Anand K. Parekh

Defining and measuring chronic conditions: imperatives for research, policy, program, and practice.

Current trends in US population growth, age distribution, and disease dynamics foretell rises in the prevalence of chronic diseases and other chronic conditions. These trends include the rapidly growing population of older adults, the increasing life expectancy associated with advances in public health and clinical medicine, the persistently high prevalence of some risk factors, and the emerging high prevalence of multiple chronic conditions. Although preventing and mitigating the effect of chronic conditions requires sufficient measurement capacities, such measurement has been constrained by lack of consistency in definitions and diagnostic classification schemes and by heterogeneity in data systems and methods of data collection. We outline a conceptual model for improving understanding of and standardizing approaches to defining, identifying, and using information about chronic conditions in the United States. We illustrate this model’s operation by applying a standard classification scheme for chronic conditions to 5 national-level data systems.

Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life.

The escalating problem of multiple chronic conditions (MCC) among Americans is now a major public health and medical challenge, associated with suboptimal health outcomes and rising health-care expenses. Despite this problems growth, the delivery of health services has continued to employ outmoded “siloed” approaches that focus on individual chronic diseases. We describe an action-oriented framework—developed by the U.S. Department of Health and Human Services with additional input provided by stakeholder organizations—that outlines national strategies for maximizing care coordination and for improving health and quality of life for individuals with MCC. We note how the frameworks potential can be optimized through some of the provisions of the new Patient Protection and Affordable Care Act, and through public-private partnerships.

The Challenge of Multiple Comorbidity for the US Health Care System

THE AGING OF THE US POPULATION, COMBINED WITH improvements in modern medicine, has created a new challenge: approximately 75 million people in the United States have multiple (2 or more) concurrent chronic conditions, defined as “conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living.” Is the 21st-century US health care system prepared to deal with the consequences of successfully treating patients who have conditions, often multiple, that they would not have survived in the early 20th century? Current indications suggest that it is not. As the number of chronic conditions affecting an individual increases, so do the following outcomes: unnecessary hospitalizations; adverse drug events; duplicative tests; conflicting medical advice; and, most important, poor functional status and death. Approximately 65% of total health care spending is directed at the approximately 25% of US population who have multiple chronic conditions. Individuals with multiple chronic conditions also face financial challenges related to the out-of-pocket costs of their care, including higher prescription drug costs and total out-ofpocket health care spending. The knowledge base for interrelated or unrelated but concurrent illnesses is limited, in part because of reliance on a scientific method that maximizes internal validity but excludes patients with complicating comorbidities from both epidemiologic studies and therapeutic trials. As a consequence of these knowledge gaps, clinical practice guidelines rarely account for or contain modifications for patients with multiple chronic conditions. In addition, it is not clear that health care professional trainees are being adequately prepared to care for this population, specifically regarding interdisciplinary care. Improving the health status of this population should involve increased care coordination, but achieving this goal for patients with up to a dozen clinicians and prescribers has been difficult. The current model of fee-forservice medical care offers few financial incentives to provide care coordination, and in some cases, there are incentives to permit duplication of services, rehospitalizations, and additional unnecessary care. Although the future of health care reform is uncertain, Congress has drafted legislation that includes experimental and pilot approaches to realigning such incentives and payments. Even if these necessary reforms were enacted, the effects of the clinician in improving health outcomes would remain dependent on the active participation of the individual patient. It is not clear whether the potential benefits of chronic disease self-care management; personal health records; and other health information exchange platforms, such as secure messaging, are being fully realized to maximize patient participation and health. One area in which some initial progress is being made to reduce the burden of multiple chronic conditions on society is advancing evidence-based clinical decision making in the care for patients with comorbidities. In September 2007, the Agency for Healthcare Research and Quality (AHRQ) sought proposals for observational research and modelbased studies with a focus on persons who have multiple chronic conditions. This funding opportunity used the list of 14 priority conditions in the Medicare Modernization Act and encouraged applications that included a mental health comorbidity and 1 or more physical conditions. Grants funded under this program are supporting work in several high-interest areas, including diabetes mellitus, mental illness, and preventive services. Diabetes is common (10% prevalence in the US adult population), and more than 90% of persons with diabetes have 1 or more comorbid chronic conditions. One AHRQfunded study is evaluating how flares of comorbid illnesses, such as chronic obstructive pulmonary disease, affect therapy for and outcomes of diabetes. Another study is investigating the relationships between comorbid conditions and diabetes treatment failure and mortality in patients with coexisting heart disease. A large, detailed database of patients with diabetes should provide information on how control of hemoglobin A1C, lipids, and blood pressure is associated with short-term harms in patients with diabetes and those with comorbid renal or heart disease. The coexistence of mental disease or disability with chronic medical illness is an area that has been understudied and

