The Tromsø Study is a cohort study with a longitudinal design utilizing a survey approach with physical examinations in the Tromsø municipality from 1974 to 2008, where in total 40051 subjects participated. We used Tromsø 4 as reference population and the Norwegian Institute of Public Health (FHI) panel as validation population. Ordinal regression was used to assess the effect of comorbid disease on Self-Reported Health (SRH). The model is controlled for interaction between diseases, mental health, age, and gender. The health impact index estimated levels of SRH. The comparison of predicted and observed SRH showed no significant differences. Spearman’s correlation showed that increasing levels of comorbidity were related to lower levels of SRH (R_S = -0.36, p <.001). The Charlson Comorbidity Index(CCI) was also associated with SRH (r = -.25, p <.001). When focusing on only individuals with a comorbid disease, the relation between SRH and the Health Impact Index (HII) was strengthened (r = -.42, p <.001), while the association between SRH and CCI was attenuated (r = -.14, p <.001). CCI was designed to control for comorbid conditions when survival/mortality is the outcome of interest but is inaccurate when the outcome is SRH. We conclude that HII should be used when SRH is not available, and well-being or quality of survival/life is the outcome of interest.

Prevalence of comorbidity in primary care patients with type 2 diabetes and its association with elevated HbA1c: A cross-sectional study in Croatia

OBJECTIVE

To the authors' knowledge, there are few valid data that describe the prevalence of comorbidity in type 2 diabetes mellitus (T2DM) patients seen in family practice. This study aimed to investigate the prevalence of comorbidities and their association with elevated (≥ 7.0%) haemoglobin A1c (HbA1c) using a large sample of T2DM patients from primary care practices.

DESIGN

A cross-sectional study in which multivariate logistic regression was applied to explore the association of comorbidities with elevated HbA1c.

SETTING

Primary care practices in Croatia.

SUBJECTS

Altogether, 10 264 patients with diabetes in 449 practices.

MAIN OUTCOME MEASURES

Comorbidities and elevated HbA1c.

RESULTS

In total 7979 (77.7%) participants had comorbidity. The mean number of comorbidities was 1.6 (SD 1.28). Diseases of the circulatory system were the most common (7157, 69.7%), followed by endocrine and metabolic diseases (3093, 30.1%), and diseases of the musculoskeletal system and connective tissue (1437, 14.0%). After adjustment for age and sex, the number of comorbidities was significantly associated with HbA1c. The higher the number of comorbidities, the lower the HbA1c. The prevalence of physicians' inertia was statistically significantly and negatively associated with the number of comorbidities (Mann-Whitney U test, Z = -12.34; p < 0.001; r = -0.12).

CONCLUSION

There is a high prevalence of comorbidity among T2DM patients in primary care. A negative association of number of comorbidities and HbA1c is probably moderated by physicians' inertia in treatment of T2DM strictly according to guidelines.

KEY POINTS

There is a high prevalence of comorbidity among T2DM patients in primary care. Patients with breast cancer, obese patients, and those with dyslipidaemia and ischaemic heart disease were more likely to have increased HbA1c. The higher the number of comorbidities, the lower the HbA1c.

Impact of the Prevalence of Concordant and Discordant Conditions on the Quality of Diabetes Care in Family Practices in England

PURPOSE

The purpose of this study was to examine the association between the prevalence of both diabetes-concordant and diabetes-discordant conditions and the quality of diabetes care at the family practice level in England. We hypothesized that the prevalence of concordant (or discordant) conditions would be associated with better (or worse) quality of diabetes care.

METHODS

We conducted a cross-sectional study using practice-level data (7,884 practices). We estimated the practice-level prevalence of diabetes and 15 other chronic conditions, which were classified as diabetes concordant (ie, with the same pathophysiologic risk profile and therefore more likely to be part of the same management plan) or diabetes discordant (ie, not directly related in either their pathogenesis or management). We measured quality of diabetes care with diabetes-specific indicators (8 processes and 3 intermediate outcomes of care). We used linear regression models to quantify the effect of the prevalence of the conditions on aggregate achievement rate for quality of diabetes care.

