Jako S Burgers, MD, PhD, Harkness Fellow
Eric C Schneider, MD, MSc, Associate
Professor
HARVARD SCHOOL OF PUBLIC HEALTH
Department of Health Policy and Management
Annual Research Meeting
Academyhealth, Chicago
June 28-30, 2009

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Healthcare research and practice is traditionally focused on managing single diseases or conditions
Half of patients with chronic conditions have more than one condition (CWF Survey 2007)
Managing multiple conditions is more complex, which might affect quality of care
Technical quality of care is the same and even better in patients with multiple conditions (Higashi et al., NEJM 2007)
Patients ratings of healthcare are not associated with technical quality of their care (Chang et al, Ann Intern Med 2006)

To analyze experiences of patients with multiple conditions focusing on coordination of care

 Data source: Commonwealth Fund International Survey of ‘Sicker Adults’ 2008
 Definition of ‘Sicker adults’:
−
Perceived health as fair or poor
−
Serious illness, injury, or disability
−
Hospitalized in last two years
−
Major surgery in last two years
 Telephone interview about experience with several aspects of quality of care
 Final analytic sample of 8973 sicker adults from Australia,
Canada, France, Germany, Netherlands, New Zealand, United
Kingdom, United States

1. Morbidity score (ranging from 1 to 10):
N + (2 x HS) -1
N = Number of chronic conditions with a maximum of 5
HS = Health Status ranging from 1 (good) to 3 (poor)
2. Type of condition:
• Hypertension
• Heart disease, including heart attack
• Diabetes
• Arthritis
• Asthma/COPD or chronic lung problems
• Depression, anxiety or mental health problems
• Cancer
3. Type of combination:
• Concordant (hypertension, heart disease, diabetes)
• Discordant (other combinations)

I.
Coordination of care:
A.
Patient experience with regular doctor
B.
Patient experience with specialists
C.
Patient reported care management
D.
Patient reported care for multiple chronic conditions
II.
Patient rating of overall quality of care

A. Questions related to regular doctor:
• Does your regular doctor know important information about your medical history?
• Does your regular doctor help coordinate or arrange the care received from other doctors and places?
B. Questions related to specialist:
• Did the specialist have information about your medical history?
• After you saw the specialist, did your regular doctor seem informed and up-to-date about the care you got?

C. Questions related to care management:
• Were test results, medical records, or reasons for referral not available at the time of your appointment?
• Did you feel that a medical test was unnecessary because the test had already been done?
• Did you feel that time was wasted because your medical care was poorly organized?
D. Care for multiple chronic conditions:
• Did the specialists seem aware of your different conditions?
• Did a doctor give you instructions that conflicted with what have been told for another condition?

How do you rate the quality of medical care that you have received in the past 12 months?

 Dichotomous variables created from Likert-scaled items
 Answers reverse-coded so that a higher percentage represent higher quality
 Comparisons stratified by
 Morbidity score: low (1 -3), medium (4-6), high (7-10)
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Type of conditions (in combination with one or more conditions)
Type of combinations (concordant vs. discordant)
 Chi-square tests for comparisons
 Multivariate logistic regression analysis, adjusting for age, gender, marital status, migration status, country, education, income, number of doctors seen, and having a regular doctor

Number of conditions (%)
0
1
2
3
4
5 or more
Type of conditions (%)
Hypertension
Arthritis
Depression, anxiety or other mental health problems
Asthma, COD or other chronic lung problems
Heart disease
Diabetes mellitus
Cancer
Type of combinations (%)
Concordant (hypertension, heart disease, diabetes)
Discordant (any other combination)
Analytic sample
(N = 8,973)
25
29
24
14
6
3
38
29
25
18
17
15
13
6
40

Prevalence (%) of morbidity score in study sample
25
20
15
10
5
0
1 2 3 4 5 6
Morbidity Score
7 8 9 10

Experience with Regular Doctor
Favorable Experience With Regular Doctor (%)
100
80
60
40
20
0
1 2 3 4 5 6
Morbidity Score
7 8 9 10
OR Adj*
(95% CI)
Low
1
Medium
0.89 (0.80-1.00)
High
1.01 (0.85-1.21)
* OR Adj = Odds Ratio adjusted for age, sex, marital status, education, migration status, income, country, regular doctor, and number of doctors seen

