Does Diabetes Care Differ by Type of Chronic Comorbidity? An evaluation of the Piette and Kerr framework

Department of Veterans Affairs, Center for Health Care Knowledge and Management, Veterans Affairs New Jersey Health Care System, East Orange, New Jersey, USA.
Diabetes care (Impact Factor: 8.42). 03/2012; 35(6):1285-92. DOI: 10.2337/dc11-1569
Source: PubMed


To evaluate the relationship between diabetes care and types of comorbidity, classified by the degree to which their treatment is concordant with that for diabetes.
Retrospective cohort study (fiscal year [FY] 2001 to FY 2004) of 42,826 veterans with new-onset diabetes in FY 2003. Veterans were classified into five chronic comorbid illness groups (CCIGs): none, concordant only, discordant only, both concordant and discordant, and dominant. Five diabetes-related care measures were assessed in FY 2004 (guideline-consistent testing and treatment goals for HbA(1c) and LDL cholesterol and diabetes-related outpatient visits). Analyses included logistic regressions adjusting for age, race, sex, marital status, priority code, and interaction between CCIGs and visit frequency.
Only 20% of patients had no comorbidities. Mean number of visits per year ranged from 7.8 (no CCIG) to 17.5 (dominant CCIG). In unadjusted analyses, presence of any illness was associated with equivalent or better care. In the fully adjusted model, we found interaction between CCIG and visit frequency. When visits were <7 per year, the odds of meeting the goal of HbA(1c) <8% were similar in the concordant (odds ratio 0.96 [95% CI 0.83-1.11]) and lower in the discordant (0.90 [0.81-0.99]) groups compared with the no comorbidity group. Among patients with >24 visits per year, these odds were insignificant. Dominant CCIG was associated with substantially reduced care for glycemic control for all visit categories and for lipid management at all but the highest visit category.
Our study indicates that diabetes care varies by types of comorbidity. Concordant illnesses result in similar or better care, regardless of visit frequency. Discordant illnesses are associated with diminished care: an effect that decreases as visit frequency increases.