RESULTS

Consistent with the proposed model, the prevalence rates of 4 of 7 concordant conditions (obesity, chronic kidney disease, atrial fibrillation, heart failure) were positively associated with quality of diabetes care. Similarly, negative associations were observed as predicted for 2 of the 8 discordant conditions (epilepsy, mental health). Observations for other concordant and discordant conditions did not match predictions in the hypothesized model.

CONCLUSIONS

The quality of diabetes care provided in English family practices is associated with the prevalence of other major chronic conditions at the practice level. The nature and direction of the observed associations cannot be fully explained by the concordant-discordant model.

The impact of comorbid chronic conditions on quality of life in type 2 diabetes patients

Objective

To study the prevalence, impact and dose–response relationship of comorbid chronic conditions on quality of life of type 2 diabetes patients.

Research design and methods

Cross-sectional data of 1676 type 2 diabetes patients, aged 31–96 years, and treated in primary care, were analyzed. Quality of life (QoL) was measured using the mental component summary (MCS) and the physical component summary (PCS) scores of the Short Form-12. Diagnosis of type 2 diabetes was obtained from medical records and comorbidities from self-reports.

Results

Only 361 (21.5 %) of the patients reported no comorbidities. Diabetes patients with comorbidities showed significantly lower mean difference in PCS [−8.5; 95 % confidence interval (CI) −9.8 to −7.3] and MCS scores (−1.9; 95 % CI −3.0 to −0.9), compared to diabetes patients without. Additional adjustments did not substantially change these associations. Both MCS and PCS scores decrease significantly with the number of comorbid conditions, yet most pronounced regarding physical QoL. Comorbidities that reduced physical QoL most significantly were retinopathy, heart diseases, atherosclerosis in abdomen or legs, lung diseases, incontinence, back, neck and shoulder disorder, osteoarthritis and chronic rheumatoid arthritis, using the backwards stepwise regression procedure.

Conclusion

Comorbidities are highly prevalent among type 2 diabetes patients and have a negative impact on the patient’s QoL. A strong dose–response relationship between comorbidities and physical QoL was found. Reduced physical QoL is mainly determined by musculoskeletal and cardiovascular disorders.

Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review

The simultaneous presence of multiple conditions in one patient (multi-morbidity) is a key challenge facing healthcare systems globally. It potentially threatens the coordination, continuity and safety of care. In this paper, we report the results of a scoping review examining the impact of multi-morbidity on the quality of healthcare. We used its results as a basis for a discussion of the challenges that research in this area is currently facing. In addition, we discuss its implications for health policy and clinical practice. The review identified 37 studies focussing on multi-morbidity but using conceptually different approaches. Studies focusing on 'comorbidity' (i.e. the 'index disease' approach) suggested that quality may be enhanced in the presence of synergistic conditions, and impaired by antagonistic or neutral conditions. Studies on 'multi-morbidity' (i.e. multiplicity of problems) and 'morbidity burden' (i.e. the total severity of conditions) suggested that increasing number of conditions and severity may be associated with better quality of healthcare when measured by process or intermediate outcome indicators, but with worse quality when patient-centred measures are used. However, issues related to the conceptualization and measurement of multi-morbidity (inconsistent across studies) and of healthcare quality (restricted to evaluations for each separate condition without incorporating considerations about multi-morbidity itself and its implications for management) compromised the generalizability of these observations. Until these issues are addressed and robust evidence becomes available, clinicians should apply minimally invasive and patient-centred medicine when delivering care for clinically complex patients. Health systems should focus on enhancing primary care centred coordination and continuity of care.

