The impact of a patient’s concordant and discordant chronic conditions on diabetes care quality measures

https://doi.org/10.1016/j.jdiacomp.2014.10.003Get rights and content

Abstract

Aims

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.

Methods

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.

Results

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.

Conclusions

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.

Introduction

Over 21 million people in the US have diabetes and at least one other chronic condition, and the majority have suboptimal care, which has critical implications for the health outcomes of this growing population (Centers for Disease Control and Prevention, 2011, National Committee for Quality Assurance, 2012). Less than two thirds of patients achieve glycemic control and less than half achieve goal blood pressure control (National Committee for Quality Assurance, 2012). Diabetes is progressive, and suboptimal treatment leads to severe complications (American Diabetes Association, 2014). Comorbid conditions, and the challenges of managing multiple competing demands from multiple conditions, could lead to worse diabetes care by distracting from diabetes care goals (Boyd and Fortin, 2010, Piette and Kerr, 2006). Providers face time constraints during office visits when managing patients with diabetes and comorbidities, as guidelines suggest providers spend 11 hours/day on chronic condition management (Yarnall et al., 2009). Patients face time and financial constraints as well, as guidelines recommend 143 minutes/day on diabetes self-care and 19 medications for diabetes plus four co-morbid conditions (Boyd et al., 2005, Russell et al., 2005, Yarnall et al., 2009). Guidelines do not support providers and patients in integrating multiple care needs of diabetes and co-morbid chronic conditions (Boyd et al., 2005, Zulman et al., 2014). The combined impact of multiple care needs and lack of integration of these needs could mean that patients with a high number of comorbidities are less likely to receive adequate care. We are unable to improve and tailor guidelines and interventions for patients with diabetes without better understanding how multimorbidity impacts diabetes care quality.

The impact of multimorbidity is often measured as the total count of comorbid conditions but this approach ignores a potentially important consideration: if the comorbidity has similar or dissimilar management to diabetes (Huntley et al., 2012, Kerr et al., 2007). Piette and Kerr’s conceptual framework of Concordance and Discordance suggests that diabetes co-morbidities can be either concordant (similar) or discordant (dissimilar) with respect to diabetes management and can either support or compete with diabetes care (Piette & Kerr, 2006). Patients with more concordant conditions will receive better diabetes care due to provider cuing and synergistic care, while patients with more discordant conditions will receive worse diabetes care due to distraction and competition for limited resources (Jaen et al., 1994, Piette and Kerr, 2006). There is no neutral category in this framework as any condition that is not concordant is by definition discordant and competes with diabetes for health care resources. This framework suggests that past studies that have shown improved outcomes in patients with more chronic conditions (Higashi et al., 2007, Min et al., 2007) were likely showing the beneficial effect of having more concordant conditions.

There is conflicting evidence that the presence of concordant and discordant conditions leads to differences in the receipt of recommended diabetes care (Desai et al., 2002, Kerr et al., 2007, Krein et al., 2009, Pentakota et al., 2012, Redelmeier et al., 1998, Sales et al., 2009, Thorpe et al., 2012, Vitry et al., 2010, Voorham et al., 2012). 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.

The purpose of our study was to improve understanding of the impact of the number of concordant and discordant chronic conditions on diabetes care goal achievement (care quality) for patients with diabetes. We hypothesized that patients with more concordant conditions would have better diabetes care quality than those with fewer concordant conditions, and that patients with more discordant conditions would have worse diabetes care quality than those with fewer discordant conditions.

Section snippets

Sample

Our sample consisted of adult patients (aged 18–75) with diabetes (type 1 or type 2) who were medically homed in ambulatory practices within 7 health systems that participate in a Midwestern quality reporting collaborative, the Wisconsin Collaborative for Healthcare Quality (WCHQ). The age limit reflects the standard age range for public reporting of quality metrics, based on diabetes care guidelines, as children and the very elderly have different care needs (National Committee for Quality

Results

Our sample had 23,430 patients with diabetes, between the ages of 18 and 75 (Table 1). The sample was 58 years old on average, 48% female, and 70% white. The majority had health care coverage, with 12% uninsured or with unreported coverage. The majority (85%) had 10 or fewer face-to-face provider visits in the baseline year. The mean total active co-morbid chronic conditions (in addition to diabetes) was 3.8 (SD = 2.5), and 92% had at least one co-morbid condition (multimorbidity). Patients had a

Discussion

We found that having 2 or more concordant conditions is associated with better diabetes care quality for testing and control goals, except blood pressure control. The patients with the fewest concordant conditions had the lowest likelihood of achieving diabetes care goals. The impact of the number of concordant conditions was strongest for testing goals. We found an inconsistently significant effect of having more discordant conditions. In general, the impact of the number of concordant

Conclusions

As the prevalence of diabetes and diabetes with multimorbidity increases, we need adequate approaches to treat these patients and prevent future complications in our time-constrained environment. Our findings suggest that the patients most at risk for suboptimal diabetes care are the patients with the fewest comorbidities, especially the fewest concordant comorbidities. These patients are likely earlier in their disease progression, and represent important targets for interventions to prevent

Acknowledgments

Funding/Financial Support: This project was funded by grant R21 HS021899 from the Agency for Healthcare Research and Quality. Additional support was provided by the Health Innovation Program, the UW School of Medicine and Public Health from The Wisconsin Partnership Program, and the Community–Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research (UW ICTR) through the National Center for Advancing Translational Sciences (NCATS), grant

References (39)

  • American Diabetes Association

    Standards of medical care in diabetes—2011

    Diabetes Care

    (2011)
  • American Diabetes Association

    Standards of medical care in diabetes–2014

    Diabetes Care

    (2014)
  • E. Aung et al.

