The Impact of Comorbid Chronic Conditions on Diabetes Care

  1. John D. Piette, PHD and
  2. Eve A. Kerr, MD, MPH
  1. Address correspondence and reprint requests to Dr. John D. Piette, Center for Practice Management and Outcomes Research, VA Ann Arbor Health Care System, P.O. Box 130170, Ann Arbor, MI 48113-0170. E-mail: jpiette{at}

Effective diabetes management often presents enormous challenges. Not surprisingly, clinicians and patients alike can be overwhelmed by the need to address comorbid chronic conditions in addition to patients’ diabetes-specific treatment goals. Ignoring concurrent disease management, however, can lead to ineffective control of diabetes-specific risk factors and may miss opportunities to improve patients’ functioning, quality of life, and mortality risk.

Other chronic conditions are common among people with diabetes and account for much of the morbidity these patients face. According to the Medical Expenditure Panel Survey, most adults with diabetes have at least one comorbid chronic disease (1) and as many as 40% have at least three (2,3). The increasing prevalence of multimorbidity among older diabetic adults is at least in part an unintended consequence of our success in improving diabetes treatment quality. Improvements in HbA1c (A1C) monitoring and glycemic control have been documented in several large systems of care (4–7). More widespread use of treatments such as ACE inhibitors and aspirin have decreased patients’ risk of cardiovascular death (8–10). Diabetic patients are living longer, and like all Americans, this increases their chance of acquiring one of the many chronic diseases associated with aging.

Other more troubling trends have conspired to increase the impact of multimorbidity on diabetes management. In many health care systems, providers see patients during brief office visits and are overwhelmed by the number of health maintenance activities recommended by guidelines and quality monitoring agencies (11,12). When diabetic patients have multiple chronic conditions, screening, counseling, and treatment needs can far exceed the time available for patient-provider visits. Health problems that used to be treated in inpatient settings are increasingly managed within outpatient care, further straining providers’ resources for addressing diabetes-specific management goals (13). With inadequate health system support and …

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