Dosing of U-100 insulin and associated outcomes among Medicare enrollees with type 1 or type 2 diabetes

Objective

To examine costs, resource utilization, adherence, and hypoglycemic events among various doses of U-100 insulin regimens among elderly patients (age ≥65 years) diagnosed with diabetes.

Methods

Truven Health Analytics Medicare databases from January 1, 2008 through December 31, 2011 were utilized. General linear models with a gamma distribution and log link were used to examine costs, while logistic and negative binomial regressions were used to examine resource utilization and hypoglycemic events. Analyses controlled for patient characteristics, pre-period comorbidities, general health, and use of antidiabetic medications as well as index dose of insulin.

Results

All-cause inpatient, emergency room, and outpatients costs, as well as diabetes-related inpatient costs, were highest among individuals who were treated with an index dose of 10–100 units/day followed by >300 units/day, while drug costs and total costs generally increased as index dosage increased. Resource utilization generally followed the same pattern as costs, with number of office visits increasing as the dose increased and the highest hospital length of stay, number of hospitalizations, number of emergency room visits, and number of diabetes-related hospitalizations were generally highest among those in the lowest and highest index dose cohorts. Compared to patients who initiated with an index dose of 10–100 units/day, all other patients were significantly less likely to achieve an adherence threshold of 80% based upon index dose range, and while those with an index dose of >100–150 units/day were significantly more likely to experience a hypoglycemic event.

Conclusion

These results suggest that, for elderly individuals with diabetes, there is a higher patient burden among those who receive the lowest and highest insulin doses.

Diagnosis and treatment of incident hypertension among patients with diabetes: a U.S. multi-disciplinary group practice observational study

BACKGROUND

Early hypertension control reduces the risk of cardiovascular complications among patients with diabetes mellitus. There is a need to improve hypertension management among patients with diabetes mellitus.

OBJECTIVE

We aimed to evaluate rates and associations of hypertension diagnosis and treatment among patients with diabetes mellitus and incident hypertension.

DESIGN

This was a 4-year retrospective analysis of electronic health records.

PARTICIPANTS

Adults ≥ 18 years old (n = 771) with diabetes mellitus, who met criteria for incident hypertension and received primary care at a large, Midwestern academic group practice from 2008 to 2011 were included

MAIN MEASURES

Cut-points of 130/80 and 140/90 mmHg were used to identify incident cases of hypertension. Kaplan-Meier analysis estimated the probability of receiving: 1) an initial hypertension diagnosis and 2) antihypertensive medication at specific time points. Cox proportional-hazard frailty models (HR; 95 % CI) were fit to identify associations of time to hypertension diagnosis and treatment.

KEY RESULTS

Among patients with diabetes mellitus who met clinical criteria for hypertension, 41 % received a diagnosis and 37 % received medication using the 130/80 mmHg cut-point. At the 140/90 mmHg cut-point, 52 % received a diagnosis and 49 % received medication. Atrial fibrillation (HR 2.18; 1.21-4.67) was associated with faster diagnosis rates; peripheral vascular disease (HR 0.18; 0.04-0.74) and fewer primary care visits (HR 0.93; 0.88-0.98) were associated with slower diagnosis rates. Atrial fibrillation (HR 3.07; 1.39-6.74) and ischemic heart disease/congestive heart failure (HR 2.16; 1.24-3.76) were associated with faster treatment rates; peripheral vascular disease (HR 0.16; 0.04-0.64) and fewer visits (HR 0.93; 0.88-0.98) predicted slower medication initiation. Diagnosis and treatment of incident hypertension were similar using cut-points of 130/80 and 140/90 mmHg.

CONCLUSIONS

Among patients with diabetes mellitus, even using a cut-point of 140/90 mmHg, approximately 50 % remained undiagnosed and untreated for hypertension. Future interventions should target patients with multiple comorbidities to improve hypertension and diabetes clinical care.

