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Complex Medical Patients

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 Examples: Diabetes, CAD, depression

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Complex Medical Patients

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  1. Complex Medical Patients Wayne Katon, MD

  2. 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

  3. 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 Kerr E et al. 2001

  4. “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

  5. 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

  6. Comorbid Depression & Diabetes Adversely affects self-care: adherence to diet, exercise, cessation of smoking, taking medications as prescribed Comorbid Depression & Diabetes • 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

  7. 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 Skyleret al. 2009

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