The Changing Face of Chronic Illness Management in Primary Care: A Qualitative Study of Underlying Influences and Unintended Outcomes

Linda M. Hunt; Meta Kreiner; Howard Brody

doi:10.1370/afm.1380

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Figure 1
Schematic representation of potential benefit and harm when the diagnostic threshold for type 2 diabetes is moved lower, increasing the number of people taking medications.

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Table 1

Criteria for Diagnosing Diabetes and Hypertension: Temporal Trends in Cutoffs for Starting Treatment^9,11

Condition and Cutoff	1992	1993	1998	2003	Increase in Diagnosed Cases
Diabetes: fasting plasma glucose, mg/dL
Diabetes	140	–	126	–	10.3 million^a
Prediabetes	None	–	110	100	–
Hypertension: blood pressure, mm Hg
In nondiabetic patients	160/95	140/90	–	–	22.0 million^b
In diabetic patients	–	–	–	130/80	–
Prehypertension	None	–	–	120/80	–

↵a Difference in the number of diagnosed cases of diabetes reported by the Centers for Disease Control and Prevention for 1997 and for 2009.³⁹
↵b Difference in number of diagnosed cases of hypertension reported by the Centers for Disease Control and Prevention for 1991 and 2008.^40,41 Because these numbers were reported as a percentage of the population aged older than 20 years (25% in 1991 and 30% in 2008), we used the US census reports of adult population size¹² to convert to millions of people for this table.

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Table 2

Selected Characteristics of 58 Clinicians Interviewed, 2009–2010

Characteristic	No. (%)
Sex
Male	26 (45)
Female	32 (55)
Race/ethnicity
Non-Hispanic white	37 (63)
African American	10 (17)
Native American	2 (3)
Pacific Islander	2 (3)
Asian	5 (9)
Hispanic	2 (3)
Age-group, y^a
24–34	12 (21)
35–44	19 (33)
45–55	16 (27)
>55	11 (19)
Degree
Doctor of medicine	34 (59)
Doctor of osteopathy	17 (29)
Physician assistant	2 (3)
Nurse practitioner	5 (9)
Type of clinic
University	3 (5)
Hospital/health system	21 (36)
Physician owned	21 (36)
FQHC	8 (14)
Other	5 (9)
Location of clinic
Urban	40 (69)
Rural	7 (12)
Suburban	11 (19)

FQHC=Federally Qualified Health Center.
↵a Age range: 27 to 77 years; median: 43 years.

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Table 3

Selected Characteristics of 70 Patients Interviewed, 2009–2010

Characteristic	No. (%)
Sex
Male	33 (47)
Female	37 (53)
Race/ethnicity
Non-Hispanic white	27 (38)
African American	21 (30)
Native American	3 (4)
Hispanic	19 (27)
Age-group, y^a
24–34	2 (3)
35–44	9 (13)
45–54	17 (24)
55–65	20 (29)
>65	22 (31)
Diagnosis
Diabetes only	15 (21)
Hypertension only	14 (20)
Both diabetes and hypertension	41 (59)
Interview language
English	53 (76)
Spanish	17 (24)
Income ranges reported
<$10,000	21 (30)
$11,000–$20,000	16 (23)
$21,000–$50,000	15 (21)
$51,000–$70,000	4 (6)
$71,000–$90,000	4 (6)
>$90,000	4 (6)
No answer	6 (9)

↵a Age range: 32 to 85 years; median: 58 years.

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The Article in Brief

Linda M. Hunt , and colleagues

Background This study of management of type 2 diabetes and hypertension examines clinicians' treatment strategies, factors influencing treatment decisions, and patient understandings and experiences in managing these illnesses.

What This Study Found With 11 percent of the US population and 40 percent of people older than 60 years taking 5 or more medications, this study examines the underlying influence and unintended outcomes of the dramatic rise in polypharmacy in patients with diabetes, hypertension, or both. The authors suggest that heavy use of pharmaceuticals is caused by a number of factors, most notably (1) increasingly stringent diagnostic and treatment thresholds for common chronic conditions, (2) clinician auditing and reward systems, and (3) a prescribing cascade whereby more medications are prescribed to control the effects of already prescribed medications. The authors identify several challenges to patient well-being resulting from a heavy reliance on pharmaceuticals, including financial costs and adverse drug effects. They present a conceptual model, the inverse benefit law, to provide insight into the impact of pharmaceutical marketing efforts on the observed trends.

Implications

The authors call for (1) policies that will exclude individuals or organizations with financial conflicts of interest from involvement with guideline-writing panels, (2) physicians to be discouraged from seeing drug representatives, and (3) the monitoring of pay-for-performance plans for evidence of unintended negative effects on patients.