Establishing chronic condition concordance and discordance with diabetes: a Delphi study

BACKGROUND

The vast majority of patients with diabetes have multiple chronic conditions, increasing complexity of care; however, clinical practice guidelines, interventions, and public reporting metrics do not adequately address the interaction of these multiple conditions. To advance the understanding of diabetes clinical care in the context of multiple chronic conditions, we must understand how care overlaps, or doesn't, between diabetes and its co-occurring conditions. This study aimed to determine which chronic conditions are concordant (share care goals with diabetes) and discordant (do not share care goals) with diabetes care, according to primary care provider expert opinion.

METHODS

Using the Delphi technique, we administered an iterative, two-round survey to 16 practicing primary care providers in an academic practice in the Midwestern USA. The expert panel determined which specific diabetes care goals were also care goals for other chronic conditions (concordant) and which were not (discordant). Our diabetes care goals were those commonly used in quality reporting, and the conditions were 62 ambulatory-relevant condition categories.

RESULTS

Sixteen experts participated and all completed both rounds. Consensus was reached on the first round for 94% of the items. After the second round, 12 conditions were concordant with diabetes care and 50 were discordant. Of the concordant conditions, 6 overlapped in care for 4 of 5 diabetes care goals and 6 overlapped for 3 of 5 diabetes care goals. Thirty-one discordant conditions did not overlap with any of the diabetes care goals, and 19 overlapped with only 1 or 2 goals.

CONCLUSIONS

This study significantly adds to the number of conditions for which we have information on concordance and discordance for diabetes care. The results can be used for future studies to assess the impact of concordant and discordant conditions on diabetes care, and may prove useful in developing multimorbidity guidelines and interventions.

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.

The relationship of individual comorbid chronic conditions to diabetes care quality

OBJECTIVE

Multimorbidity affects 26 million persons with diabetes, and care for comorbid chronic conditions may impact diabetes care quality. The aim of this study was to determine which chronic conditions were related to lack of achievement or achievement of diabetes care quality goals to determine potential targets for future interventions.

RESEARCH DESIGN AND METHODS

This is an exploratory retrospective analysis of electronic health record data for 23 430 adults, aged 18-75, with diabetes who were seen at seven Midwestern US health systems. The main outcome measures were achievement of six diabetes quality metrics in the reporting year, 2011 (glycated haemoglobin (HbA1c) control and testing, low-density lipoprotein control and testing, blood pressure control, kidney testing). Explanatory variables were 62 chronic condition indicators. Analyses were adjusted for baseline patient sociodemographic and healthcare utilization factors.

RESULTS

The 62 chronic conditions varied in their relationships to diabetes care goal achievement for specific care goals. Congestive heart failure was related to lack of achievement of cholesterol management goals. Obesity was related to lack of HbA1c and BP control. Mental health conditions were related to both lack of achievement and achievement of different care goals. Three conditions were related to lack of cholesterol testing, including congestive heart failure and substance-use disorders. Of 17 conditions related to achieving control goals, 16 were related to achieving HbA1c control. One-half of the comorbid conditions did not predict diabetes care quality.

CONCLUSIONS

Future interventions could target patients at risk for not achieving diabetes care for specific care goals based on their individual comorbidities.

Prevalence of multimorbidity in a geographically defined American population: patterns by age, sex, and race/ethnicity

OBJECTIVE

To describe the prevalence of multimorbidity involving 20 selected chronic conditions in a geographically defined US population, emphasizing age, sex, and racial/ethnic differences.

PATIENTS AND METHODS

Using the Rochester Epidemiology Project records linkage system, we identified all residents of Olmsted County, Minnesota, on April 1, 2010, and electronically extracted the International Classification of Diseases, Ninth Revision codes associated with all health care visits made between April 1, 2005, and March 31, 2010 (5-year capture frame). Using these codes, we defined the 20 common chronic conditions recommended by the US Department of Health and Human Services. We counted only persons who received at least 2 codes for a given condition separated by more than 30 days, and we calculated the age-, sex-, and race/ethnicity-specific prevalence of multimorbidity.

