Although health care systems have recognized and begun to respond to the special needs of outpatients with chronic diseases through such initiatives as the creation of clinical practice guidelines and case manager programs, most of these strategies target single chronic illnesses. Although these disease-specific strategies may be effective in improving some outcomes, they can also result in fragmentation of care and overlook the complex needs of patients with multimorbidity.
The immediate objectives are to: 1) Identify and describe the most prevalent chronic disease clusters among veterans; and 2) Identify and describe collaborative care needs and preferences among veterans with multiple chronic illnesses.
Objective 1: we analyzed 46 months of encounter diagnoses extracted from the VHA administrative databases. The sample consisted of veterans who had 1 or more primary care clinic visits recorded during FY 97-FY00. ICD-9-CM diagnosis codes representing chronic illnesses that are highly prevalent in the veteran population or considered to be high priority diseases by the VHA were selected to create 45 diagnosis groups. All inpatient and outpatient encounter diagnoses were extracted for patients meeting primary care visit eligibility criteria. For each patient, the presence or absence of each of the 45 diagnosis groups was coded. Hierarchical cluster analysis was used to determine the number and type of multiple disease clusters. Objective 2: we used mixed qualitative/ quantitative methods. First, we conducted 8 focus groups with 60 primary care patients with 2 or more chronic illnesses at 4 VAMCs and 4 OPCs in 4 VISNs. A general interview guide approach was used that derived open-ended questions from the 4 collaborative care elements (i.e., patient centered problems, targeting & goal-setting, self-management needs, and active sustained follow-up) thought to enhance the management of chronic illness. Identified themes were used to survey primary care patients to examine differences in needs and preferences among patients with multiple chronic illnesses and those with only 1 chronic illness.
Objective 1: 1,645,314 unique veterans met the eligibility criteria for primary care visits. Of these, 101,814(6%) had none of the diseases and 216,118(13%) had only 1 of the diseases, while 1,327,382(81%) had 2 or more of the 45 chronic diseases. The average number of chronic diseases per patient was 3.49, SD=2.2, and ranged from 0-20. Among patients who had 2 or more chronic diseases, 5 clinically meaningful multiple disease clusters of relevance to collaborative care were identified. The most prevalent cluster of diseases consisted of diabetes, hypertension, hyperlipidemia, and ischemic heart disease. Objective 2: Focus group patients identified a number of health care system hassles including polypharmacy, concerns that were overlooked or ignored by their physicians, disagreements between physicians, problems in accessing nonscheduled urgent care, and poor continuity of care between primary care and subspecialty clinics. 422 surveys were returned (60% adjusted return rate). Patients with multimorbidity reported significantly more health care hassles and problems with polypharmacy, but greater satisfaction with their primary care providers. Patients with multimorbidity were more likely than patients with only a single chronic illness to have been monitored between appointments, participated in health education, or been seen by a nonphysician provider in the prior 6 months, but the overwhelming majority did not receive these services. Patients with multimorbidity were also more likely to express a desire to learn self-care skills, including strategies to manage medications, improve communication with their providers, lose weight, manage pain, and improve their sexual relationships.
Multimorbidity creates an enormous burden for patients and their health care providers. Identification of the most commonly occurring multi-disease clusters can guide the allocation of health care resources and assist in the development of system-level interventions. Future research derived from this work will design and test cross-cutting chronic disease management programs that can better meet the needs of these complex patients.
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- Bayliss EA, Bosworth HB, Noel PH, Wolff JL, Damush TM, Mciver L. Supporting self-management for patients with complex medical needs: recommendations of a working group. Chronic Illness. 2007 Jun 1; 3(2):167-75.
- Noël PH, Frueh BC, Larme AC, Pugh JA. Collaborative care needs and preferences of primary care patients with multimorbidity. Health Expectations. 2005 Mar 1; 8(1):54-63.
- Noel PH. Self-management learning needs of veterans with multimorbidity. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
- Fihn S, Ho M, Kinsinger L, Noel PH, Pogach L. Managing chronic disease in the VA integrated health system [panelist]. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jan 1; Seattle, WA.
- Noel PH, Parchman ML, Williams JW, Cornell JE, Kazis LE, Frueh BC, Larme A, Pugh JA. Collaborative Care Needs and Preferences of Primary Care Patients with Multimorbidity. Paper presented at: AcademyHealth Annual Research Meeting; 2004 Jun 8; San Diego, CA.
- Noel PH, Pugh JA, Williams JW, Cornell JE, Kazis LE, Lee A, Parchman ML, Montgomery KA. Patterns of multimorbidity in veteran primary care patients. Paper presented at: VA HSR&D National Meeting; 2003 Feb 13; Washington, DC.
Treatment - Observational
Clinical practice guidelines, Comorbidity, Patient preferences