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Comorbidity: implications for the importance of primary care in 'case' management
Barbara Starfield1, Klaus W Lemke, Terence Bernhardt
1Department of Health Policy and Management, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD 21205, USA. bstarfie@jhsph.edu
Insights
People with multiple health conditions, known as comorbidity, utilize more healthcare services for other conditions than their primary diagnosis. Primary care physicians manage most of these visits, highlighting the need for comprehensive care strategies.
Area of Science:
- Health Services Research
- Clinical Epidemiology
- Public Health
Background:
- Comorbidity is prevalent, yet understanding healthcare utilization patterns for individuals with multiple conditions remains limited.
- Existing research has not sufficiently detailed the specific types of health services accessed by patients with comorbid conditions.
Purpose of the Study:
- To investigate variations in healthcare resource utilization among nonelderly individuals based on diagnosis and the extent of comorbidity.
- To analyze patterns of visits to primary care physicians versus specialists in relation to the degree of comorbidity.
Main Methods:
- Utilized claims data from the nonelderly population, classifying cases by diagnosis and comorbidity using the Johns Hopkins Adjusted Clinical Groups (ACG) case-mix measure.
- Examined patient visits (adults and children) for 11 conditions, categorizing them by provider type (primary care physician or specialist) and condition focus (index vs. comorbid).
Main Results:
- Healthcare resource use was primarily driven by the degree of comorbidity, not the specific diagnosis.
- Visits for comorbid conditions surpassed those for the index condition across most comorbidity levels and provider types.
- Primary care physicians managed the majority of visits for both index and comorbid conditions, exceeding specialist visits, except for rare conditions managed by specialists.
Conclusions:
- Single-disease management strategies are insufficient for patients with high comorbidity, even in younger populations.
- Primary care physicians play a crucial role in managing the majority of care for both index and comorbid conditions.
- A patient-centered approach focusing on overall health needs within ongoing primary care, with enhanced generalist-specialist coordination, is more promising than disease-specific care.
Background:
Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions.
Methods:
Data from claims on the nonelderly were classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions.
Results:
Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions.
Conclusions:
In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients' overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.
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