Impact of the Prevalence of Concordant and Discordant Conditions on the Quality of Diabetes Care in Family Practices in England

Dear authors,

Your article on practice-level chronic condition prevalence and the association with diabetes care is an important step towards understanding the complex influence of multimorbidity on chronic condition care. The major contributions are: the concordant-discordant model alone is incomplete to understand the influence of multimorbdiity on diabetes care quality, and system and population-level interventions are likely needed.

Your findings that the concordant-discordant model does not fully explain differences in care outcomes at a practice-level parallels findings at a patient-level in smaller studies (Lagu et al. 2008, Pentakota et al. 2012, Magnan et al. 2015). There is great variability in condition severity and symptomology that can contribute to the influence a comorbid condition has on diabetes care quality (Piette and Kerr 2006). Conditions that are more severe, such as cancer, COPD or heart failure, might garner more attention than conditions that are less severe or are asymptomatic. The increased attention could result in improved quality of diabetes care, as in your findings, through more intense medical care and more interactions with the health system. However, other all severe or symptomatic conditions in your findings were related to worse diabetes care quality. This mixed picture suggests, as you state, that the concordant-discordant model cannot fully explain the interaction between multimorbidity and care outcomes. The specific conditions, or combination of conditions, seem to have an influence that is separate from the concordant-discordant characteristic.

Also important is your comment that on the implications of your findings for system- and population-level interventions tailored to the populations they serve. Management of complex patients with multimorbidity will necessitate a multidisciplinary approach within the health system, with chronic care managers, pharmacists, dieticians, educators, physicians, and other professionals working together efficiently. Community support is paramount as most care takes place outside the health system: medication adherence, patient self-monitoring, and lifestyle choices. Additionally, your findings suggest that there is a potential for lower quality of care for patients living in areas of increased social deprivation, a well-established pattern in the US. Socioeconomic status, health literacy, and access to care (financial and geographic) are key influences that need to be addressed for optimal chronic condition management (Bayliss et al. 2014). It would be interesting to see this study repeated in diverse populations, especially those without standardized, universal health care coverage.

Multimorbidity is a clinical and research priority (US DHHS 2010), and your article demonstrates how complex the associations can be. Future work to elucidate the mechanisms behind the mix of positive and negative associations with different conditions, as well as with patient contextual factors, is needed.

References:

Lagu T, Weiner MG, Hollenbeak CS, Eachus S, Roberts CS, Schwartz JS, Turner BJ. The impact of concordant and discordant conditions on the quality of care for hyperlipidemia. J Gen Intern Med. 2008;23(8):1208-1213.

Pentakota SR, Rajan M, Fincke BG, Tseng CL, Miller DR, Christiansen CL, Kerr EA, Pogach LM. Does diabetes care differ by type of chronic comorbidity?: An evaluation of the Piette and Kerr framework. Diabetes Care. 2012;35(6):1285-1292.

Magnan E, Palta M, Mahoney J, Pandhi N, Bolt D, Fink J, Greenlee R, Smith M. The Relationship of Individual Comorbid Chronic Conditions to Diabetes Care Quality. BMJ Open Diabetes Research and Care. 2015; 3(1).

Piette JD, Kerr EA. The impact of comorbid chronic conditions on diabetes care. Diabetes Care. 2006;29(3):725-731.

Bayliss EA, Bonds DE, Boyd CM, Davis MM, Finke B, Fox MH, Glasgow RE, Goodman RA, Heurtin-Roberts S, Lachenmayr S, Lind C, Madigan EA, Meyers DS, Mintz S, Nilsen WJ, Okun S, Ruiz S, Salive ME, Stange KC. Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters. Ann Fam Med. 2014;12(3):260-269.

U.S. Department of Health & Human Services. Multiple Chronic Conditions--A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. Washington, D.C. U.S. Department of Health & Human Services; December 2010.

Competing interests: None declared