RESULTS

Of the 138,858 study participants, 52.4% were women (n=72,732) and 38.9% had 1 or more conditions (n=54,012), 22.6% had 2 or more conditions (n=31,444), and 4.9% had 5 or more conditions (n=6853). The prevalence of multimorbidity (≥2 conditions) increased steeply with older age and reached 77.3% at 65 years and older. However, the absolute number of people affected by multimorbidity was higher in those younger than 65 years. Although the prevalence of multimorbidity was similar in men and women overall, the most common dyads and triads of conditions varied by sex. Compared with white persons, the prevalence of multimorbidity was slightly higher in black persons and slightly lower in Asian persons.

CONCLUSION

Multimorbidity is common in the general population; it increases steeply with older age, has different patterns in men and women, and varies by race/ethnicity.

Quality of diabetes care in Dutch care groups: no differences between diabetes patients with and without co-morbidity

Objective

To evaluate the relationship between presence and nature of co-morbidity and quality of care for diabetes patients enrolled in diabetes disease management programmes provided by care groups.

Methods

We performed an observational study within eight Dutch diabetes care groups. Data from patient record systems of care groups and patient questionnaires were used to determine quality of care. Quality of care was measured as provision of the recommended diabetes care, patients’ achievement of recommended clinical outcomes and patients’ perception of coordination and integration of care.

Results

527 diabetes patients without and 1187 diabetes patients with co-morbidity were included. Of the co-morbid patients, 7.8% had concordant co-morbid conditions only, 63.8% had discordant co-morbid diseases only and 28.4% had both types of conditions. Hardly any differences were observed between patients with and without co-morbidity in terms of provided care, achievement of clinical outcomes and perceived coordination and integration of care.

Conclusions

Our study implies that care groups are able to provide similar quality of diabetes care for diabetes patients with and without co-morbidity. Considering the expected developments regarding additional disease management programmes in care groups, it is of importance to monitor quality of care, including patient experiences, for all chronic diseases. It will then become clear whether accountable provider-led organisations such as care groups are able to ensure quality of care for the increasing number of patients with multiple chronic conditions.

The impact of concordant and discordant comorbidities on patient-assessed quality of diabetes care

OBJECTIVE

To examine the impact of concordant and discordant comorbidities on patients' assessments of providers' adherence to diabetes-specific care guidelines and quality of chronic illness care.

RESEARCH DESIGN AND METHODS

A population-based survey of 3761 adults with type 2 diabetes, living in Queensland, Australia was conducted in 2008. Based on self-reports, participants were grouped into four mutually exclusive comorbid categories: none, concordant only, discordant only and both concordant and discordant. Outcome measures included patient-reported providers' adherence to guideline-recommended care and the Patient Assessment of Chronic Illness Care (PACIC), which measures care according to the Chronic Care Model. Analyses using the former measure included logistic regressions, and the latter measure included univariate analysis of variance, both unadjusted and adjusted for sampling region, gender, age, educational attainment, diabetes duration and treatment status.

RESULTS

Having concordant comorbidities increased the odds of patient-reported providers' adherence for 7 of the 11 guideline-recommended care activities in unadjusted analyses. However, the effect remained significant for only two provider activities (reviews of medication and/or complications and blood pressure examinations) when adjusted. A similar pattern was found for the both concordant and discordant comorbidity category. The presence of discordant comorbidities influenced only one provider activity (blood pressure examinations). No association between comorbidity type and the overall PACIC score was found.

CONCLUSIONS

Comorbidity type is associated with diabetes-specific care, but does not seem to influence broader aspects of chronic illness care directly. Providers need to place more emphasis on care activities which are not comorbidity-specific and thus transferable across different chronic conditions.