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Available from: Cindy L Christiansen, Sep 04, 2014
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    • "For example, concordant conditions have been associated with a higher likelihood of HbA1c and cholesterol control in one study (Woodard, Urech, Landrum, Wang, & Petersen, 2011) but only with cholesterol control in another (Pentakota et al., 2012). Discordant conditions were associated with both better and worse diabetes care (Dixon et al., 2004; Pentakota et al., 2012; Woodard et al., 2011). However, these studies used limited lists of chronic conditions (the majority under 10), and none assessed the role of both the number of concordant and the number of discordant chronic conditions on diabetes care goal achievement. "
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    ABSTRACT: Most patients with diabetes have comorbid chronic conditions that could support (concordant) or compete with (discordant) diabetes care. We sought to determine the impact of the number of concordant and discordant chronic conditions on diabetes care quality. Logistic regression analysis of electronic health record data from 7 health systems on 24,430 patients with diabetes aged 18-75 years. Diabetes testing and control quality care goals were the outcome variables. The number of diabetes-concordant and the number of diabetes-discordant conditions were the main explanatory variables. Analysis was adjusted for health care utilization, health system and patient demographics. A higher number of concordant conditions were associated with higher odds of achieving testing and control goals for all outcomes except blood pressure control. There was no to minimal positive association between the number of discordant conditions and outcomes, except for cholesterol testing which was less likely with 4+ discordant conditions. Having more concordant conditions makes diabetes care goal achievement more likely. The number of discordant conditions has a smaller, inconsistently significant impact on diabetes goal achievement. Interventions to improve diabetes care need to align with a patient's comorbidities, including the absence of comorbidities, especially concordant comorbidities. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Diabetes and its Complications 10/2014; 29(2). DOI:10.1016/j.jdiacomp.2014.10.003 · 3.01 Impact Factor
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    • "Literature regarding the relationship between co-morbidity and quality of care is controversial. There is evidence that quality of care differs by co-morbidity type [35–37]. The study of Pentakota et al. (2012) [35], for example, suggests that discordant co-morbid conditions are associated with diminished diabetes care, whereas quality of diabetes care for diabetes patients with concordant co-morbid conditions is similar compared to diabetes patients without co-morbidity. "
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    ABSTRACT: To evaluate the relationship between presence and nature of co-morbidity and quality of care for diabetes patients enrolled in diabetes disease management programmes provided by care groups. We performed an observational study within eight Dutch diabetes care groups. Data from patient record systems of care groups and patient questionnaires were used to determine quality of care. Quality of care was measured as provision of the recommended diabetes care, patients' achievement of recommended clinical outcomes and patients' perception of coordination and integration of care. 527 diabetes patients without and 1187 diabetes patients with co-morbidity were included. Of the co-morbid patients, 7.8% had concordant co-morbid conditions only, 63.8% had discordant co-morbid diseases only and 28.4% had both types of conditions. Hardly any differences were observed between patients with and without co-morbidity in terms of provided care, achievement of clinical outcomes and perceived coordination and integration of care. Our study implies that care groups are able to provide similar quality of diabetes care for diabetes patients with and without co-morbidity. Considering the expected developments regarding additional disease management programmes in care groups, it is of importance to monitor quality of care, including patient experiences, for all chronic diseases. It will then become clear whether accountable provider-led organisations such as care groups are able to ensure quality of care for the increasing number of patients with multiple chronic conditions.
    International journal of integrated care 12/2013; 13:e057. · 1.50 Impact Factor
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    • "A number of different frameworks have been developed that categorise comorbid conditions according to their influence on the clinical management of the index condition [8]. The most recent was developed by Piette & Kerr [9] and has since been used in a number of published studies [10-12]. The original paper classified chronic comorbid conditions as being either concordant or discordant with diabetes. "
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    ABSTRACT: Background Comorbidity in patients with diabetes is associated with poorer health and increased cost. The aim of this study was to investigate the prevalence and ingredient cost of comorbidity in patients ≥ 65 years with and without medication treated type 2 diabetes using a national pharmacy claims database. Methods The Irish Health Service Executive Primary Care Reimbursement Service pharmacy claims database, which includes all prescribing to individuals covered by the General Medical Services scheme, was used to identify the study population (≥ 65 years). Patients with medication treated type 2 diabetes (T2DM) were identified using the prescription of oral anti-hyperglycaemic agents alone or in combination with insulin as a proxy for disease diagnosis. The prevalence and ingredient prescribing cost of treated chronic comorbidity in the study population with and without medication treated T2DM were ascertained using a modified version of the RxRiskV index, a prescription based comorbidity index. The association between T2DM and comorbid conditions was assessed using logistic regression adjusting for age and sex. Bootstrapping was used to ascertain the mean annual ingredient cost of treated comorbidity. Statistical significance at p < 0.05 was assumed. Results In 2010, 43165 of 445180 GMS eligible individuals (9.7%) were identified as having received medication for T2DM. The median number of comorbid conditions was significantly higher in those with T2DM compared to without (median 5 vs. 3 respectively; p < 0.001). Individuals with T2DM were more likely to have ≥ 5 comorbidities when compared to those without (OR = 2.82, 95% CI = 2.76-2.88, p < 0.0001). The mean annual ingredient cost for comorbidity was higher in the study population with T2DM (€1238.67, 95% CI = €1238.20 - €1239.14) compared to those without the condition (€799.28, 95% CI = €799.14 - € 799.41). Conclusions Individuals with T2DM were more likely to have a higher number of treated comorbid conditions than those without and this was associated with higher ingredient costs. This has important policy and economic consequences for the planning and provision of future health services in Ireland, given the expected increase in T2DM and other chronic conditions.
    BMC Health Services Research 01/2013; 13(1):23. DOI:10.1186/1472-6963-13-23 · 1.71 Impact Factor
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