BACKGROUND/RATIONALE:
Clinical guidelines have been established to increase the effectiveness of the health care system by standardizing care for chronic conditions. However, their focus on individual conditions and failure to account for patient preferences does not fully reflect the complexities of care for patients with multimorbidity and thus, may inadvertently promote less patient-centered care. The goal of this study was to assess the relationship between guideline-recommended care and patient-centered measures of care in a cohort of Veterans with multimorbidity.

OBJECTIVE(S):
1) To measure patient perceptions of their chronic illness care using validated survey items in a cohort of multimorbid Veterans; 2) To determine whether those who receive guideline-recommended care perceive their care as patient-centered.

METHODS:
We developed a survey to assess patient perceptions of their chronic illness care using previously validated items for satisfaction, trust, activation, decision-making preferences, health status, and health literacy. Using VA administrative data, we identified patients receiving care at the Michael E. DeBakey VA Medical Center from November-December 2010 with the following coexisting conditions: hypertension, ischemic heart disease, and diabetes. We mailed self-administered surveys to participants meeting study eligibility criteria. We performed a structured chart review to obtain diagnoses, laboratory values, and vital signs among participants completing the survey. We used regression models to examine the association between the domains of care assessed by the survey and the level of quality received by participants for blood pressure (<130/80 mm Hg), hemoglobin (Hb) A1c (<9% and <7%), and low-density lipoprotein cholesterol (LDL-C <100 mg/dL) control.

FINDINGS/RESULTS:
A total of 195 individuals (50.4%) returned surveys. The study cohort was 71% White, 25% Black, and 4% Other, 99% male, and had a mean age of 68.1years. 87% of patients had HbA1c levels <9%, while only 42% had HbA1c levels <7%. 87% had controlled blood pressure and 89% had controlled LDL-C levels. Controlling for age and race, patient activation (p=0.048) and physical health status (p=0.042) were positively associated with glycemic control. Further, patients with higher levels of activation were more likely to view their care as patient-centered (p<0.001). There was no association between patient-centered care and blood pressure, LDL-C, or glycemic (HbA1c <9%) control. However, using the more stringent threshold of HbA1c <7%, patients achieving glycemic control were less likely than those who were uncontrolled to view their care as patient-centered, controlling for patient activation (p=0.036).

IMPACT:
These findings suggest that increasing patient activation may be an important way to improve outcomes and promote more patient-centered care among diabetic patients with multimorbidity. While strict glycemic control has proven benefits for most diabetic patients, among patients with multimorbidity, achieving HbA1c levels of <7% was associated with less patient-centered care, likely reflecting the additional treatment burden necessary to meet this threshold. Accounting for patient-level factors, such as activation, and individualizing care to meet the needs of patients with multimorbidity, may promote more patient-centered chronic illness care.

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External Links for this Project

NIH Reporter

Grant Number: I01HX000315-01
Link: https://reporter.nih.gov/project-details/7868954

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PUBLICATIONS:

Journal Articles

1. Virani SS, Steinberg L, Murray T, Negi S, Nambi V, Woodard LD, Bozkurt B, Petersen LA, Ballantyne CM. Barriers to non-HDL cholesterol goal attainment by providers. The American journal of medicine. 2011 Sep 1; 124(9):876-80.e2. [view]
2. Virani SS, Woodard LD, Chitwood SS, Landrum CR, Urech TH, Wang D, Murawsky J, Ballantyne CM, Petersen LA. Frequency and correlates of treatment intensification for elevated cholesterol levels in patients with cardiovascular disease. American heart journal. 2011 Oct 1; 162(4):725-732.e1. [view]
3. Woodard LD, Landrum CR, Urech TH, Wang D, Virani SS, Petersen LA. Impact of clinical complexity on the quality of diabetes care. The American journal of managed care. 2012 Sep 1; 18(9):508-14. [view]
4. Woodard LD, Urech T, Landrum CR, Wang D, Petersen LA. Impact of comorbidity type on measures of quality for diabetes care. Medical care. 2011 Jun 1; 49(6):605-10. [view]
5. Woodard LD, Landrum CR, Amspoker AB, Ramsey D, Naik AD. Interaction between functional health literacy, patient activation, and glycemic control. Patient preference and adherence. 2014 Jul 24; 8:1019-24. [view]
6. Woodard LD, Landrum CR, Urech TH, Profit J, Virani SS, Petersen LA. Treating chronically ill people with diabetes mellitus with limited life expectancy: implications for performance measurement. Journal of the American Geriatrics Society. 2012 Feb 1; 60(2):193-201. [view]

Conference Presentations

1. Woodard LD. Association between health literacy, patient activation, and glycemic control among diabetic Veterans with multimorbidity. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2012 May 9; Orlando, FL. [view]
2. Woodard LD, Landrum CR, Hysong SJ, Profit J, Wang D, Petersen LA, Sansgiry S, Naik A. Association between patient-centered care and quality of chronic illness care among Veterans with multimorbidity. Poster session presented at: VA HSR&D National Meeting; 2012 Jul 18; Washington, DC. [view]
3. Virani S, Woodard LD, Petersen LA. Has LDL cholesterol (LDL-C) and non-HDL cholesterol (non-HDL-C) goal attainment improved 7 years after adult treatment panel III (ATP III) guidelines were published? Poster session presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2010 May 21; Washington, DC. [view]
4. Woodard LD, Landrum CR, Wang D, Urech T, Virani S, Petersen LA. The effect of clinical complexity on the receipt of comprehensive care for diabetes. Paper presented at: Society of General Internal Medicine Annual Meeting; 2011 May 4; Phoenix, AZ. [view]
5. Woodard LD, Landrum CR, Wang D, Urech T, Virani S, Petersen LA. The impact of clinical complexity on achievement of glycemic, blood pressure, and lipid control among patients with diabetes. Paper presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA. [view]

DRA: Other Conditions
DRE: Epidemiology
Keywords: Patient preferences, Patient-centered Care, Satisfaction (patient)
MeSH Terms: none