Complex Medical Patients (Text Version)
On September 27, 2010, Wayne Katon, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (595 KB).
Complex Medical Patients
Wayne Katon, MD
Challenge: Development of Health Services Models for "Natural" Clusters of Illness
- Definition: Illnesses with high prevalence, high comorbidity and bidirectional adverse interactions.
- Diabetes, CAD, depression
- Depression, chronic pain, substance abuse
Pitfalls of Processes of Care Measures
- Many measures of processes of care lack strong links to outcomes.
- Actionable processes of care are not measured.
- Measures do not target those at highest risk.
- Measures do not allow for patient exceptions.
- Intermediate outcome measures are not severity adjusted.
"Tightly Linked" Quality of Care Measures
- Evidence links these process measures to improved outcomes.
- Adding a beta-blocker to HCTZ in patients with poorly controlled blood pressure.
Kerr E et al. 2001
161,697 Patients with Diabetes were Examined to Estimate Rates and Reasons for Poor Disease Control (HbA1c, SBP, LDLs)
- 20% to 23% poor adherence.
- Among those with adequate adherence, 30% to 47% had no evidence of treatment intensification.
- Poor adherence and lack of treatment intensification were found in 53% to 68% of patients with poor disease control.
Schmittdiel J et al. 2008
Comorbid Depression & Diabetes
- Adversely affects self-care: adherence to diet, exercise, cessation of smoking, taking medications as prescribed.
- Does not affect quality of care measures under more direct physician control):
- Number of HbA1c, LDL tests, annual retinal and foot exams.
- Intensification of medication in patients with poor disease control.
ACCORD, ADVANCE and VADT Trials
- Limited evidence that intensive glucose control decreased macrovascular events.
- Subset analysis suggested that patients with shorter duration of diabetes without established atherosclerosis might benefit from intensive glucose control.
- Risks of intensive glucose control might outweigh benefits in those with a long history of diabetes, known history of hypoglycemia, advanced atherosclerosis and advanced age/fragility.
Skyler et al. 2009.