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Zupa MF, Vimalananda VG, Rothenberger SD, Lin JY, Ng JM, McCoy RG, Rosland AM. Patterns of Telemedicine Use and Glycemic Outcomes of Endocrinology Care for Patients With Type 2 Diabetes. JAMA Netw Open 2023; 6:e2346305. [PMID: 38055278 PMCID: PMC10701613 DOI: 10.1001/jamanetworkopen.2023.46305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/23/2023] [Indexed: 12/07/2023] Open
Abstract
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.
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Affiliation(s)
- Margaret F. Zupa
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pennsylvania
| | - Varsha G. Vimalananda
- Center for Health Outcomes Research, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts
- Department of Medicine, Boston University School of Medicine, Massachusetts
| | - Scott D. Rothenberger
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Jonathan Y. Lin
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Jason M. Ng
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pennsylvania
| | - Rozalina G. McCoy
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore
- University of Maryland Institute for Health Computing, Bethesda
| | - Ann-Marie Rosland
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
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Naik AD. Pragmatic Evidence for Theory-Based Innovations in Diabetes Primary Care. Diabetes Care 2023; 46:1750-1752. [PMID: 37729505 DOI: 10.2337/dci23-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/01/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Aanand D Naik
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX
- Institute on Aging, University of Texas Health Science Center, Houston, TX
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX
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Uddin J, Uddin H, Rahman M, Saha P, Hossin MZ, Hajizadeh M, Kirkland S. Socioeconomic disparities in diabetes-concordant comorbidity: national health interview survey, 1997-2018. Public Health 2023; 222:160-165. [PMID: 37544127 DOI: 10.1016/j.puhe.2023.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/20/2023] [Accepted: 06/30/2023] [Indexed: 08/08/2023]
Abstract
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.
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Affiliation(s)
- J Uddin
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, B3H 4R2, Canada.
| | - H Uddin
- Department of Global Public Health, Karolinska Institutet, Solna, 17177, Sweden; Department of Sociology, East West University, Dhaka, 1212, Bangladesh.
| | - M Rahman
- Department of Science and Humanities, Bangabandhu Sheikh Mujibur Rahman Aviation and Aerospace University, Dhaka, 1206, Bangladesh.
| | - P Saha
- Institute of Statistical Research and Training, University of Dhaka, Dhaka, 1000, Bangladesh.
| | - M Z Hossin
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, 171 76, Sweden.
| | - M Hajizadeh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, B3H 4R2, Canada.
| | - S Kirkland
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, B3H 4R2, Canada.
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Cai CX, Kim M, Lundeen EA, Benoit SR. Differences in receipt of recommended eye examinations by comorbidity status and healthcare utilization among nonelderly adults with diabetes. J Diabetes 2022; 14:749-757. [PMID: 36285845 PMCID: PMC9705799 DOI: 10.1111/1753-0407.13328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/27/2022] [Accepted: 09/30/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Cindy X. Cai
- Wilmer Eye Institute, Johns Hopkins HospitalBaltimoreMarylandUSA
| | - Minchul Kim
- Center for Outcomes Research, Department of Internal MedicineUniversity of Illinois College of Medicine PeoriaPeoriaIllinoisUSA
| | - Elizabeth A. Lundeen
- Division of Diabetes TranslationNational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Stephen R. Benoit
- Division of Diabetes TranslationNational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and PreventionAtlantaGeorgiaUSA
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Sund R, Peltonen T, Lehtimäki AV, Martikainen J. Hospital treatment costs associated with incident complications in patients with type 2 diabetes—real-world study based on electronic patient information systems. BMC Health Serv Res 2022; 22:469. [PMID: 35397604 PMCID: PMC8994912 DOI: 10.1186/s12913-022-07895-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Wooldridge JS, Soriano EC, Harris DE, Afari N. Feasibility and Acceptability of Ecological Momentary Assessment of Psychosocial Factors and Self-Management Behaviors Among Veterans With Type 2 Diabetes. Diabetes Spectr 2022; 35:76-85. [PMID: 35308149 PMCID: PMC8914587 DOI: 10.2337/ds21-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Jennalee S. Wooldridge
- VA San Diego Healthcare System, San Diego, CA
- Department of Psychiatry, University of California, San Diego, La Jolla, CA
- Center of Excellence for Stress and Mental Health, San Diego, CA
- Corresponding author: Jennalee S. Wooldridge,
| | - Emily C. Soriano
- VA San Diego Healthcare System, San Diego, CA
- Department of Psychiatry, University of California, San Diego, La Jolla, CA
- Department of Psychological & Brain Sciences, University of Delaware, Newark, DE
| | | | - Niloofar Afari
- VA San Diego Healthcare System, San Diego, CA
- Department of Psychiatry, University of California, San Diego, La Jolla, CA
