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Comorbidities Lead to Neglected Diabetes Self-Care

Posted: Friday, November 23, 2007

When patients with diabetes have severe comorbidities, they are likely to deal with them while neglecting glucose monitoring and other self-care tasks, according to a new study. 

Eve Kerr, M.D., M.P.H., of the University of Michigan, and colleagues report that, the type and severity of comorbid conditions, not just the comorbidity count or whether these conditions are linked to diabetes, compete with patients' ability to manage diabetes.

For example, the researchers said, many patients with diabetes do not realize that their disease increases their risk for heart disease and stroke, leading them to neglect blood pressure and cholesterol control. In fact, scores for diabetes self-care were worse among patients who had both diabetes and heart disease.

The findings emerged from a cross-sectional study of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study diabetes survey, sponsored by the National Institute on Aging.

Of the patients (ages 55 to 64 at the study start, the rest older than 65), 19% were African-American, 53% were women, and 25% used insulin.

Using multivariate models and controlling for patient demographics, the researchers assessed the association between comorbidities and each of two self-reported (phone and interview) outcomes, diabetes prioritization, and self-management ability.

In this sample of middle-age and older adults, only 8% reported having no comorbid conditions, whereas 70% reported two or more, the researchers said.  Of the respondents, 40% had at least one microvascular comorbidity, such as damage to blood vessels and therefore to nerves, eyes, and kidneys. At least 79% had at least one macrovascular comorbidity, including coronary artery disease, stroke, or heart failure, all aggravated or triggered by diabetes. 

Of the patients, 61% had at least one non-diabetes-related comorbidity. These included pulmonary disease for 10%, cancer for 14%, and arthritis for 55%.

Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management scores, the researchers reported.

For example, for three comorbid conditions compared with a reference of none, the diabetes prioritization was -8.1 (P0.001) and the self-management ability score was -5.9 (P=0.001).

For the most part, macrovascular and non-diabetes-related comorbidities took priority over diabetes care. On the other hand, microvascular conditions, often part of diabetes care, did not affect prioritization, the researchers said.

Nevertheless, higher numbers of all these conditions, including microvascular conditions, were all associated with lower diabetes self-management scores.

Severity also mattered. For the one condition for which the researchers had severity data, they found that in models examining the association between heart failure severity and diabetes prioritization and self-management, severe, but not mild, heart failure was associated with lower scores for these abilities.

Certain conditions, such as severe heart failure significantly interfered with diabetes self-care. This study suggests that patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about their care.

"It is clear that our aging population is facing significant challenges in managing the demands of multiple chronic conditions," the researchers said. Health professionals need to find a better understanding of how to adapt care so that it can balance the benefits and risks of multiple medical recommendations and also incorporate patient preferences, they added.

In an accompanying editorial Jacqueline A. Pugh, M.D., of the University of Texas at San Antonio, wrote that the study authors remind us that our continuing desire to focus on treatment of a single disease at a time does not match the vast majority of our patients who have multiple diagnoses.

However, Dr. Pugh wrote, "I would argue the importance of the study is in reminding us that we do a lousy job of integrating information and treatment for a given patient."

We need to take care of the whole person, she said, "not just their heart, knee, or pancreas, and to truly let that person be the decision maker with the care team providing information and support."

Practice Points:
Explain to interested patients that those with diabetes who have other severe medical problems, such as heart disease, are likely to neglect diabetes self-care tasks, such as glucose and diet monitoring.

Source: Diabetes In Control: Kerr EA, et al "Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management?" J Gen Intern Med 2007; DOI: 10.1007/s11606-007-0313-2. Pugh JA, "Priority setting for patients with multiple comorbidities: diabetes may not end up number one" J Gen Intern Med 2007; DOI: 10.1007/s11606-007-0434-7.

 
 
 
 
 
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