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Comorbidity and PCCs
Cynthia M. Boyd, MD MPH
Assistant Professor of Medicine and
Health Policy and ManagementJohns Hopkins University Clinical Practice Guidelines (CPGs)
•Developed for management of a specific •How do they apply to people with multiple Copyright 2006 The Johns Hopkins University Does CPG Address Older Patients with Multiple Guideline
Does CPG mention treatment ?
Discuss quality
Older | Multimorbid | Both
of evidence ?
Multimorbid
Diabetes
Hypertension
Osteoarthritis
Osteoporosis
Atrial Fibrillation
Hypercholesterolemi
a
Total Addressed:
7/9 6/9 4/9
Source: Boyd, C. M. et al. JAMA 2005;294:716-724.
Copyright 2006 The Johns Hopkins University Did CPG Give Specific Recommendations for Treatment of Older Patients with Multiple Comorbid Conditions ? Disease guideline
Single comorbid
Multiple comorbid
condition
conditions
needed to
benefit/treat
Diabetes
Hypertension
Osteoarthritis
Osteoporosis
COPD
Atrial Fibrillation
Chronic Heart
cholesterolemia
Total Addressed:
* Only in reference to certain diseases or situations.
Copyright 2006 The Johns Hopkins University • 79 year old woman with 5 chronic conditions of moderate severity: COPD, HTN, DM, OA, Osteoporosis • We generated an aggregate treatment regimen for this hypothetical patient by combining the relevant CPGs. We: – Followed explicit instructions when available– Assumed once a day drug dosing when available– Assumed generic drugs when available– Took advantage of potential synergies between CPGs– Chose medicines with least adverse effects / interactions Copyright 2006 The Johns Hopkins University Time Medications
Periodic
pharmacologic
Ipratropium MDI
Check feet
Joint protection
Pneumonia vaccine,
Alendronate 70mg
Sit upright 30 min.
Yearly influenza vaccine
Check blood sugar
conservation
All provider
visits:Evaluate Self-
Eat Breakfast
2.4gm Na, 90mm K,
Exercise (non-
monitoring blood
HCTZ 12.5 mg
Adequate Mg, ↓
weight bearing
glucose, foot exam and
Lisinopril 40mg
cholesterol &
if severe foot
Glyburide 10 mg
saturated fat, medical disease, weight
ECASA 81 mg
nutrition therapy for
bearing for
Quarterly HbA1c,
Metformin 850mg
diabetes, DASH
osteoporosis)
biannual LFTs
Naproxen 250mg
strengthening
Yearly creatinine,
electrolytes,
Omeprazole 20mg
exercises,
microalbuminuria,
Calcium + Vit D 500mg
Exercise ROM
cholesterol
Eat Lunch
Diet as above
exercises
Referrals: Pulmonary
Ipratropium MDI
rehabilitation
Calcium+ Vit D 500 mg
environmental
Physical Therapy
exposures that
DEXA scan every 2 years
Eat Dinner
Diet as above
exacerbate
Yearly eye exam
Ipratropium MDI
Medical nutrition therapy
Metformin 850mg
appropriate
Patient Education: High-
Naproxen 250mg
footwear
risk foot conditions, foot
Calcium 500mg
care, foot wear
Albuterol MDI
Lovastatin 40mg
Osteoarthritis
Ipratropium MDI
Limit Alcohol
COPD medication and
delivery system training
Maintain normal Diabetes Mellitus
body weight
Implications for Development of PCCs
– Cluster of related conditions– Prevalent combinations of conditions • Treatment regimen complexity• Synergies/interactions between treatments – What to do about multitude of infrequent but yet – Metrics based on single disease guidelines Copyright 2006 The Johns Hopkins University PCCs: future potential with electronic
health records (EHRs)
1) Claims based: HgbA1c measurement2) Rx – utilization of medicationsEHR1) Laboratory values (e.g. LDL level)2) Clinical information (e.g. BP level)3) Complex Clinical Info: ADEs (ACEi → high K)4) Patient Factors: Social /Behavioral / 5) Provider Response to Value (e.g. titration of BP Copyright 2006 The Johns Hopkins University

Source: http://www.acg.jhsph.edu/ACGDocuments/2006_Conf/Plenary_2_Boyd.pdf