- Center of Excellence for Stress and Mental Health, San Diego, CA
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Alfian SD, Annisa N, Iskandarsyah A, Perwitasari DA, Denig P, Hak E, Abdulah R. 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. Ther Clin Risk Manag 2021; 17:1333-1342. [PMID: 34908842 PMCID: PMC8665871 DOI: 10.2147/tcrm.s329694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/10/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Sofa D Alfian
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Jatinangor, Indonesia.,Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Jatinangor, Indonesia
| | - Nurul Annisa
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Jatinangor, Indonesia.,Unit of Clinical Pharmacy and Community, Faculty of Pharmacy, Universitas Mulawarman, Samarinda, Indonesia
| | - Aulia Iskandarsyah
- Department of Clinical Psychology, Faculty of Psychology, Universitas Padjadjaran, Jatinangor, Indonesia
| | - Dyah A Perwitasari
- Department of Clinical Pharmacy, Faculty of Pharmacy, Universitas Ahmad Dahlan, Yogyakarta, Indonesia
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Eelko Hak
- Unit of Pharmaco-Therapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Rizky Abdulah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Jatinangor, Indonesia.,Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Jatinangor, Indonesia
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Scuteri A. Characteristics that influence the diagnosis and treatment of diabetes in geriatric patients over 75. JOURNAL OF GERONTOLOGY AND GERIATRICS 2021. [DOI: 10.36150/2499-6564-n448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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A valid self-help tool to measure the role of spousal support in the care of persons with diabetes mellitus. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-01001-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Lane NE, Ling V, Glazier RH, Stukel TA. Primary care physician volume and quality of care for older adults with dementia: a retrospective cohort study. BMC FAMILY PRACTICE 2021; 22:51. [PMID: 33750310 PMCID: PMC7945328 DOI: 10.1186/s12875-021-01398-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/11/2021] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Natasha E. Lane
- Department of Medicine, University of British Columbia, British Columbia, 2775 Laurel Street, 10th Floor , Vancouver, V5Z 1M9 Canada
- ICES, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
| | - Vicki Ling
- ICES, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
| | - Richard H. Glazier
- ICES, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7 Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, Toronto, ON M5T 3M7 Canada
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON M5G 1V7 Canada
- MAP Centre for Urban Health Solutions, St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8 Canada
| | - Thérèse A. Stukel
- ICES, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, Toronto, ON M5T 3M7 Canada
- Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine At Dartmouth, 74 College Street, Hanover, NH 03755 USA
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Clustering 5-Year Multidimensional Health Care Trajectory Patterns in Alzheimer's Disease and Related Syndromes. J Am Med Dir Assoc 2021; 22:1525-1534.e3. [PMID: 33689689 DOI: 10.1016/j.jamda.2021.01.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 01/20/2021] [Accepted: 01/31/2021] [Indexed: 11/21/2022]
Abstract
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.
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Zhang JJ, Rothberg MB, Misra-Hebert AD, Gupta NM, Taksler GB. Assessment of Physician Priorities in Delivery of Preventive Care. JAMA Netw Open 2020; 3:e2011677. [PMID: 32716515 PMCID: PMC8103855 DOI: 10.1001/jamanetworkopen.2020.11677] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Jessica J. Zhang
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Michael B. Rothberg
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
- Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anita D. Misra-Hebert
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
- Medicine Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | | | - Glen B. Taksler
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
- Medicine Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Center for Health Care Research and Policy, Case Western Reserve University and MetroHealth Medical Center, Cleveland, Ohio
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Friis K, Lasgaard M, Pedersen MH, Duncan P, Maindal HT. Health literacy, multimorbidity, and patient-perceived treatment burden in individuals with cardiovascular disease. A Danish population-based study. PATIENT EDUCATION AND COUNSELING 2019; 102:1932-1938. [PMID: 31151781 DOI: 10.1016/j.pec.2019.05.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/11/2019] [Accepted: 05/14/2019] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Karina Friis
- DEFACTUM, Central Denmark Region, Olof Palmes Allé 15, 8200 Aarhus N, Denmark.
| | - Mathias Lasgaard
- DEFACTUM, Central Denmark Region, Olof Palmes Allé 15, 8200 Aarhus N, Denmark.
| | | | - Polly Duncan
- Centre for Academic Primary Care, University of Bristol, 39 Whatley Road, Bristol BS8 2PS, UK.
| | - Helle Terkildsen Maindal
- Department of Public Health, Section for Health Promotion and Health Services, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark.
