XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)62167-9.pdf

Frailty in elderly people

Background: There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use. Methods: We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools. Results: The CSHA Clinical Frailty Scale was highly correlated ( r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%–30.6%) and entry into an institution (23.9%, 95% CI 8.8%–41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality). Interpretation: Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.

/pdf/a-global-clinical-measure-of-fitness-and-frailty-in-elderly-17k380brym.pdf

A global clinical measure of fitness and frailty in elderly people

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)60240-2.pdf

Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study

Frailty Consensus: A Call to Action

Three terms are commonly used interchangeably to identify vulnerable older adults: comorbidity, or multiple chronicconditions,frailty, anddisability. However, in geriatricmedicine,there isagrowingconsensusthatthese are distinct clinical entities that are causally related. Each, individually, occurs frequently and has high import clinically. This article provides a narrative review of current understanding of the definitions and distinguishing characteristics of each of these conditions,including theirclinical relevance and distinct prevention and therapeutic issues, and how they are related. Review of the current state of published knowledge is supplemented by targeted analysesin selectedareas where no current publisheddataexists. Overall,the goalof this articleis to providea basis fordistinguishingbetweenthesethreeimportantclinicalconditionsinolderadultsandshowinghowuseofseparate, distinct definitions of each can improve our understanding of the problems affecting older patients and lead to development of improved strategies for diagnosis, care, research, and medical education in this area.

/pdf/untangling-the-concepts-of-disability-frailty-and-3jhe15an05.pdf

Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care

ContextClinical practice guidelines (CPGs) have been developed to improve the
quality of health care for many chronic conditions. Pay-for-performance initiatives
assess physician adherence to interventions that may reflect CPG recommendations.ObjectiveTo evaluate the applicability of CPGs to the care of older individuals
with several comorbid diseases.Data SourcesThe National Health Interview Survey and a nationally representative
sample of Medicare beneficiaries (to identify the most prevalent chronic diseases
in this population); the National Guideline Clearinghouse (for locating evidence-based
CPGs for each chronic disease).Study SelectionOf the 15 most common chronic diseases, we selected hypertension, chronic
heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes
mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis,
which are usually managed in primary care, choosing CPGs promulgated by national
and international medical organizations for each.Data ExtractionTwo investigators independently assessed whether each CPG addressed
older patients with multiple comorbid diseases, goals of treatment, interactions
between recommendations, burden to patients and caregivers, patient preferences,
life expectancy, and quality of life. Differences were resolved by consensus.
For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease,
type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated
the recommendations from the relevant CPGs.Data SynthesisMost CPGs did not modify or discuss the applicability of their recommendations
for older patients with multiple comorbidities. Most also did not comment
on burden, short- and long-term goals, and the quality of the underlying scientific
evidence, nor give guidance for incorporating patient preferences into treatment
plans. If the relevant CPGs were followed, the hypothetical patient would
be prescribed 12 medications (costing her $406 per month) and a complicated
nonpharmacological regimen. Adverse interactions between drugs and diseases
could result.ConclusionsThis review suggests that adhering to current CPGs in caring for an
older person with several comorbidities may have undesirable effects. Basing
standards for quality of care and pay for performance on existing CPGs could
lead to inappropriate judgment of the care provided to older individuals with
complex comorbidities and could create perverse incentives that emphasize
the wrong aspects of care for this population and diminish the quality of
their care. Developing measures of the quality of the care needed by older
patients with complex comorbidities is critical to improving their care.

/pdf/clinical-practice-guidelines-and-quality-of-care-for-older-4dkwbw3b1x.pdf

Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance.

/pdf/clinical-practice-guidelines-and-quality-of-care-for-older-3n73ffhr3n.pdf

Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid Diseases

Purpose.Although more than 125 million North Americans have one or more chronic conditions, medical training may not adequately prepare physicians to care for them. The authors evaluated physicians’ perceptions of the adequacy of their chronic illness care training to and the effects of trai

More training needed in chronic care: A survey of U.S. physicians

Context Although hospitals have devoted substantial resources to critical pathways, it is not known whether they routinely evaluate the clinical or economic effects of these pathways. Objective To determine how use and evaluation of critical pathways differ between academic and community hospitals. Design Cross-sectional survey. Participants Hospitals participating in consortia for improving quality of care associated with the Institute of Health Care Improvement and the VHA, Inc. (formerly known as the Voluntary Hospitals of America, Inc.). Hospital administrators at 41 hospitals completed the survey (71% response rate), representing 13 academic medical centers, 13 community teaching hospitals, and 15 community hospitals. Measures Use of critical pathways and measurement of clinical and economic outcomes of pathways. Results The median number of adult critical pathways used by academic hospitals, community teaching hospitals, and community hospitals was 25, 18, and 3, respectively. The most common pathways were community-acquired pneumonia, total hip or knee replacement, and stroke or transient ischemic attack. The percentage of hospitals with pathways dedicating staff to manage them was 78% for academic hospitals, 22% for community teaching hospitals, and 14% for community hospitals (P = 0.02). Evaluation practices varied widely among hospitals with pathways. Measures assessed included monitoring length of stay (85%), total hospital costs (74%), in-hospital mortality (62%), infectious complications (53%), readmission rates (47%), functional status (18%), and adverse drug events (15%). Conclusion The use of critical pathways varies substantially among hospitals participating in quality improvement consortia. Use was highest in academic centers and lowest in community hospitals. Many hospitals with pathways do not track important clinical outcomes as part of their evaluation practices.

Jonathan Darer

Papers

Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care

Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance.

Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid Diseases

More training needed in chronic care: A survey of U.S. physicians

Use and evaluation of critical pathways in hospitals.