A Rational Approach to Managing Comorbidities
Short-and long-term treatment plans, acute exacerbations, new disorders, interactions, complicated monitoring, and specialist referrals. Comorbidities frustrate providers and patients, and few management guidelines exist. Some health plans offer disease or case management programs for patients with comorbidities, but most patients see individual providers, increasing the risk of fragmented care and negative outcomes.
Comorbidity is a predictor of mortality.1 Concordant comorbidities, such as obesity and diabetes, emanate from the same pathophysiology, whereas discordant conditions arise from separate pathophysiologies.2 Discordant comorbidities among those suffering from mental illness, for example, include hypertension (22.2%), gastroesophageal reflux disease (13.7%), and asthma (10.5%).3
Approximately half of all patients with chronic conditions have comorbidities. Increasing age is a factor: among people over 65 years old, 84% present with 2 or more chronic conditions, compared with 35% of patients 45 to 65 years of age and 13% of those aged 20 to 44.4
The pervasiveness of comorbidity is especially apparent in hospitals. In 1997 and 2002, respectively, 54% and 60% of hospitalized patients had at least 1 comorbidity, and 33% and 37% had 2 or more.5 The top 6 in 2002 were hypertension (29.4%), chronic obstructive lung disease (12.1%), diabetes mellitus (11.8%), fluid/electrolyte disorders (11.7%), iron deficiency/anemia (7.9%), and congestive heart failure (5.7%).5 Obesity, absent from the top 10 in 1997, earned the dubious distinction of 10th place in 2002. Age matters here, too. Fluid and electrolyte disorders are more likely among pediatric patients.5
Medication management concerns vary for different comorbidities. Table 12,6-11 lists common comorbidities and disease states.
Whereas all comorbidities need attention, acute or life-threatening conditions need priority assessment and treatment guided by rational drug use. Rational drug use addresses verified patient information with scientifically sound evidence to select the least expensive medication that meets individual patients' needs in appropriate doses for an adequate period of time. It means that patients can store medications correctly and conveniently and take them as prescribed.12 Rational drug use increases in importance with complex, lifelong treatment, especially because patients can be unpredictable, and new science constantly augments existing knowledge. Some suggestions for pharmacists follow.
Review All Medication-use Patterns
Problems with patient nonadherence and self-medication escalate with chronic comorbidities. Prescriber issues include inappropriate or needless drug use, antibiotic overuse or misuse, prescribing of ineffective drugs intentionally for placebo effect, and undertreatment. Systemic pressure points include reliance on pharmaceutical sales representatives for information, inadequate assessment opportunity or appointment duration, and poor consensus about treatments or alternatives.12,13 These problems can be frustrating. At the patient, prescriber, and system levels, adequate knowledge may not always change behavior.13
Understand Predictable Paths
Distinct patient populations have similar comorbidities, and pharmacists need to know their clientele's most common ones. Clinicians must appreciate that not all comorbidities require the same level of clinical effort; focusing solely on concordant comorbidities is short-sighted.2 Acknowledging common comorbidities as well as related and unrelated risk factors, clinicians should employ appropriate screening tools; encourage lifestyle modifications such as weight control, exercise, and smoking cessation; and teach trigger avoidance.8
Time the Treatments
Addressing all comorbidities concurrently may be unwise and impractical. With heavy workloads and care plans dictating shorter visits, clinicians often have insufficient time to cover all problems simultaneously or comprehensively. Even if they did, the process might overwhelm patients. Alternatively, clinicians must negotiate problem lists with patients, agreeing on problems of greatest urgency and time frames in which to address others. Pressured primary care providers will welcome care and counseling provided by other clinicians, especially if it is reinforcing.2
Evaluate Disease Trajectory
When comorbidities are identified, clinicians prognosticate?forecast the disease's probable trajectory?based on the individual patient's age, gender, functional status, lifestyle, and life expectancy. Reversible causes or exacerbating factors should be addressed first. Patients' preference to address symptomatic problems and de-emphasize symptomless issues underscores the preventive care challenge, especially if prophylaxis causes side effects.