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14
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Gupta N, Sheng Z. A population-based study of the association between food insecurity and potentially avoidable hospitalization among persons with diabetes using linked survey and administrative data. Int J Popul Data Sci 2019; 4:1102. [PMID: 32935031 PMCID: PMC7482516 DOI: 10.23889/ijpds.v4i1.1102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- N Gupta
- Department of Sociology, University of New Brunswick, PO Box 4400, Fredericton, New Brunswick E3B 5A3, Canada
| | - Z Sheng
- Department of Sociology, University of New Brunswick, PO Box 4400, Fredericton, New Brunswick E3B 5A3, Canada
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Taksler GB, Beth Mercer M, Fagerlin A, Rothberg MB. Assessing Patient Interest in Individualized Preventive Care Recommendations. MDM Policy Pract 2019; 4:2381468319850803. [PMID: 31192307 PMCID: PMC6540511 DOI: 10.1177/2381468319850803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/12/2019] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Glen B Taksler
- Medicine Institute, Division of Clinical Epidemiology, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | | | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
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Kamradt M, Ose D, Krisam J, Jacke C, Salize HJ, Besier W, Mayer M, Szecsenyi J, Wensing M. 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. Diabetes Res Clin Pract 2019; 150:184-193. [PMID: 30872067 DOI: 10.1016/j.diabres.2019.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 02/18/2019] [Accepted: 03/05/2019] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Martina Kamradt
- Dept. of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany.
| | - Dominik Ose
- Dept. of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany; University of Utah, Dept. of Family and Preventive Medicine, 375 Chipeta Way A, Salt Lake City, UT 84108, USA.
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics, Dept. of Medical Biometry, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany.
| | - Christian Jacke
- Central Institute of Mental Health, Medical Faculty Mannheim/University Heidelberg, D6, 68159 Mannheim, Germany.
| | - Hans-Joachim Salize
- Central Institute of Mental Health, Medical Faculty Mannheim/University Heidelberg, D6, 68159 Mannheim, Germany.
| | - Werner Besier
- Genossenschaft Gesundheitsprojekt Mannheim, Liebfrauenstraße 21, 68259 Mannheim, Germany.
| | - Manfred Mayer
- Genossenschaft Gesundheitsprojekt Mannheim, Liebfrauenstraße 21, 68259 Mannheim, Germany.
| | - Joachim Szecsenyi
- Dept. of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany.
| | - Michel Wensing
- Dept. of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany.
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Hirst JA, Farmer AJ, Smith MC, Stevens RJ. Timings for HbA 1c testing in people with diabetes are associated with incentive payments: an analysis of UK primary care data. Diabet Med 2019; 36:36-43. [PMID: 30175871 PMCID: PMC6519368 DOI: 10.1111/dme.13810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- J. A. Hirst
- Nuffield Department of Primary Care Health ScienceUniversity of OxfordOxfordUK
| | - A. J. Farmer
- Nuffield Department of Primary Care Health ScienceUniversity of OxfordOxfordUK
| | - M. C. Smith
- Nuffield Department of Primary Care Health ScienceUniversity of OxfordOxfordUK
| | - R. J. Stevens
- Nuffield Department of Primary Care Health ScienceUniversity of OxfordOxfordUK
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An J, Le QA, Dang T. Association between different types of comorbidity and disease burden in patients with diabetes. J Diabetes 2019; 11:65-74. [PMID: 29956479 DOI: 10.1111/1753-0407.12818] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/06/2018] [Accepted: 06/16/2018] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- JaeJin An
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California, USA
| | - Quang A Le
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California, USA
| | - Tracy Dang
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California, USA
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19
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Chang AY, Gómez-Olivé FX, Manne-Goehler J, Wade AN, Tollman S, Gaziano TA, Salomon JA. Multimorbidity and care for hypertension, diabetes and HIV among older adults in rural South Africa. Bull World Health Organ 2018; 97:10-23. [PMID: 30618461 PMCID: PMC6307505 DOI: 10.2471/blt.18.217000] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 09/29/2018] [Accepted: 10/08/2018] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Angela Y Chang
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, Massachusetts, United States of America (USA)
| | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Alisha N Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thomas A Gaziano
- Department of Cardiovascular Medicine, Harvard Medical School, Boston, USA
| | - Joshua A Salomon
- Department of Medicine, Stanford University School of Medicine, Stanford, USA
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Lin PJ, Pope E, Zhou FL. Comorbidity Type and Health Care Costs in Type 2 Diabetes: A Retrospective Claims Database Analysis. Diabetes Ther 2018; 9:1907-1918. [PMID: 30097994 PMCID: PMC6167298 DOI: 10.1007/s13300-018-0477-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Pei-Jung Lin
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.
