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January/February 2012 Annals of Family Medicine

The January/February issue of Annals takes an up-close look at multimorbidity, the coexistence of multiple chronic health conditions in a single individual, a phenomenon that is growing at an alarming rate and bankrupting the U.S. health care system. It is estimated by the year 2020, 25 percent of the American population will be living with multiple chronic conditions, and costs for managing these conditions will reach $1.07 trillion. In fact, more than three-fifths of health care spending is on behalf of people with multiple chronic conditions, according to an analysis of the 2001 Medical Expenditure Survey.

As the articles in this issue point out, care for patients with multimorbidity is costly and ineffective in large part due to the mismatch between the acute care-orientation of the delivery system and the chronic care needs of these patients. This mismatch induces many failures: medical errors, underdiagnoses, inconsistent disease monitoring, insufficient education and counseling, adverse drug reactions, conflicting advice, and the duplication of some services and inappropriate omission of others.

Three research articles, a policy brief and an editorial in this issue on the care of complex patients advance our understanding of this problem and begin to offer solutions that address the changing nature of disease and look beyond the system's current fragmented, specialty-driven, one-disease-at-a-time approach. These articles challenge clinicians, educators, researchers, and decision makers to consider integrated approaches that focus on the patient as a whole and offer continuous care and coordination across health care settings and providers.

Medical Home Elements Associated with Lower Mortality

Patients who report greater access to the primary care attributes of comprehensiveness, patient-centeredness and enhanced access have lower mortality, a finding which strongly supports the ongoing patient-centered medical home health care redesign efforts in the United States. Analyzing nationally representative data on 52,241 patients aged 18 to 90 years from the Medical Expenditure Panel Survey, researchers found patients' primary care attributes scores (which measured to what degree the patients' usual source of care had the three primary care attributes) were inversely associated with mortality with greater reported patient access to the studied attributes associated with lower mortality (adjusted hazard ratio 0.79 during up to six years of follow-up.) Adoption of these attributes, the authors conclude, may have the potential to reduce preventable deaths. They also believe their findings may have important implications for the medical home movement because the attributes studied all feature prominently in the blueprints for primary care practice redesign. Notably, the researchers also found evidence of social and demographic disparities in access to the primary care attributes racial/ethnic minorities, poorer and less educated individuals, and those without health insurance reported significantly lower access to the attributes. The authors call for interventions that promote equitable access to these primary care attributes.

Primary Care Attributes and Mortality: A National Person-Level Study

By Anthony Jerant, MD, et al

University of California, Davis

Intervention Improves Care for Complex Patients with Diabetes, Heart Disease and Depression

Complex patients with multiple chronic illnesses are source of significant suffering and great cost to the health care system. Researchers describe the positive effect of a team-based care management intervention on the initiation and adjustment of drug therapy for patients with uncontrolled diabetes and/or coronary heart disease and depression. The randomized controlled trial of 214 patients with poorly controlled diabetes or coronary heart disease and coexisting depression found patients in the intervention group 1) increased self-monitoring of key disease parameters relative to usual care patients and 2) had higher pharmacotherapy adjustment rates relative to usual care patients. At 12 months, the average rate of blood pressure monitoring was more than three times higher in the intervention group compared with the usual care group (3.6 days vs. 1.1 days per week), and the average blood glucose monitoring rate was 4.9 days per week vs. 3.8 days per week, respectively. Pharmacotherapy initiation and adjustment rates were six times higher for antidepressants, three times higher for insulin and nearly two times higher for antihypertensive medications among patients in the intervention group relative to usual care. Researchers did not find any difference in medication adherence rates. High baseline rates, they hypothesize, may have exerted a ceiling effect on potential improvements in medication adherence. The authors conclude these findings support the use of collaborative, team-based care management programs that target self-monitoring and timely treatment adjustment for patients with complex care needs.

