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Study Finds Older Adults With T2DM, Comorbidities Aren't Getting Enough Treatment Time

Tony Hagen
CMS' decision to pay primary care physicians to coordinate for seniors with multiple chronic conditions cannot soon enough, if a study in Clinical Diabetes is any sign.
The CMS policy change that will pay primary care doctors to coordinate care, taking more time with patients who have multiple chronic conditions, is probably long overdue, if a 2014 study of older adults is any sign. (See cover story). Researchers conducted a series of small-group interviews involving 32 older patients, all of whom suffered from type 2 diabetes mellitus (T2DM) and other comorbidities.
 
The older adults expressed great frustration over not having enough time to consult with doctors, and said they needed more individualized treatment plans than they are getting, according to results published in Clinical Diabetes, a journal of the American Diabetes Association.1
 
The study also concluded that both doctors and older patients need tools and training, so that patients’ needs can be better interpreted and addressed. Based on the results, this may be true even if patients are achieving relatively good glycemic control—patients who by some standards were receiving quality care nonetheless told researchers they often felt overwhelmed. The research team encouraged greater consideration of older adults’ preferences for care, in part because the Affordable Care Act (ACA) calls for shared decision making in healthcare.

But the ACA also presents some inherent conflicts: while in some aspects it calls for personalized approaches to care, it is also moving toward a “value-based” reimbursement approach that rewards accountable care organizations, or ACOs, for population health management. Diabetes measures are a key component of ACO Medicare reimbursement.
 
In the January issue of Evidence-Based Diabetes Management, Patrick J. O’Connor, MD, MA, MPH, a senior clinical investigator for HealthPartners, discussed how the importance of meeting targets impacts both doctors and patients. He said that physicians and researchers alike must start to pay attention to the concept of “minimally disruptive medicine.” Patients get frustrated when doctors pile on too many pills to help patients meet targets when they are already very close to goal, if it means living with too many side effects or high out-of-pocket costs.2

And, there has long been a recognition that Medicare reimbursements do not reward physicians for taking time to tailor treatment plans to individual patients. So starting this year, CMS has moved to reward primary care physicians with payments of $40 per month per patient to coordinate care for patients with more than 1 chronic condition. Collecting this fee will require the patient’s involvement, consent, and a personal care plan.3
 
The focus group study, which took place in central Pennsylvania, involved patients aged 60 to 88 years (average age, 75.3 years). Most study participants were overweight, with an average body mass index of 32.5. Participants were 44% male and 100% non-Hispanic white; 52% had a college degree or higher level of education, 60% were married, and 84% were retired. The study recruited patients who had been diagnosed with T2DM for at least 1 year, and who suffered from at least 1 other comorbidity. On average, patients had lived with T2DM for 15 years, and 87.5% were taking at least 1 oral hypoglycemic medication.

Nearly half (46%) had been prescribed injectable insulin, although as a group they enjoyed good glycemic control, with their mean glycated hemoglobin (A1C) at 7.0 (range 5.6-8.2). Importantly, the authors cited 2 recent qualitative studies involving providers that “spoke of conflicts between balancing patients’ preferences with their own decisions for care and weighing the risks and benets of adhering to treatment guidelines.”1 These studies called for more “patient-centered” approaches to care.4,5
 
Eight 60-minute focus group sessions took place, with between 2 and 6 participants in each group. The participants’ chief complaints about their doctors were lack of empathy and understanding, unwillingness to hear patients talk about their health concerns, insensitivity and age discrimination, and an unwillingness to treat older patients with T2DM. “Strategies that facilitate a mutual understanding of treatment preferences may help providers and older adults with T2DM manage multiple health conditions more effectively and with greater peace of mind,” the authors wrote.
 
The 6 most commonly reported conditions participants had, in addition to T2DM, were hypertension, arthritis, retinopathy, hypercholesterolemia, coronary artery disease, and neuropathy. The study’s goal was to determine what perceived challenges the patients felt served as barriers to the kind of care they expected from their doctors. Among the conclusions was that financial savings could be achieved by addressing some of these challenges. The report indicated that these patients “described feeling frustrated and overwhelmed with the multiple lifestyle, self-care and medical demands required to manage their diabetes and other chronic comorbidities.”

However, the arrival of diabetes-specic complications tended to motivate older patients to better self-manage their health, the study said. A frequent complaint (by 18 of 32 participants) was that healthcare providers were hesitant to treat them after finding out they had T2DM. “If I have a cut on my finger, they don’t want to take care of it because I’m diabetic,” an unnamed patient was quoted as saying. “They told me there was surgery for spinal stenosis, but they won’t do the surgery because I’m diabetic,” the patient said, adding, “I think they’re worried about complications and malpractice. But they aren’t looking out for my best interests.”

Others told the authors they believed that age discrimination was a factor in their treatment, with 1 woman stating that doctors were sometimes not as aggressive in treating someone her age because she was “closer to death” than younger patients. Another woman said doctors tend to offer meaningless reassurance to older patients, even though genuine acknowledgment of the patient’s condition would be more helpful. “I think doctors discriminate against older people in that respect. They say that you’re OK, and you’re not,” she said.
 
More time reviewing individual preferences for care would be appreciated, the study participants said. In addition, some told the research team that doctors are not tailoring care to address the specic medical histories of older patients. For example, 1 patient expressed frustration with a doctor’s orders to exercise more. “I used to walk all the time, and now I can’t with the spinal stenosis and arthritis. I don’t know what to do about it. They just don’t want to understand that I can’t exercise,” the patient said.
 
Study authors concluded that older adults need individualized treatment plans and more “in-depth” communication with their healthcare providers. “Discussing perceived challenges to diabetes and comorbidity management may provide a systematic way to include older adults in the evaluation and treatment process, thereby enhancing the therapeutic alliance and lowering the economic burden of T2DM care,” the authors wrote.
 
Participants in the study stated that doctors were not fully aware of the difficulties of living with T2DM and managing other chronic ailments. The Clinical Diabetes researchers cited studies that appeared in 2011 and 2012 in which care providers acknowledged the difculty of managing comorbidities, and the need for individualized medicine.4,5
 
These studies cited the challenge of balancing a patient’s desire for more involvement in the treatment process with the provider’s own judgment about the best course of treatment and the need to avoid risk. The researchers who interviewed the older patients acknowledged that care providers were not similarly interviewed as part of their study and recommended that future research “involve the collection of mixed-method data from physician-patient pairs to assess communication and shared decision making regarding T2DM and comorbidity management.”
REFERENCES
 
1. Beverly EA, Wray LA, Chiu CJ, LaCoe CL. Older adults’ perceived challenges with health care providers treating their type 2 diabetes and comorbid conditions. Clin Diabetes. 2014;32(1)12-17.
 
2. Caffrey MK. A look beyond findings on telephone intervention reveals why having data matters. Am J Manag Care. 2015;21(SP2):SP45.
 
3. Caffrey MK. How will managed care implement the new $40 CMS coordination fee? AJMC website. http://www.ajmc.com/focus-of-the-week/1114/How-Will-Managed-Care-Implement-
the-New-40-CMS-Coordination-Fee. Published November 14, 2014. Accessed February 5, 2015.
 
4. Luijks HD, Loeffen MJ, Lagro-Janssen AL, van Weel C, Lucassen PL, Schermer TR. GPs considerations in multimorbidity management: a qualitative study. Br J Gen Pract. 2012; 62:e503-e510.
 
5. Fried TR, Tinetti ME, Iannone L. Primary care clinicians’ experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med. 2011;171:75-80.
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