| | - Elle Pope
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Fang Liz Zhou
- Real World Evidence and Clinical Outcomes, Sanofi, Bridgewater, NJ, USA
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21
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Gilstrap LG, Mehrotra A, Bai B, Rose S, Blair RA, Chernew ME. National Rates of Initiation and Intensification of Antidiabetic Therapy Among Patients With Commercial Insurance. Diabetes Care 2018; 41:1776-1782. [PMID: 29794151 PMCID: PMC8742144 DOI: 10.2337/dc17-2585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/23/2018] [Indexed: 02/03/2023]
Abstract
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 HbA1c ≥8% (64 mmol/mol) and an intensification cohort of patients with an HbA1c ≥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 HbA1c test. In the intensification cohort (n = 10,941), 82% had their existing antidiabetic therapy intensified within 6 months of the elevated HbA1c test. Higher HbA1c 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 HbA1c 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 HbA1c in a commercially insured population. Patient factors explain 7-8% of the variation in diabetes treatment patterns.
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Affiliation(s)
- Lauren G Gilstrap
- Department of Health Care Policy, Harvard Medical School, Boston, MA .,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Barbara Bai
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Sherri Rose
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Rachel A Blair
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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22
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Taksler GB, Pfoh ER, Stange KC, Rothberg MB. Association Between Number of Preventive Care Guidelines and Preventive Care Utilization by Patients. Am J Prev Med 2018; 55:1-10. [PMID: 29773491 PMCID: PMC6014877 DOI: 10.1016/j.amepre.2018.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 02/12/2018] [Accepted: 03/12/2018] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
| | | | - Kurt C Stange
- Department of Family Medicine and Community Health, Case Western Reserve University, Cleveland, Ohio
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Chalasani S, Peiris DP, Usherwood T, Redfern J, Neal BC, Sullivan DR, Colagiuri S, Zwar NA, Li Q, Patel A. Reducing cardiovascular disease risk in diabetes: a randomised controlled trial of a quality improvement initiative. Med J Aust 2017; 206:436-441. [DOI: 10.5694/mja16.00332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 12/13/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Santhi Chalasani
- The George Institute for International Health, University of Sydney, Sydney, NSW
| | - David P Peiris
- The George Institute for International Health, University of Sydney, Sydney, NSW
| | - Tim Usherwood
- Sydney Medical School, University of Sydney, Sydney, NSW
| | - Julie Redfern
- The George Institute for International Health, University of Sydney, Sydney, NSW
- Sydney Medical School, University of Sydney, Sydney, NSW
| | - Bruce C Neal
- The George Institute for International Health, University of Sydney, Sydney, NSW
| | | | - Stephen Colagiuri
- Boden Institute of Obesity, Nutrition and Exercise, University of Sydney, Sydney, NSW
- UNSW Australia, Sydney, NSW
| | | | - Qiang Li
- The George Institute for International Health, University of Sydney, Sydney, NSW
| | - Anushka Patel
- The George Institute for International Health, University of Sydney, Sydney, NSW
- Sydney Medical School, University of Sydney, Sydney, NSW
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Alemán-Vega G, Garrido-Elustondo S, Del Cura-González I, Sarria-Santamera A. [¿Is a maintained glycemia between 110/125 mg/dl a risk factor in the development of diabetes?]. Aten Primaria 2017; 49:557-558. [PMID: 28318684 PMCID: PMC6876033 DOI: 10.1016/j.aprim.2016.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 06/28/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Sofía Garrido-Elustondo
- Unidad de Investigación de Atención Primaria de Madrid, Madrid, España; Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas, REDISSEC, España
| | - Isabel Del Cura-González
- Unidad de Investigación de Atención Primaria de Madrid, Madrid, España; Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas, REDISSEC, España; Departamento de Medicina Preventiva, Universidad Rey Juan Carlos, Madrid, España
| | - Antonio Sarria-Santamera
- Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas, REDISSEC, España; Escuela Nacional de Sanidad, Instituto de Salud Carlos III, Madrid, España; Facultad de Medicina, Universidad de Alcalá, Madrid, España
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Kamradt M, Krisam J, Kiel M, Qreini M, Besier W, Szecsenyi J, Ose D. Health-Related Quality of Life in Primary Care: Which Aspects Matter in Multimorbid Patients with Type 2 Diabetes Mellitus in a Community Setting? PLoS One 2017; 12:e0170883. [PMID: 28125691 PMCID: PMC5268781 DOI: 10.1371/journal.pone.0170883] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 01/13/2017] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Martina Kamradt