    The impact of concordant and discordant comorbidities on patient-assessed quality of diabetes care

    Health Expectations

    (2013)
  • C.M. Bartels et al.

    Monitoring diabetes in patients with and without rheumatoid arthritis: A Medicare study

    Arthritis Research and Therapy

    (2012)
  • E.A. Bayliss et al.

    Understanding the context of health for persons with multiple chronic conditions: Moving from what is the matter to what matters

    Annals of Family Medicine

    (2014)
  • C.M. Boyd et al.

    Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases—Implications for pay for performance

    JAMA

    (2005)
  • C.M. Boyd et al.

    Future of multimorbidity research: How should understanding of multimorbidity inform health system design?

    Public Health Reviews

    (2010)
  • D.A. Calhoun et al.

    Resistant hypertension: Diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research

    Hypertension

    (2008)
  • Centers for Disease Control and Prevention

    National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States

    (2011)
  • M.M. Desai et al.

    Mental disorders and quality of diabetes care in the veterans health administration

    The American Journal of Psychiatry

    (2002)
  • L.B. Dixon et al.

    A comparison of type 2 diabetes outcomes among persons with and without severe mental illnesses

    Psychiatric Services

    (2004)
  • T. Higashi et al.

    Relationship between number of medical conditions and quality of care

    New England Journal of Medicine

    (2007)
  • A.L. Huntley et al.

    Measures of multimorbidity and morbidity burden for use in primary care and community settings: A systematic review and guide

    Annals of Family Medicine

    (2012)
  • W. Hwang et al.

    Out-of-pocket medical spending for care of chronic conditions

    Health Affairs (Project Hope)

    (2001)
  • C.R. Jaen et al.

    Competing demands of primary care. A model for the delivery of clinical preventive services

    Journal of Family Practice

    (1994)
  • P.A. James et al.

    2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8)

    JAMA

    (2014)
  • E.A. Kerr et al.

    Beyond comorbidity counts: How do comorbidity type and severity influence diabetes patients' treatment priorities and self-management?

    Journal of General Internal Medicine

    (2007)
  • S.L. Krein et al.

    More than a pain in the neck: How discussing chronic pain affects hypertension medication intensification

    Journal of General Internal Medicine

    (2009)
  • T. Lagu et al.

    The impact of concordant and discordant conditions on the quality of care for hyperlipidemia

    Journal of General Internal Medicine

    (2008)
  • Cited by (42)

    • Association of musculoskeletal pain with the achievement of treatment targets for type 2 diabetes among primary care patients

      2022, Primary Care Diabetes
      Citation Excerpt :

      Type 2 diabetes (T2D) is a prevalent condition causing a significant cost and disability burden for those affected, and for societies worldwide [1,2]. It appears to co-exist with other long-term diseases [3–6] and show high prevalence, especially among those of working age and older adults [7]. T2D is known to be driven by both genetic and environmental/behavioural factors including unhealthy behaviours, such as physical inactivity and obesity [8,9].

    • Untangling the complexity of multimorbidity with machine learning

      2020, Mechanisms of Ageing and Development
      Citation Excerpt :

      The resulting patterns, due to non-negativity, are pushed to be sparse and, therefore, easier to interpret (Hassaine et al., 2019; Ho et al., 2020; Wang et al., 2020b; Afshar et al., 2019; Zhao et al., 2019). However, we know that some diseases are likely to have a suppression (negative) effect on each other; diseases A and B can be said to have suppressive effect on each other if the presence of disease A leads to lower risk (or prevention) of disease B, perhaps because of shared risk factors and clinical management (e.g. treatment of disease A has also some clinical benefit to disease B, or assessment of disease A also identified disease B) (Lagu et al., 2008; Magnan et al., 2015; Min et al., 2007). The non-negative factorisation techniques, while effective in mining coincidence patterns (e.g., where each disease belongs to disease clusters with a non-negative membership score), are not able to mine such suppressive patterns (e.g., where each disease belongs to disease clusters with either a negative or non-negative membership score).

    • Longitudinal trends and predictors of statin use among patients with diabetes

      2018, Journal of Diabetes and its Complications
      Citation Excerpt :

      One potential explanation for this emerging pattern is that diabetes was not widely perceived as a CHD risk equivalent at the time of the Jackson et al. study, but it has subsequently gained recognition as such. Recent data identify cardiovascular disease and diabetes as concordant comorbidities that now share similar clinical management strategies and goals.21,22 This increases the odds of achieving shared goals, including LDL-cholesterol level targets.23

    View all citing articles on Scopus

    Conflict of Interest: No conflicts of interest were declared.

    View full text