NSF CHOT IUCRC PROGRESS REPORT – PROJECT # 13 Chronic disease management - clinical, community, and patient-centered approaches Research team Eva K Lee, Xin Wei, Cory Girard, Georgia Tech Description 68% Medicare spending goes to people with five or more chronic diseases. Reports found that between 44% - 57% of older patients take more than one unnecessary drug. The management of multiple diseases is complicated and offers daunting challenges to healthcare providers. More drugs are prescribed for treatment, which causes reduced adherence of patient to drug therapy, higher possibility of drug-drug interactions, more side effects observed on patients, less effective treatment, and more frequent changes in drug therapies. This results in more hospital visits, heavier burden on the use of health resources and higher medical expenses. The objective of this study is to optimize the medical interventions, treatment plan, and drug therapy decisions to reduce risks of adverse/side effects, increase efficacy of treatment, minimize mortality risk, and improve quality of life. How is this different than related research? First, the project focuses on coexisting multiple conditions, rather than a single disease. Thus, it is more challenging, interesting, and clinically relevant. So far, there is no mathematical model developed for long-term, dynamic, and all-around treatment of multiple diseases. A quantitative model based on clinical desirable outcome will reduce the negative effect of individual provider’s subjectivity on decision making process on managing treatments and drug therapy. The project helps to identify guidelines of multiple disease treatment. It will reduce the time pressure of Potential member benefits doctors on unnecessary patient visits, and assists doctors to manage complex treatments. This project considers multiple stakeholder perspectives (patients, doctors, caretakers). Chronic disease also requires pro-active patient participation as well as fostering a community and culture for healthy living. Active home and community engagement provides a supporting environment. Remote sensors can be fun and offers unique opportunity for health engagement and communication between providers and patients for sustained health improvement. Milestones achieved to date Completed retrospective review of 2011 and 2012 patients with multiple chronic conditions. Data relevant to treatment of patient, drugs, disease patterns were analyzed. Examined decision making process of doctors on treatment planning (e.g., treatment, drug prescription). This was done via interviews, observations, and analyzing of clinical notes. Focusing on diabetes with other chronic conditions, mathematical models were derived and implemented for optimal drug therapy decision and intervention plan. Established polypharmacy relationship on drugs used in multiple-diseased patients. Prepared a clinical paper for submission (still in progress). Next Steps Compare our treatment plan against actual treatment. Design new treatment practice guidelines Design remote patient sensors and monitoring devices. Incorporate community outreach and activities to promote healthy living environment. Produce quality personalized treatment plans for patients with multiple conditions. Return optimal outcome-driven treatment for multiple conditions with lower cost and better control of disease symptoms. The resulting treatment will also use minimum amount of drugs, thus reducing the risk of adverse/side effects and increasing the efficacy of the treatment (more drugs mean high risk of non-compliance). This all will translate to improve the quality of care and quality of life of patients. From hospital care coordination viewpoint, it will allow clinicians to optimize patients’ hospital visits and focus on personalized outcome-driven treatment. Positive and healthy home and community environment facilitate pro-active patient health engagement, and promote healthy eating. Remote sensors offer care continuation (outside clinic), promote active engagement to sustain broader health improvement.