Complex Medical Patients (Text Version)

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

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Slide 1

Complex Medical Patients

Wayne Katon, MD

Slide 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

Slide 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.

Slide 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

Slide 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

Slide 6

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.

Slide 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.

Skyler et al. 2009.