Complex Medical Patients Wayne Katon, MD

 Definition: Illnesses with high prevalence, high comorbidity and bidirectional adverse interactions Examples: Diabetes, CAD, depression Depression, chronic pain, substance abuse Challenge: Development of Health Services Models for “Natural” Clusters of Illness

 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 Pitfalls of Processes of Care Measures Kerr E et al. 2001

“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

161,697 Patients with Diabetes were Examined to Estimate Rates and Reasons for Poor Disease Control (HbA 1c, 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 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 Comorbid Depression & Diabetes

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