- Department of General Practice and Health Services Research; University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics; Department of Medical Biometry; University Hospital Heidelberg, Heidelberg, Germany
| | - Marion Kiel
- Department of General Practice and Health Services Research; University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Qreini
- Department of General Practice and Health Services Research; University Hospital Heidelberg, Heidelberg, Germany
| | - Werner Besier
- Genossenschaft Gesundheitsprojekt Mannheim e.G., Mannheim, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research; University Hospital Heidelberg, Heidelberg, Germany
| | - Dominik Ose
- Department of General Practice and Health Services Research; University Hospital Heidelberg, Heidelberg, Germany
- Department of Population Health Sciences, Health System Innovation and Research; University of Utah, Salt Lake City, UT, United States of America
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Bowling CB, Plantinga L, Phillips LS, McClellan W, Echt K, Chumbler N, McGwin G, Vandenberg A, Allman RM, Johnson TM. Association of Multimorbidity with Mortality and Healthcare Utilization in Chronic Kidney Disease. J Am Geriatr Soc 2016; 65:704-711. [PMID: 27880003 DOI: 10.1111/jgs.14662] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- C Barrett Bowling
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia.,Department of Medicine, Emory University, Atlanta, Georgia
| | | | - Lawrence S Phillips
- Department of Medicine, Emory University, Atlanta, Georgia.,Atlanta VA Medical Center, Decatur, Georgia
| | - William McClellan
- Department of Medicine, Emory University, Atlanta, Georgia.,Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Katharina Echt
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia.,Department of Medicine, Emory University, Atlanta, Georgia
| | | | - Gerald McGwin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ann Vandenberg
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia.,Department of Medicine, Emory University, Atlanta, Georgia
| | - Richard M Allman
- Geriatrics and Extended Care Services, Department of Veterans Affairs, Washington, District of Columbia
| | - Theodore M Johnson
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VA Medical Center, Decatur, Georgia.,Department of Medicine, Emory University, Atlanta, Georgia
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Cho YY, Sidorenkov G, Denig P. Role of Patient and Practice Characteristics in Variance of Treatment Quality in Type 2 Diabetes between General Practices. PLoS One 2016; 11:e0166012. [PMID: 27806107 PMCID: PMC5091743 DOI: 10.1371/journal.pone.0166012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/21/2016] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Yeon Young Cho
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Epidemiology, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Grigory Sidorenkov
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- * E-mail:
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Petrosyan Y, Bai YQ, Koné Pefoyo AJ, Gruneir A, Thavorn K, Maxwell CJ, Bronskill SE, Wodchis WP. The Relationship between Diabetes Care Quality and Diabetes-Related Hospitalizations and the Modifying Role of Comorbidity. Can J Diabetes 2016; 41:17-25. [PMID: 27789111 DOI: 10.1016/j.jcjd.2016.06.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/17/2016] [Accepted: 06/21/2016] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Yelena Petrosyan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Yu Qing Bai
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Anna J Koné Pefoyo
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Cancer Care Ontario, Toronto, Ontario, Canada
| | - Andrea Gruneir
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kednapa Thavorn
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Colleen J Maxwell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, Ontario, Canada
| | - Susan E Bronskill
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, Toronto, Ontario, Canada.
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Iglay K, Hannachi H, Joseph Howie P, Xu J, Li X, Engel SS, Moore LM, Rajpathak S. Prevalence and co-prevalence of comorbidities among patients with type 2 diabetes mellitus. Curr Med Res Opin 2016; 32:1243-52. [PMID: 26986190 DOI: 10.1185/03007995.2016.1168291] [Citation(s) in RCA: 262] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Jinfei Xu
- a Merck & Co. Inc. , Kenilworth , NJ , USA
| | - Xueying Li
- a Merck & Co. Inc. , Kenilworth , NJ , USA
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Kekäläinen P, Tirkkonen H, Laatikainen T. How are metabolic control targets of patients with Type 1 diabetes mellitus achieved in daily practice in the area with high diabetes prevalence? Diabetes Res Clin Pract 2016; 115:9-16. [PMID: 27242117 DOI: 10.1016/j.diabres.2016.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 01/26/2016] [Accepted: 03/01/2016] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Päivi Kekäläinen
- Department of Internal Medicine, Hospital District of North Karelia, Joensuu, Finland.
