Beyond Comorbidity Counts: How Do Comorbidity Type and Severity Influence Diabetes Patients’ Treatment Priorities and Self-Management?

BACKGROUNDThe majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three.OBJECTIVEWe sought to understand how the number, type, and severity of comorbidities influence diabetes patients’ self-management and treatment priorities.DESIGNCross-sectional observation study.PATIENTSA total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey.MEASUREMENTSWe constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF).RESULTS40% of respondents had at least 1 microvascular comorbidity, 79% at least 1 macrovascular comorbidity, and 61% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores.CONCLUSIONSThe type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients’ self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.

[1]  R. Deyo,et al.  Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. , 1992, Journal of clinical epidemiology.

[2]  R. Suzman,et al.  An Overview of the Health and Retirement Study , 1995 .

[3]  A. Hillman,et al.  Competing Practice Guidelines: Using Cost-Effectiveness Analysis To Make Optimal Decisions , 1998, Annals of Internal Medicine.

[4]  A. Bandura.  Social Foundations of Thought and Action , 1986 .

[5]  Dylan M. Smith,et al.  The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management , 2002, Journal of General Internal Medicine.

[6]  J. Ware.  SF-36 health survey: Manual and interpretation guide , 2003 .

[7]  R. Glasgow,et al.  Personal-Model Beliefs and Social-Environmental Barriers Related to Diabetes Self-Management , 1997, Diabetes Care.

[8]  A. Bandura.  Social Foundations of Thought and Action: A Social Cognitive Theory , 1985 .

[9]  E. Deci,et al.  Supporting Autonomy to Motivate Patients With Diabetes for Glucose Control , 1998, Diabetes Care.

[10]  M. Dimatteo.  Variations in Patients’ Adherence to Medical Recommendations: A Quantitative Review of 50 Years of Research , 2004, Medical care.

[11]  B. Starfield,et al.  Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. , 2002, Archives of internal medicine.

[12]  W. Katon,et al.  Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. , 2000, Archives of internal medicine.

[13]  R. Glasgow,et al.  Psychosocial Barriers to Diabetes Self-Management and Quality of Life , 2001 .

[14]  M. Tinetti,et al.  Potential pitfalls of disease-specific guidelines for patients with multiple conditions. , 2004, The New England journal of medicine.

[15]  D. Redelmeier,et al.  The treatment of unrelated disorders in patients with chronic medical diseases. , 1998, The New England journal of medicine.

[16]  R. Hayward,et al.  Treatment of Hypertension in Type 2 Diabetes Mellitus: Blood Pressure Goals, Choice of Agents, and Setting Priorities in Diabetes Care , 2003, Annals of Internal Medicine.

[17]  K C Stange,et al.  Competing demands of primary care: a model for the delivery of clinical preventive services. , 1994, The Journal of family practice.

[18]  R. Rubin,et al.  Adherence to pharmacologic therapy in patients with type 2 diabetes mellitus. , 2005, The American journal of medicine.

[19]  A. Bandura.  SOCIAL COGNITIVE THEORY , 2008 .

[20]  Eve A Kerr,et al.  The impact of comorbid chronic conditions on diabetes care. , 2006, Diabetes care.

[21]  Rodney A Hayward,et al.  How well do patients' assessments of their diabetes self-management correlate with actual glycemic control and receipt of recommended diabetes services? , 2003, Diabetes Care.

[22]  Fatima Makki,et al.  The effect of chronic pain on diabetes patients' self-management. , 2005, Diabetes care.

[23]  E. Yano,et al.  Health habit counseling amidst competing demands: effects of patient health habits and visit characteristics. , 1999, Medical care.

[24]  H A Pincus,et al.  Comparing the national economic burden of five chronic conditions. , 2001, Health affairs.

[25]  S. Studenski,et al.  Co-morbidity adjustment for functional outcomes in community-dwelling older adults , 2002, Clinical rehabilitation.

[26]  F. Dickerson,et al.  A comparison of type 2 diabetes outcomes among persons with and without severe mental illnesses. , 2004, Psychiatric services.

[27]  R. Hayward,et al.  When there is too much to do: How practicing physicians prioritize among recommended interventions , 2004, Journal of General Internal Medicine.

[28]  A. Wu,et al.  Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. , 2005, JAMA.

[29]  C. Mackenzie,et al.  A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. , 1987, Journal of chronic diseases.

[30]  N. Schoenberg,et al.  Barriers to Non–Insulin Dependent Diabetes Mellitus (NIDDM) Self-Care Practices among Older Women , 2001, Journal of aging and health.

[31]  R. Verbrugge,et al.  Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost , 2005, Medical care.

[32]  Louise B Russell,et al.  Time requirements for diabetes self-management: too much for many? , 2005, The Journal of family practice.

[33]  J. Cramer.  A systematic review of adherence with medications for diabetes. , 2004, Diabetes care.

[34]  John F. Steiner,et al.  Descriptions of Barriers to Self-Care by Persons with Comorbid Chronic Diseases , 2003, The Annals of Family Medicine.