September 29th, 2010
How Are You Managing Co-Morbid Conditions?
Joseph S. Ross, MD, MHS
Some of you may remember a 2005 paper in JAMA, in which relevant clinical practice guidelines were applied to a hypothetical 79-year-old woman. This woman had multiple co-morbid conditions, otherwise known as multimorbidity, including COPD, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis. The authors surmised that, if guideline-directed care were followed, this hypothetical patient would be prescribed at least 12 medications (costing at least $406/month) and would require a modified diet and exercise interventions.
Since this paper was published, we better recognize the importance and challenge of managing mulitmorbidity when making recommendations for treatment and prevention to patients in our practices.
However, no easy fixes to the problem have been identified.
I raise this issue here since all physicians, particularly general internists and preventive cardiologists, are frequently making a multitude of treatment and prevention decisions for patients, for problems within and outside of their clinical specialty.
Another more recently published paper in Archives of Internal Medicine is also worth considering. In this study, the authors interviewed primary care physicians (PCPs) about how they make treatment decisions for older patients with multiple chronic diseases. They identified 3 important challenges that all physicians face as when attempting to improve practice.
1. These PCPs were concerned about their patients’ ability to adhere to complex guideline-directed care and uniformly supported the need to tailor care to individual patients. But beyond this certainty, opinions diverged. Some believed that the benefits of guideline-directed care outweigh the harms, while others believed the opposite to be true, and still others thought there wasn’t sufficient data to support either position.
2. PCPs used varying strategies to balance risks and benefits while adhering to complex guideline-directed care. Some tried to prioritize certain clinical problems; for example, focusing on cardiovascular disease no matter what other conditions the patient had. Others stratified risk for individual diseases and focused treatment accordingly, such as focusing on fall risk, as opposed to cardiovascular risk, for an 85-year-old patient, but reversing the focus for a 70-year-old patient. Still others modified treatment in anticipation of adverse effects.
3. Many PCPs described conflicts between what they wanted to do for the patient and what the patient wanted.
What do you think? Is there a “right way” to manage patients with multimorbidity?
How are you balancing the risks and benefits of providing guideline-directed care in practice?
As general internists or preventive cardiologists, do you prioritize treating cardiovascular disease or tailor care in other ways?
Have you found any strategies to be helpful with patients or any tricks to facilitating care?
How do those of you who are interventionalists consider multimoribidity when making treatment decisions?
One Response to “How Are You Managing Co-Morbid Conditions?”
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The first fact to recognize is that as soon as the patient is on more than three drugs, he/she is pharmacologically unique, in that this particular combination of drugs was never evaluated for efficacy or morbidity. And there was an article in Annals within the past two years, which showed that if you try to manage any patient with 5 co-morbid conditions, some of the disease guidelines will conflict with another (and my computer-driven pharmacy order system at one of my hospitals constantly asks me about this).You just have to do the best you can, as we always do, trying to keep the patient alive and then cured within the narrow set of metabolic parameters the diseases allow. It’s almost like looking for the common overlap in a Venn diagram. And at discharge, the hospital billing computer always scrambles the conditions so that the hospital can get the most money (is the DRG better for ASCVD primary with AODM secondary, or the reverse?).