Chronic disease management - clinical, community, and

Chronic disease management - clinical, community, and
patient-centered approaches
Research team
Eva K Lee, Xin Wei, Cory Girard, Georgia Tech
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
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
Next Steps
 Compare our treatment plan against actual
 Design new treatment practice guidelines
 Design remote patient sensors and monitoring
 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.