Complex Medical Patients (Text Version)

Complex Medical Patients

Slide Presentation from the AHRQ 2010 Annual Conference

On September 27, 2010, Wayne Katon, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (595 KB). Free PowerPoint® Viewer (Plugin Software Help).

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Complex Medical Patients

Wayne Katon, MD

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Challenge: Development of Health Services Models for "Natural" Clusters of Illness

• Definition: Illnesses with high prevalence, high comorbidity and bidirectional adverse interactions.
  • Examples:
    • Diabetes, CAD, depression
    • Depression, chronic pain, substance abuse

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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.

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"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

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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

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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 HbA_1c, LDL tests, annual retinal and foot exams.
  • Intensification of medication in patients with poor disease control.

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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.