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
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Comorbidity and PCCs
Clinical Practice Guidelines (CPGs)
Does CPG Address Older Patients with Multiple
Guideline
Did CPG Give Specific Recommendations for Treatment of Older
Patients with Multiple Comorbid Conditions ?
Disease guideline
• 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
Implications for Development of PCCs
PCCs: future potential with electronic