AHA/ACC/HHS Strategies to Enhance Application of Clinical Practice Guidelines in Patients With Cardiovascular Disease and Comorbid Conditions

Cardiovascular disease, the leading cause of death in the United States and worldwide, accounts for substantial suffering and healthcare-related expenditures.1–3 For more than 30 years, the American Heart Association (AHA) and the American College of Cardiology (ACC) have partnered with other organizations to translate the best available scientific evidence into clinical practice guidelines (CPGs) for cardiovascular conditions. These efforts reflect a shared vision and responsibility for using scientific evidence and the expert clinical opinion of leaders in the field to develop recommendations for healthcare providers. These CPGs, based on systematic methods to evaluate and classify evidence, have provided the cornerstones for delivering quality cardiovascular care. CPGs are essential tools for optimizing care for patients with cardiovascular conditions. Enhancing the utility of CPGs requires that the development process reflect the evolution of relevant foundational domains, such as biomedical discoveries, public policy, clinical care systems, and epidemiological knowledge. Dynamic changes in these domains pose substantial implications for organizations that develop CPGs. Among these changes is the increasing prevalence of ≥2 chronic conditions among individual Americans, estimated to be present in more than one quarter of adults.4 In the large population of Medicare beneficiaries, the prevalence of persons with multiple chronic conditions is considerably greater: more than two thirds (68%) have ≥2 chronic conditions, and 14% have ≥6 chronic conditions.5,6 CPGs jointly developed by the AHA/ACC are cardiovascular disease-specific documents focused on the prevention, diagnosis, and management of conditions such as ischemic heart disease, heart failure, and atrial fibrillation. These CPGs often contain considerations for special factors (eg, older adults) and common problems affecting pharmacokinetics (eg, renal impairment). For example, the 2014 CPG on atrial fibrillation7 highlights special considerations for acute myocardial infarction, pregnancy, hyperthyroidism, and other conditions. With the exception of the CPGs on …

AHA/ACC/HHS Strategies to Enhance Application of Clinical Practice Guidelines in Patients With Cardiovascular Disease and Comorbid Conditions From the American Heart Association, American College of Cardiology, and US Department of Health and Human Services

Cardiovascular disease, the leading cause of death in the United States and worldwide, accounts for substantial suffering and healthcare-related expenditures.1–3 For more than 30 years, the American Heart Association (AHA) and the American College of Cardiology (ACC) have partnered with other organizations to translate the best available scientific evidence into clinical practice guidelines (CPGs) for cardiovascular conditions. These efforts reflect a shared vision and responsibility for using scientific evidence and the expert clinical opinion of leaders in the field to develop recommendations for healthcare providers. These CPGs, based on systematic methods to evaluate and classify evidence, have provided the cornerstones for delivering quality cardiovascular care. CPGs are essential tools for optimizing care for patients with cardiovascular conditions. Enhancing the utility of CPGs requires that the development process reflect the evolution of relevant foundational domains, such as biomedical discoveries, public policy, clinical care systems, and epidemiological knowledge. Dynamic changes in these domains pose substantial implications for organizations that develop CPGs. Among these changes is the increasing prevalence of ≥2 chronic conditions among individual Americans, estimated to be present in more than one quarter of adults.4 In the large population of Medicare beneficiaries, the prevalence of persons with multiple chronic conditions is considerably greater: more than two thirds (68%) have ≥2 chronic conditions, and 14% have ≥6 chronic conditions.5,6 CPGs jointly developed by the AHA/ACC are cardiovascular disease-specific documents focused on the prevention, diagnosis, and management of conditions such as ischemic heart disease, heart failure, and atrial fibrillation. These CPGs often contain considerations for special factors (eg, older adults) and common problems affecting pharmacokinetics (eg, renal impairment). For example, the 2014 CPG on atrial fibrillation7 highlights special considerations for acute myocardial infarction, pregnancy, hyperthyroidism, and other conditions. With the exception of the CPGs on …

