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The burden of comorbid medical conditions and quality of diabetes care

¹Divisions of Preventive Medicine
²General Internal Medicine
³Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Deep South Center on Effectiveness at the Birmingham VA Medical Center, Birmingham, AL

jhalanych{at}uab.edu

ABSTRACT

Objective: With performance-based reimbursement pressures, it is concerning that most performance measurements treat each condition in isolation, ignoring the complexities of patients with multiple comorbidities. We examined the relationship between comorbidity and commonly assessed services for diabetic patients in a managed care organization.

Research Design and Methods: In 6,032 diabetic patients, we determined the association between the independent variable medical comorbidity, measured by the Charlson Comorbidity Index (CCI), and the dependent variables hemoglobin A1c (A1c) testing, lipid testing, dilated eye exam, and urinary microalbumin testing. We calculated predicted probabilities (PP) of receiving tests for patients with increasing comorbid illnesses, adjusting for patient demographics.

Results: A1c and lipid testing decreased slightly at higher CCI: PP (95% CI) for CCI quartiles 1, 2, 3, and 4 were 0.83 (0.70, 0.91), 0.83 (0.69, 0.92), 0.82 (0.68, 0.91), 0.78 (0.61, 0.88) for A1c and 0.82 (0.69, 0.91), 0.81(0.67, 0.90), 0.79 (0.64, 0.89), 0.77 (0.61, 0.88) for lipids. Dilated eye exam and urinary microalbumin testing did not differ across CCI quartiles: PP (95% CI) were 0.48 (0.33, 0.63), 0.54 (0.38, 0.69), 0.50 (0.34, 0.65), 0.50 (0.34, 0.65) for eye exam and 0.23 (0.12, 0.40), 0.24 (0.12, 0.42), 0.24 (0.12, 0.41), 23 (0.11, 0.40) for urinary microalbumin.

Conclusions: Services received did not differ based on comorbid illness burden. Because it is not clear whether equally aggressive care confers equal benefits to patients with varying comorbid illness burden, more evidence confirming such benefits may be warranted prior to wide spread implementation of Pay for Performance programs using currently available "one size fits all" performance measures.

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