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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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Presentation Transcript
challenge development of health services models for natural clusters of illness
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
pitfalls of processes of care measures
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

tightly linked quality of care measures
“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

slide5
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
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
accord advance and vadt trials
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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