The prevalence and ingredient cost of chronic comorbidity in the Irish elderly population with medication treated type 2 diabetes: a retrospective cross-sectional study using a national pharmacy claims database

Background

Comorbidity in patients with diabetes is associated with poorer health and increased cost. The aim of this study was to investigate the prevalence and ingredient cost of comorbidity in patients ≥ 65 years with and without medication treated type 2 diabetes using a national pharmacy claims database.

Methods

The Irish Health Service Executive Primary Care Reimbursement Service pharmacy claims database, which includes all prescribing to individuals covered by the General Medical Services scheme, was used to identify the study population (≥ 65 years). Patients with medication treated type 2 diabetes (T2DM) were identified using the prescription of oral anti-hyperglycaemic agents alone or in combination with insulin as a proxy for disease diagnosis. The prevalence and ingredient prescribing cost of treated chronic comorbidity in the study population with and without medication treated T2DM were ascertained using a modified version of the RxRiskV index, a prescription based comorbidity index. The association between T2DM and comorbid conditions was assessed using logistic regression adjusting for age and sex. Bootstrapping was used to ascertain the mean annual ingredient cost of treated comorbidity. Statistical significance at p < 0.05 was assumed.

Results

In 2010, 43165 of 445180 GMS eligible individuals (9.7%) were identified as having received medication for T2DM. The median number of comorbid conditions was significantly higher in those with T2DM compared to without (median 5 vs. 3 respectively; p < 0.001). Individuals with T2DM were more likely to have ≥ 5 comorbidities when compared to those without (OR = 2.82, 95% CI = 2.76-2.88, p < 0.0001). The mean annual ingredient cost for comorbidity was higher in the study population with T2DM (€1238.67, 95% CI = €1238.20 - €1239.14) compared to those without the condition (€799.28, 95% CI = €799.14 - € 799.41).

Conclusions

Individuals with T2DM were more likely to have a higher number of treated comorbid conditions than those without and this was associated with higher ingredient costs. This has important policy and economic consequences for the planning and provision of future health services in Ireland, given the expected increase in T2DM and other chronic conditions.

A clinical action measure to assess glycemic management in the 65-74 year old veteran population

OBJECTIVES

To evaluate the effect of including of clinical actions within 6 months of a glycosylated hemoglobin (HbA1c) level greater than 8% upon measure adherence (pass rates) and to assess the association between patient factors and the likelihood of not passing.

SETTING

Veterans Health Administration.

DESIGN

Retrospective cohort study for FY2002 to FY2004.

PARTICIPANTS

One hundred fifty-three thousand one hundred thirty-two veterans aged 65-74 with diabetes mellitus not taking insulin; 99% were male and 86% white.

MEASUREMENTS

The clinical action measure included three categories: (a) initial pass (index HbA1c < 8%); (b) modified pass (index HbA1c ≥ 8%), and the hierarchical occurrence of one of the following events within 6 months after date of index HbA1c: subsequent HbA1c < 8%, being started on insulin (100% weight), new oral medication (50% weight), care in a diabetes mellitus-related clinic (25% weight); and (c) failure (no category met or HbA1c > 9%). Multinomial logistic regression models were used to evaluate associations between participant factors and the likelihood of not passing initially.

RESULTS

Most (82.6%) or the participants had an index HbA1c of less than 8%, and 10.6% were in the modified pass group. The failure rate (17.4%) fell to 6.8% when actions were weighted equally and to 9.4% using different weights. Veterans who are African American (odds ratios (ORs) = 1.43 and 1.44), unmarried (ORs = 1.19 and 1.24), poor (ORs = 1.36 and 1.17), or taking two or more oral antihyperglycemic agents (ORs = 2.61 and 3.72) were significantly more likely to be in the modified pass and failure groups, respectively.

CONCLUSION

Most veterans with an initial HbA1c of 8% or greater had clinical actions within 6 months. A measure that incorporates multiple treatment options, including education and nutrition, could be of benefit by encouraging dialogue of such options between patients and clinicians.