The challenge of prioritizing care for complex patients
Research Activities September 2011, No. 373
A patient with only one chronic condition walks into an exam room. This is becoming less common than it used to be. Optimizing health care and ultimately the health of Americans is getting harder as patients increasingly have more than one chronic condition: diabetes, depression, heart disease, and more.
"We're not surprised to have patients with five or more chronic conditions anymore," says Cynthia Boyd, M.D., of the Johns Hopkins University School of Medicine's Division of Geriatric Medicine and Gerontology, who is studying how complex health status is associated with treatment burden. "We face enormous challenges trying to figure out which things are most important," says Dr. Boyd.
Researchers are looking at how to prioritize treatment and preventive care for these patients. For example, how do you decide which medications to prescribe when treating patients with multiple conditions when the medicines may have dangerous interactions? And, what are the harms and benefits of preventive tests that may unnecessarily burden patients with multiple chronic conditions who are already juggling numerous drugs and doctors' visits?
The care costs for these patients are also a concern. Treating patients with several chronic conditions can cost as much as seven times more than treating patients with only one chronic illness. Among Medicare beneficiaries, 66 percent of spending is for those with five or more chronic conditions. Since 2008, the Agency for Healthcare Research and Quality (AHRQ) has awarded 47 grants to researchers looking for better ways to study and provide care for complex patients.
The perfect storm
Maureen Smith, M.D., refers to the growing number of complex patients as "a perfect storm." And it's a fast moving one. "We don't have time to look for the perfect answer, but we do have the opportunity to look into treatments that will work in the real world," says Dr. Smith, director of the Health Innovation Program at the University of Wisconsin School of Medicine and Public Health.
Dr. Smith is examining how tight adherence to diabetes treatments may affect patients with diabetes who also have chronic kidney disease and congestive heart failure. Her work aims to help clinicians prioritize which of these issues to address first in caring for complex patients. "Our project examined whether tight adherence to diabetes guidelines, particularly tight control of blood sugar, is indicated for all patients with diabetes," Dr. Smith told Research Activities. "We found that diabetes patients with very tight control of their blood sugar (hemoglobin A1c <5.5%) had a higher risk of hospitalization, emergency department visits, or death, and this risk was significantly increased in more complex patients."
David M. Kent, M.D., of Tufts Medical Center, has spent the past 10 years studying this real world as he explores better ways to do subgroup analysis. "Because patients have too many different characteristics that can potentially alter the risks and benefits of therapy to consider each one separately, we advocate a risk-modeling approach to the interpretation of clinical trials," Dr. Kent told Research Activities. "In contrast to the conventional one-variable-at-a-time approach to subgroup analysis, this approach seeks to describe the dimensions that determine the likelihood that a patient might benefit or be harmed by therapy."
The role of prevention
By studying the benefits and harms of preventive interventions in elderly patients with cognitive impairment, Greg A. Sachs, M.D., hopes to improve decisionmaking. All of his patients are by definition "complex patients."
Early in Dr. Sachs's career, he received a fax from a pharmacist wondering why a woman with diabetes in the nursing home wasn't on a statin for her cholesterol. The patient was 95 and had advanced dementia, among other conditions. "She was dead by the time the fax arrived," says Dr. Sachs, of the Indiana University Division of General Internal Medicine and Geriatrics and Regenstrief Institute, Inc. He's even had to explain why an 85-year-old patient with dementia and multiple other conditions shouldn't be subject to a colonoscopy. "When patients don't benefit from screenings, it's not good medicine and it's not smart spending," he told Research Activities.
For clinicians like Dr. Boyd of Johns Hopkins University, who work with complex patients every day, one of the most difficult things to convey can be uncertainty. Yet, she says, "I have to communicate what I know and don't know. We need to balance both patient-centered care and evidence-based guidelines. We can't think about one without the other."
In an article published in the Journal of the American Medical Association in 2005, Dr. Boyd and her coauthors applied evidence-based guidelines to a hypothetical elderly woman with five common chronic diseases. They found she would need at least 12 medications (costing her $406 per month) and a complicated nonpharmacological regimen to manage her conditions. Creating a care management plan that is achievable and not burdensome requires a large dose of reality. "If we try to do everything, it will be overwhelming for our patients and not even in line with their goals," says Dr. Boyd. "I'm constantly trying to figure out the best way to energize and motivate my patients for the self-management, treatment, and interventions that are the highest priorities for their well-being."
Caring for the whole patient
"We need to shift from caring for each of a patient's conditions to caring for the patient as a whole," says Dr. Victor Montori of the Mayo Clinic. His AHRQ grant focuses on how to optimize prevention and health care management for patients with diabetes. On average, patients with diabetes often have coexisting medical conditions, with depression, hypertension, and hyperlipidemia (high levels of cholesterol or other lipids) being most common.
"When patients aren't achieving guideline-recommended levels of control of sugar or cholesterol, our reflex is to intensify care by offering more treatment. This intensification leads to more visits, tests, side effects, and costs. Some end up being superfluous," says Dr. Montori.
"They don't fit with the patient's goals. Sometimes, the solution is minimally disruptive medicine that allows patients to pursue their dreams," he explains. For an elderly man with diabetes, depression, and a disability who desperately wants to maintain his independence, Dr. Montori is working to reduce the man's workload as a patient and simplify his routine to focus on preventing another stroke. "We need more care that fits the patient," Dr. Montori asserts. AHRQ's investments in exploratory research projects like these, as well as projects that develop new methods and data resources, will help researchers improve our understanding of complex patients and help personalize care for better results.