| | | | - Tiina Laatikainen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Hospital District of North Karelia, Joensuu, Finland; Chronic Disease Prevention Unit, National Institute for Health and Welfare (THL), Helsinki, Finland
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Lorem GF, Schirmer H, Emaus N. Health Impact Index. Development and Validation of a Method for Classifying Comorbid Disease Measured against Self-Reported Health. PLoS One 2016; 11:e0148830. [PMID: 26849044 PMCID: PMC4746071 DOI: 10.1371/journal.pone.0148830] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 01/21/2016] [Indexed: 11/17/2022] Open
Abstract
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 (RS = -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.
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Affiliation(s)
- Geir Fagerjord Lorem
- Department of caring and health science, Faculty of health sciences, The Arctic University of Norway, Tromsø, Norway
| | - Henrik Schirmer
- Department of clinical medicine, Faculty of health sciences, The Arctic University of Norway, Tromsø, Norway.,Division of Cardiothoracic and Respiratory Medicine, University Hospital of Northern Norway, Tromsø, Norway
| | - Nina Emaus
- Department of caring and health science, Faculty of health sciences, The Arctic University of Norway, Tromsø, Norway
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Comorbidity Burden and Health Services Use in Community-Living Older Adults with Diabetes Mellitus: A Retrospective Cohort Study. Can J Diabetes 2016; 40:35-42. [DOI: 10.1016/j.jcjd.2015.09.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 09/04/2015] [Accepted: 09/06/2015] [Indexed: 11/23/2022]
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Bralić Lang V, Bergman Marković B. Prevalence of comorbidity in primary care patients with type 2 diabetes and its association with elevated HbA1c: A cross-sectional study in Croatia. Scand J Prim Health Care 2016; 34:66-72. [PMID: 26853192 PMCID: PMC4911025 DOI: 10.3109/02813432.2015.1132886] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Valerija Bralić Lang
- Private Family Physician Office affiliated to University of Zagreb, School of Medicine, Zagreb, Croatia
- CONTACT Valerija Bralić Lang Private Family Physician Office affiliated to University of Zagreb, School of Medicine, Zvonigradska 9, 10000 Zagreb, Croatia
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Ricci-Cabello I, Stevens S, Kontopantelis E, Dalton ARH, Griffiths RI, Campbell JL, Doran T, Valderas JM. Impact of the Prevalence of Concordant and Discordant Conditions on the Quality of Diabetes Care in Family Practices in England. Ann Fam Med 2015; 13:514-22. [PMID: 26553890 PMCID: PMC4639376 DOI: 10.1370/afm.1848] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Ignacio Ricci-Cabello
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Evangelos Kontopantelis
- National Institute for Health Research (NIHR) School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Andrew R H Dalton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Robert I Griffiths
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - John L Campbell
- APEx Collaboration for Academic Primary Care, Institute for Health Services Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Tim Doran
- Department of Health Sciences, University of York, York, United Kingdom
| | - Jose M Valderas
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom APEx Collaboration for Academic Primary Care, Institute for Health Services Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
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Adriaanse MC, Drewes HW, van der Heide I, Struijs JN, Baan CA. The impact of comorbid chronic conditions on quality of life in type 2 diabetes patients. Qual Life Res 2015; 25:175-82. [PMID: 26267523 PMCID: PMC4706581 DOI: 10.1007/s11136-015-1061-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2015] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Marcel C Adriaanse
- Department of Health Sciences and EMGO Institute for Health and Care Research, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
| | - Hanneke W Drewes
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Iris van der Heide
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Jeroen N Struijs
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Caroline A Baan
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
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Ricci-Cabello I, Violán C, Foguet-Boreu Q, Mounce LTA, Valderas JM. Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review. Eur J Gen Pract 2015; 21:192-202. [PMID: 26232238 DOI: 10.3109/13814788.2015.1046046] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Ignacio Ricci-Cabello
- a Nuffield Department of Primary Care Health Sciences , University of Oxford , Oxford , UK
| | - Concepció Violán
- b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.,c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain
| | - Quinti Foguet-Boreu