Treatment Adjustment and Medication Adherence for Complex Patients With Diabetes, Heart Disease and Depression: A Randomized Controlled Trial

By Elizabeth H. B. Lin, MD, MPH, et al

Group Health Cooperative, Seattle

Intervention Integrating Care for Type 2 Diabetes and Depression Improves Patient Outcomes

A simple, brief treatment intervention using integration care managers is successful in improving medication adherence and disease outcomes for patients with comorbid depression and type 2 diabetes, a group known to have poor treatment adherence. Key components of the intervention were the integration of depression treatment with type 2 diabetes management and the provision of an individualized program to improve adherence to antidepressants and oral hypoglycemic agents that recognized the patients' social and cultural context. Primary care patients randomized to the integrated care intervention showed higher rates of adherence to oral hypoglycemic and antidepressant agents, as well as greater glucose control and fewer depressive symptoms at the final study visit, compared with patients randomized to usual care. Specifically, they found patients randomized to the integrated care intervention were more likely to achieve glycated hemoglobin levels of less than 7 percent (intervention 61 percent vs. usual care 36 percent) and remission of depression (intervention 59 percent vs. usual care 31 percent), compared to patients in the usual care group at 12 weeks. The authors call for an integrated approach to depression and type 2 diabetes treatment and conclude their intervention, which has a total contact time of only two hours, offers a sustainable solution that can be implementable in primary care for patients managing multiple medical comorbidities with varying degrees of complexity in pharmacotherapy regimens.

Integrated Management of Type 2 Diabetes Mellitus and Depression Treatment to Improve Medication Adherence: A Randomized Controlled Trial

By Hillary R. Bogner, MD, MSCE, et al

The University of Pennsylvania, Philadelphia

Summary Report on Medical Home Strategies for Caring for Patients with Complex Care Needs

The Agency for Healthcare Research & Quality and Mathematic Policy Research offer a summary report of strategies to help smaller primary care practices transform into medical homes that effectively serve patients with complex needs, particularly the frail elderly and working-age adults with disabilities. Drawing on case studies of five programs around the country that use a variety of approaches for supporting and collaborating with smaller, independent primary care practices in caring for patients with complex needs, they conclude that small practices require support and resources beyond those needed to meet current medical home standards. The two most critical supports, they assert, are additional practice reimbursement for time spent coordinating care and the integration of care coordinators within primary care teams. The summary includes a link to a longer policy brief published simultaneously on the AHRQ website.

Organizing Care for Complex Patients in the Patient-Centered Medical Home

By Eugene C. Rich, MD

Mathematic Policy Research, Washington, D.C.

Antidepressant Treatments Safe and Effective for Patients Regardless if They Have Comorbid Medical Conditions

Though past studies have suggested that patients with general medical conditions are less responsive to antidepressant therapy, researchers studying the effectiveness and side effects of three different antidepressant regimens on patients with comorbid medical conditions found only minimal differences in treatment response between groups. Analyzing data on 665 depressed patients with none (50 percent), one (24 percent), two (15 percent) or three or more (12 percent) treated medical conditions over 28 weeks, researchers found an almost lack of statistical difference in efficacy and tolerability outcome measures. Moreover, researchers did not find any differences in outcomes between antidepressant monotherapy using escitalopram and antidepressant combination therapies (either bupropion-SR plus escitalopram or venlafaxine-XR plus mirtazapine), regardless of the number of comorbid medical conditions the patient had. The authors conclude these findings suggest that depressed patients with or without comorbid conditions can receive safe and effective depression treatment without the risk of adverse effects or antidepressant tolerability, and no additional benefit is seen for combination antidepressant therapy versus monotherapy with selective serotonin reuptake inhibitors.

Depression Treatment in Patients With General Medical Conditions: Results from the CO-MED Trial

By David W. Morris, PhD, et al

The University of Texas Southwestern Medical Center, Dallas

Editorial: Simplifying Care for Patients with Depression Plus Other Comorbid Conditions

An accompanying editorial by Elizabeth Bayliss, MD, MSPH, Annals' associate editor and director of scientific development at the Kaiser Permanente Institute for Health Research, brings the aforementioned articles on multimorbidity into sharper focus. She calls for the implementation of effective, integrated, multidimensional care management for patients with complex care needs, specifically patients with depression plus other chronic medical conditions. And, she holds out hope that the increased attention being paid to patient-centered care may lead to a shift in reimbursement structures that will encourage implementation of the kind of comprehensive management strategies needed to improve care and quality of life for the growing number of people with chronic conditions.

