Complex medical patients
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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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Complex Medical Patients

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Complex medical patients

Complex Medical Patients

Wayne Katon, MD


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


Complex medical patients

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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