- b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.,c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain.,d Department of Medical Sciences , School of Medicine, University of Girona , Girona , Spain
| | - Luke T A Mounce
- e Institute for Health Research, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter , Exeter , UK
| | - Jose M Valderas
- a Nuffield Department of Primary Care Health Sciences , University of Oxford , Oxford , UK.,b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.,c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain.,e Institute for Health Research, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter , Exeter , UK.,f CIBER en Epidemiologia y Salud P blica (CIBERESP) , Barcelona , Spain
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Eby EL, Van Brunt K, Brusko C, Curtis B, Lage MJ. Dosing of U-100 insulin and associated outcomes among Medicare enrollees with type 1 or type 2 diabetes. Clin Interv Aging 2015; 10:991-1001. [PMID: 26124652 PMCID: PMC4476426 DOI: 10.2147/cia.s76398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Elizabeth L Eby
- Global Patient Outcomes and Real World Evidence, Eli Lilly and Co., Indianapolis IN USA
| | | | | | | | - Maureen J Lage
- HealthMetrics Outcomes Research, LLC, Bonita Springs, FL, USA
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Wallace ML, Magnan EM, Thorpe CT, Schumacher JR, Smith MA, Johnson HM. Diagnosis and treatment of incident hypertension among patients with diabetes: a U.S. multi-disciplinary group practice observational study. J Gen Intern Med 2015; 30:768-76. [PMID: 25650264 PMCID: PMC4441679 DOI: 10.1007/s11606-015-3202-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Margaret L. Wallace
- />Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Elizabeth M. Magnan
- />Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Carolyn T. Thorpe
- />Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System and Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA USA
| | - Jessica R. Schumacher
- />Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
- />Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Maureen A. Smith
- />Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
- />Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
- />Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
- />Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Heather M. Johnson
- />Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
- />Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, H4/512 CSC, MC 3248, 600 Highland Avenue, Madison, WI 53792 USA
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Magnan EM, Gittelson R, Bartels CM, Johnson HM, Pandhi N, Jacobs EA, Smith MA. Establishing chronic condition concordance and discordance with diabetes: a Delphi study. BMC FAMILY PRACTICE 2015; 16:42. [PMID: 25887080 PMCID: PMC4391600 DOI: 10.1186/s12875-015-0253-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 03/06/2015] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth M Magnan
- Department of Family and Community Medicine, University of California, Davis, UC Davis School of Medicine, 4860 Y street, suite 2320, Sacramento, CA, 95817, USA. .,Health Innovation Program, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive Suite 210, Madison, WI, 53705, USA.
| | - Rebecca Gittelson
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive Suite 210, Madison, WI, 53705, USA.
| | - Christie M Bartels
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive Suite 210, Madison, WI, 53705, USA. .,Department of Medicine, University of Wisconsin, Madison, WI, USA.
| | - Heather M Johnson
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive Suite 210, Madison, WI, 53705, USA. .,Department of Medicine, University of Wisconsin, Madison, WI, USA.
| | - Nancy Pandhi
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive Suite 210, Madison, WI, 53705, USA. .,Department of Family Medicine, University of Wisconsin, Madison, WI, USA.
| | - Elizabeth A Jacobs
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive Suite 210, Madison, WI, 53705, USA. .,Department of Medicine, University of Wisconsin, Madison, WI, USA.
| | - Maureen A Smith
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive Suite 210, Madison, WI, 53705, USA. .,Department of Family Medicine, University of Wisconsin, Madison, WI, USA. .,Department of Population Health Sciences, University of Wisconsin, Madison, WI, USA. .,Department of Surgery, University of Wisconsin, Madison, WI, USA.
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Magnan EM, Palta M, Johnson HM, Bartels CM, Schumacher JR, Smith MA. The impact of a patient's concordant and discordant chronic conditions on diabetes care quality measures. J Diabetes Complications 2015; 29:288-94. [PMID: 25456821 PMCID: PMC4333015 DOI: 10.1016/j.jdiacomp.2014.10.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/12/2014] [Accepted: 10/06/2014] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Elizabeth M Magnan
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Family and Community Medicine, University of California, Davis, Sacramento, CA, USA.