Simplifying Care for Complex Patients

Elizabeth Bayliss, MD, MPH

Kaiser Permanente, Institute for Health Research

A Natural Experiment on Benzodiazepine Use in Primary Care Has Significant Impact

Assessing the impact of a recent Dutch reimbursement restriction on the use of benzodiazepines in primary care intended to reduce costs and limit misuse, researchers find the policy change led to a moderate decrease in the number of new diagnoses of anxiety and sleeping disorder and a reduction in benzodiazepine prescriptions among patients with newly diagnosed disorders. Analyzing data on 13,596 patients with an incident diagnosis of anxiety or sleeping disorder, researchers found a significantly lower incidence of sleeping disorder diagnoses (3,254 in 2008 vs. 2,863 in 2009) and anxiety diagnoses (3,769 in 2008 vs. 3,710 in 2009) after the restriction went into effect. Moreover, the proportion of patients being prescribed a benzodiazepine after a diagnosis was lower in 2009 than in 2008 for both anxiety (30 percent vs. 34 percent) and sleeping disorder (59 percent vs. 67 percent), as was the proportion of patients with more than one benzodiazepine prescription for both anxiety (36 percent vs. 43 percent) and sleeping disorder (35 percent vs. 43 percent). In fact, researchers note, benzodiazepines disappeared from the Netherlands' top 10 most prescribed medications and were among the top 10 medications with the steepest decrease in number of prescriptions. Notably, the authors found no increase in the use of alternative treatment for anxiety using selective serotonin reuptake inhibitors. These findings suggest that a policy measure can affect drug prescribing, and the authors conclude that physicians have room to reduce benzodiazepine prescribing.

Reimbursement Restriction and Moderate Decrease in Benzodiazepine Use in General Practice

By Jolle M. Hoebert, PharmD

Utrecht University, the Netherlands

Practice Facilitation Effective in Getting Practices to Adopt Evidence-Based Guidelines

As the country attempts to redesign medical practice, practice facilitation increasingly is used to assist with the needed practice changes. A systematic review of the literature found practice facilitation has a robust effect on the adoption of evidence-based guidelines in primary care. The review, which included 23 studies representing nearly 1,400 primary care practices, found practices are 2.76 times more likely to adopt evidence-based guidelines with practice facilitation than without. Further analysis found that tailoring the intensity of the intervention to the needs of the practice and the number of practices per facilitator impacted the effectiveness of the facilitation.

Systematic Review and Meta-Analysis of Practice Facilitation Within Primary Care Settings

By N. Bruce Baskerville, MHA, PhD, et al

University of Waterloo, Ontario, Canada

Viability of Urinary Tract Infection and Chlamydia trachomatis Testing Using a Single Specimen

Comparing first-void with midstream urine sampling, researchers find similar diagnostic accuracy for Chlamydia trachomatis testing. Of 100 patients with a first-void specimen positive for C trachomatis, 96 (96 percent) also had a positive midstream specimen. The authors conclude the use of newer nucleic acid amplification techniques makes the timing of specimen collection not as important for C trachomatis testing as previously thought. The ability to test for both C trachomatis and urinary tract infection (traditionally diagnosed using a midstream urine specimen) on a single midstream urine specimen could greatly aid clinical practice as urinary tract infection is an extremely common complaint in primary care and using one sample avoids the practical difficulty of collecting (or being unable to collect) further specimens from patients with uncertain diagnosis or reporting symptoms of both infections.

Chlamydia trachomatis Testing Sensitivity in Midstream Compared With First-Void Urine Specimens

By Derelie (Dee) Mangin, MB, ChB, DPH

University of Otago, Christchurch, New Zealand

Creating a Learning Health Care System, Possibilities and Market Limitations

Highlighting both the challenges and opportunities for using existing electronic clinical data from dispersed primary care practices to facilitate large-scale clinical research, the authors examine options and evaluate a functional software prototype for facilitating research within community practice settings. The Electronic Primary Care Research Network project was one of 12 funded by the National Institutes of Health with aim of developing clinical research. To fully realize the vision of a true learning health care system, the authors call for the creation of an open market for e-health applications. Such a system, they assert, can be achieved only through open collaboration between the various stakeholders from clinicians to vendors with the goal of creating a single shared architecture.

Envisioning a Learning Health Care System: The Electronic Primary Care Research Network, A Case Study

By Brendan C. Delaney, MA, BM, BCb, et al

Kings College, London

Lessons Learned In a Delivery Room in Rural Kenya: A Family Physician Reflects

In a compelling essay, a family physician relates an experience caring for a Kenyan woman in obstructed labor. He reflects on what he learned from the episode, which ended in the death of the woman's newborn son, and offers lessons about the transmissibility of arrogance, cross-cultural practices and the nature of science.


By Ronald E. Pust, MD

University of Arizona College of Medicine, Tucson

Contact: Angela Sharma
American Academy of Family Physicians

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