The effect of incident comorbidities on guideline-concordant chronic disease care

描述(由申请人提供)：大多数慢性疾病护理指南是针对具体疾病的。然而，面对医疗复杂性，遵守这样的指导方针可能是不可能的，或者可能导致意想不到的后果。或者，指南可能仍然适用于复杂的患者，但需要替代的护理策略。这些情况根本没有得到很好的定义。 我们提出了一个模型，该模型描述了来自共病条件的事件(如并存慢性病的恶化；或新的共病的诊断)如何影响指标条件的指南一致性护理(GCC)。大约19,000名受试者的数据将从科罗拉多州Kaiser Permanente的电子数据库中提取，该组织是一家非营利性医疗保健组织。我们将评估新发抑郁症、新发可治疗癌症和慢性肺部疾病恶化对2型糖尿病指标状态的影响。令人感兴趣的主要结果将是血红蛋白A1c，次要结果将是血压控制和血脂管理。将使用时变多元回归技术和潜在类别分析来a)评估在6年时间段内每种并存疾病对GCC的初始和持续影响；以及b)识别由于无法达到GCC的水平而面临健康结局不良风险的患者亚群。其他分析将评估服药依从性作为无法实现GCC的中介。基于这些分析的结果，我们将提出对现有糖尿病护理指南的具体适应，以及针对复杂糖尿病患者的替代护理管理策略，这将服从于进一步的研究。我们预计，我们的建议也将适用于其他慢性疾病的组合。 使用这样的模型来描述GCC的达标情况将有助于识别面临不良健康结局风险的复杂患者，以便a)可以适当修改指南，以反映复杂患者的护理过程需求；b)可以在介入试验中对这些人群进行研究，以确定最合适的护理管理；以及c)我们可以定义新开发的针对复杂患者群体的质量衡量标准可能应用于的目标人群。这些信息可能会为显著提高对日益增长的美国弱势群体的护理质量和效率提供基础。

DESCRIPTION (provided by applicant): Most guidelines for care of chronic medical conditions are disease-specific. However, adherence to such guidelines in the face of medical complexity may be impossible to carry out or may result in unintended consequences. Alternatively, guidelines may remain relevant for complex patients, but require alternate care strategies. These situations are not at all well defined. We propose a model that describes how an event from a comorbid condition (such as an exacerbation of a coexisting chronic illness; or the diagnosis of a new comorbidity) can affect guideline-concordant care (GCC) for an index condition. Data on approximately 19,000 subjects will be extracted from electronic databases from Kaiser Permanente Colorado, a not-for profit HMO. We will assess the effect of the comorbidities of new-onset depression, new-onset treatable cancer, and exacerbations of chronic pulmonary disease on the index condition of type-2 diabetes. The primary outcome of interest will be Hemoglobin A1c, and secondary outcomes will be blood pressure control and lipid management. Time-varying multivariate regression techniques and latent class analysis will be used to a) assess both the initial and ongoing effects of each comorbid condition on GCC for the index condition over a 6-year time period; and b) identify a subgroup of patients at risk for poor health outcomes due to inability to achieve GCC. Additional analyses will assess medication adherence as a mediator of inability to achieve GCC. Based on results of these analyses, we will propose both specific adaptations to existing diabetes care guidelines, and alternate care management strategies for complex patients with diabetes, that will be amenable to further investigation. We expect that our recommendations will be relevant to other combinations of chronic conditions as well. Using such a model to describe the attainment of GCC will help identify complex patients at risk for poor health outcomes so that a) guidelines can be appropriately altered to reflect the process-of-care needs of complex patients; b) these populations can be studied in interventional trials to determine the most appropriate care management; and c) we can define the target populations to which newly developed quality measures for complex patient populations may be applied. This information may provide the basis for significantly improving the quality and efficiency of care for a growing and vulnerable segment of the U.S. population.