| | - Mari Palta
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Heather M Johnson
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christie M Bartels
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jessica R Schumacher
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Maureen A Smith
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Magnan EM, Palta M, Mahoney JE, Pandhi N, Bolt DM, Fink J, Greenlee RT, Smith MA. The relationship of individual comorbid chronic conditions to diabetes care quality. BMJ Open Diabetes Res Care 2015; 3:e000080. [PMID: 26217492 PMCID: PMC4513351 DOI: 10.1136/bmjdrc-2015-000080] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
- Elizabeth M Magnan
- Department of Family and Community Medicine, University of California, Davis, Sacramento, California, USA
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Mari Palta
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jane E Mahoney
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nancy Pandhi
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Daniel M Bolt
- Department of Educational Psychology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jennifer Fink
- Department of Health Informatics and Administration, College of Health Sciences, University Wisconsin Milwaukee, Milwaukee, Wisconsin, USA
- Center for Urban Population Health, Milwaukee, Wisconsin, USA
- Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin, USA
| | - Robert T Greenlee
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Foundation, Marshfield, WI, USA
| | - Maureen A Smith
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Rocca WA, Boyd CM, Grossardt BR, Bobo WV, Finney Rutten LJ, Roger VL, Ebbert JO, Therneau TM, Yawn BP, St Sauver JL. Prevalence of multimorbidity in a geographically defined American population: patterns by age, sex, and race/ethnicity. Mayo Clin Proc 2014; 89:1336-49. [PMID: 25220409 PMCID: PMC4186914 DOI: 10.1016/j.mayocp.2014.07.010] [Citation(s) in RCA: 169] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 07/22/2014] [Accepted: 07/23/2014] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Walter A Rocca
- Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN; Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN.
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Brandon R Grossardt
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN
| | - William V Bobo
- Department of Psychiatry, College of Medicine, Mayo Clinic, Rochester, MN
| | - Lila J Finney Rutten
- Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, College of Medicine, Mayo Clinic, Rochester, MN
| | - Véronique L Roger
- Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN; Division of Cardiovascular Diseases, Department of Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, College of Medicine, Mayo Clinic, Rochester, MN
| | - Jon O Ebbert
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, College of Medicine, Mayo Clinic, Rochester, MN
| | - Terry M Therneau
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN
| | - Barbara P Yawn
- Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN; Department of Research, Olmsted Medical Center, Rochester, MN
| | - Jennifer L St Sauver
- Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, College of Medicine, Mayo Clinic, Rochester, MN
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Colorectal cancer, diabetes and survival: Epidemiological insights. DIABETES & METABOLISM 2014; 40:120-7. [DOI: 10.1016/j.diabet.2013.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/12/2013] [Accepted: 12/14/2013] [Indexed: 11/23/2022]
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Conferencia de consenso: Tratamiento de la diabetes tipo 2 en el paciente anciano. Med Clin (Barc) 2014; 142:89-90. [DOI: 10.1016/j.medcli.2013.05.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 05/28/2013] [Accepted: 05/30/2013] [Indexed: 11/29/2022]
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Quality of diabetes care in Dutch care groups: no differences between diabetes patients with and without co-morbidity. Int J Integr Care 2013; 13:e057. [PMID: 24409109 PMCID: PMC3886599 DOI: 10.5334/ijic.1141] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 11/06/2013] [Accepted: 12/02/2013] [Indexed: 12/21/2022] Open
Abstract
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.
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Aung E, Donald M, Coll J, Dower J, Williams GM, Doi SAR. The impact of concordant and discordant comorbidities on patient-assessed quality of diabetes care. Health Expect 2013; 18:1621-32. [PMID: 24151930 DOI: 10.1111/hex.12151] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2013] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Eindra Aung
- School of Population Health, University of Queensland, Brisbane, Qld, Australia
| | - Maria Donald
- School of Population Health, University of Queensland, Brisbane, Qld, Australia
| | - Joseph Coll
- School of Population Health, University of Queensland, Brisbane, Qld, Australia
| | - Jo Dower
- School of Population Health, University of Queensland, Brisbane, Qld, Australia
| | - Gail M Williams
- School of Population Health, University of Queensland, Brisbane, Qld, Australia
| | - Suhail A R Doi
- School of Population Health, University of Queensland, Brisbane, Qld, Australia
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O'Shea M, Teeling M, Bennett K. 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. BMC Health Serv Res 2013; 13:23. [PMID: 23324517 PMCID: PMC3554499 DOI: 10.1186/1472-6963-13-23] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 01/10/2013] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Miriam O'Shea
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, St James's Hospital, James's Street, Dublin 8, Ireland.
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Soroka O, Tseng CL, Rajan M, Maney M, Pogach L. A clinical action measure to assess glycemic management in the 65-74 year old veteran population. J Am Geriatr Soc 2012; 60:1442-7. [PMID: 22861151 DOI: 10.1111/j.1532-5415.2012.04079.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Orysya Soroka
- Department of Veterans Affairs New Jersey Healthcare System, Center for Healthcare Knowledge Management, East Orange, New Jersey 07018, USA
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