Multiple Chronic Conditions Among Medicare Beneficiaries: State-level Variations in Prevalence, Utilization, and Cost, 2011

OBJECTIVES Individuals with multiple (>2) chronic conditions (MCC) present many challenges to the health care system, such as effective coordination of care and cost containment. To assist health policy makers and to fill research gaps on MCC, we describe state-level variation of MCC among Medicare beneficiaries, with a focus on those with six or more conditions. METHODS Using Centers for Medicare & Medicaid Services administrative data for 2011, we characterized a beneficiary as having MCC by counting the number of conditions from a set of fifteen conditions, which were identified using diagnosis codes on the claims. The study population included fee-for-service beneficiaries residing in the 50 U.S. states and Washington, DC. RESULTS Among beneficiaries with six or more chronic conditions, prevalence rates were lowest in Alaska and Wyoming (7%) and highest in Florida and New Jersey (18%); readmission rates were lowest in Utah (19%) and highest in Washington, DC (31%); the number of emergency department visits per beneficiary were lowest in New York and Florida (1.6) and highest in Washington, DC (2.7); and Medicare spending per beneficiary was lowest in Hawaii (

Optimizing Health for Persons With Multiple Chronic Conditions

24,086) and highest in Maryland, Washington, DC, and Louisiana (over

IOM and DHHS Meeting on Making Clinical Practice Guidelines Appropriate for Patients with Multiple Chronic Conditions

37,000). CONCLUSION These findings expand upon prior research on MCC among Medicare beneficiaries at the national level and demonstrate considerable state-level variation in the prevalence, health care utilization, and Medicare spending for beneficiaries with MCC. State-level data on MCC is important for decision making aimed at improved program planning, financing, and delivery of care for individuals with MCC.

Toward a More Cogent Approach to the Challenges of Multimorbidity

The challenges for the US health care system of high health care costs and poor health outcomes in individuals with multiple (2 or more) concurrent, chronic conditions have been well documented.1,2 Estimates are that more than one-quarter of all adults have multiple chronic conditions3; in addition, more than two-thirds of Medicare fee-for-service beneficiaries have multiple chronic conditions,with14%having6ormorecommonconditions.4 Recently,theCentersforMedicare&MedicaidServices(CMS) released new data resources on chronic conditions among Medicare fee-for-service beneficiaries to better define the burden of chronic conditions among beneficiaries and the implications for the US health care system. In response to this public health challenge, the US Department of Health and Human Services (HHS) released its report “Strategic Framework on Multiple Chronic Conditions” in 2010. The strategic framework, developed with private sector input, provides HHS and its partners with a roadmap for improving the health status of persons with multiple chronic conditions across 4 overarching goals5 (Box). Within the first few years of implementation, the strategic framework has led to the following selected actions and continues to offer additional opportunities for further collaboration.

Aspirin in the Secondary Prevention of Cardiovascular Disease

BACKGROUND The increasing prevalence of Americans with multiple (2 or more) chronic conditions raises concerns about the appropriateness and applicability of clinical practice guidelines for patient management. Most guidelines clinicians currently rely on have been designed with a single chronic condition in mind, and many such guidelines are inattentive to issues related to comorbidities. PURPOSE In response to the need for guideline developers to address comorbidities in guidelines, the Department of Health and Human Services convened a meeting in May 2012 in partnership with the Institute of Medicine to identify principles and action options. RESULTS Eleven principles to improve guidelines’ attentiveness to the population with multiple chronic conditions were identified during the meeting. They are grouped into 3 interrelated categories: (1) principles intended to improve the stakeholder technical process for developing guidelines; (2) principles intended to strengthen content of guidelines in terms of multiple chronic conditions; and (3) principles intended to increase focus on patient-centered care. CONCLUSION This meeting built upon previously recommended actions by identifying additional principles and options for government, guideline developers, and others to use in strengthening the applicability of clinical practice guidelines to the growing population of people with multiple chronic conditions. The suggested principles are helping professional societies to improve guidelines’ attentiveness to persons with multiple chronic conditions.