Experience with Specialists
Favorable Experience With Specialist (%)
100
80
60
40
20
0
1 2 3 4 5 6
Morbidity Score
7 8 9 10
Low Medium High
OR Adj*
(95% CI)
1 0.95 (0.83-1.09) 1.12 (0.90-1.40)
* OR Adj = Odds Ratio adjusted for age, sex, marital status, education, migration status, income, country, regular doctor, and number of doctors seen

Care Management
Favorable Care Management (%)
100
80
60
40
20
0
1 2 3 4 5 6
Morbidity Score
7 8 9 10
OR Adj*
(95% CI)
Low
1
Medium
0.74 (0.66-0.83)
High
0.56 (0.47-0.66)
* OR Adj = Odds Ratio adjusted for age, sex, marital status, education, migration status, income, country, regular doctor, and number of doctors seen

Care for Multiple Conditions
Favorable Care for Multiple Conditions (%)
100
80
60
40
20
0
2 3 4 5 6 7
Morbidity Score
8 9 10
Low Medium High
OR Adj*
(95% CI)
1 0.65 (0.53-0.79) 0.36 (0.28-0.45)
* OR Adj = Odds Ratio adjusted for age, sex, marital status, education, migration status, income, country, regular doctor, and number of doctors seen

Good Rating Overall Quality of Care (%)
100
80
60
40
20
0
1 2 3 4 5 6
Morbidity Score
7 8 9 10
OR Adj*
(95% CI)
Low
1
Medium
0.51 (0.44-0.60)
High
0.34 (0.27-0.43)
* OR Adj = Odds Ratio adjusted for age, sex, marital status, education, migration status, income, country, regular doctor, and number of doctors seen

Results: Influence of Type of Condition
(% difference with and without condition)
HYP ART MEN LUNG HD DM CA
Favorable experience with regular doctor
+ 0.8
+ 3.1
- 4.7
- 5.4
+ 1.4
+ 4.5
+ 4.4
Favorable experience with specialist
+ 4.3 + 3.8
- 7.0
- 5.5
+ 4.5
+ 5.3
+ 0.0
Favorable experience with care management
Favorable experience with care for multiple conditions
Good rating overall quality of care
+ 7.3
+ 4.0
+ 2.3
- 0.1
- 1.9
- 1.5
- 12.5
- 13.7
- 7.6
- 9.7
- 11.0
- 3.4
+ 0.2
- 1.3
+ 0.2
+ 2.9
+ 2.3
+ 1.5
- 3.1
- 1.5
+ 1.1
HYP = Hypertension, ART = Arthritis, MEN = Mental health problems, LUNG =
Chronic lung problems, HD = Heart disease, DM = Diabetes mellitus, CA = Cancer;
Bold = p < 0.05

Results: Influence of Type of Combination
Favorable experience with regular doctor
Favorable experience with specialist
Favorable experience with care management
Favorable experience with care for multiple conditions
Good rating overall quality of care
CON
69.2
77.8
70.1
83.8
92.0
DIS Difference
66.5
+ 2.7
73.8
59.8
74.4
86.6
+ 4.0
+ 10.3
+ 9.4
+ 5.4
CON = Concordant combinations (hypertension, heart disease, diabetes);
DIS = Discordant combinations (other)
Bold = p < 0.05

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Patients with high morbidity were more likely than those with low morbidity to report problems with coordination of care (i.e. care management, care for multiple conditions) and lower quality of care
Patient experience with doctors does not appear to be associated to problems with coordination of care in patients with high morbidity
Patients with chronic lung or mental health problems were more likely than patients with other chronic conditions to report negative care experiences
Patients with concordant conditions reported better coordination and higher quality than patients with other combinations of conditions

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Data were collected from selective sample of ‘sicker adults’
Patient reported conditions may not be congruent with doctor’s diagnosis
Other major conditions were not included, such as gastrointestinal and genitourinary problems
There may be differences between countries on definitions and labeling of diseases
A single measure for health status was used as a proxy for disease severity

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Coordination of care is a specific domain of quality, which needs specific attention in patients with high morbidity
Quality improvement efforts should focus on medium or high morbidity patients with chronic lung or mental health problems
Future research
• Country differences on disease management
• Determinants of good coordination of care
• Developing and validating measures of coordination and integration of patient care