When a patient has a condition that is imminently terminal, discontinuing chronic medications may increase comfort. A patient's distraught remark, "But my doctor said I needed to take this for the rest of my life!" may reflect genuine fear, and responses require good bedside manner.14
Review Drug Regimens
When patients with comorbidities present, pharmacists must review their drug regimens carefully (Table 24). Increasingly, pharmacy software programs are doing some of the drug regimen review (DRR). Most screen for drug interactions, dosing irregularities, and blatant red flags, and some will suggest better alternatives in terms of effectiveness or cost.
Some basic issues should guide pharmacists' interventions.
Patients need a significant amount of time to self-manage comorbidities and to conduct their own risk-benefit analyses. Patient-clinician relationships will influence adherence, as will cost; comorbidities escalate out-of-pocket drug costs exponentially.2 Pharmacists are well-placed to help patients understand potential disease trajectories and care processes.
Numerous studies have examined the cost-effectiveness of patient-specific interventions, structured order forms, and educational campaigns directed at prescribers. Most evidence suggests that printed materials alone or government warnings are ineffective.15-18 Face-to-face discussions and the application of treatment guidelines work better.18-20 Before talking with prescribers or other care team members, pharmacists need to check DRR results. They should prepare to present findings and suggestions concisely, respectfully, and confidently. All recommendations should be supported and supportable.
Despite public health campaigns, Americans' waistlines continue to expand, as do comorbid conditions. For many patients, pharmacy is the unifying link. It offers an opportunity for valuable counseling services.
Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Md. Dr. Zanni is a psychologist and health-systems consultant based in Alexandria,Va. The views expressed are those of the authors and not those of any government agency.
1. Antonelli Incalzi R, Fuso L, De Rosa M, et al. Co-morbidity contributes to predict mortality of patients with chronic obstructive pulmonary disease. Eur Respir J. 1997;10:2794-2800.
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;">2. Piette JD, Kerr EA. The impact of comorbid chronic conditions on diabetes care. <em>Diabetes Care.</em> 2006;29:725-731.</span></span>
3. Dakin CL. Medical comorbidities of patients admitted to an acute care psychiatric hospital. Presented at the Eastern Nursing Research Society, 18th Annual Scientific Meeting, April 20-22, 2006. Available at: http://enrs.confex.com/enrs/18am/techprogram/P1592.HTM. Accessed July 23, 2006.
4. Partnership for Solutions, Better Living for People with Chronic Conditions. Disease management and multiple chronic conditions. Available at: www.partnershipforsolutions.org/DMS/files/DMfactsheet21final.pdf. Accessed July 23, 2006.
5. Merrill CT, Elixhauser A. Hospitalization in the United States. HCUP Fact Book No. 6. Rockville, Md: Agency for Healthcare Research and Quality; 2002. AHRQ publication 05-0056. Available at: http://www.ahrq.gov/data/hcup/factbk6/. Accessed July 23, 2006.
6. Cazzetta S, Reidel AA, Nelson M, et al. Cardiovascular comorbidities common in patients with gout. J Natl Med Assn. 2004;96:872-878.
7. Sly RM. Epidemiology of allergic rhinitis. Clin Rev Allergy Immunol. 2002;22:67-103.
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;">8. Wang BW. Managing comorbidities in the rheumatic diseases: the new reality. <em>J Rheumatol.</em> 2003;30:899-901.</span></span>
9. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617-627.
10. Moroz A, Bogey RA, Bryant PR, Geis CC, O'Neill BJ. Stroke and neurodegenerative disorders. 2. Stroke: comorbidities and complications. Arch Phys Med Rehabil. 2004;85(3 suppl 1):S11-S14.
11. National Association of State Mental Health Program Directors. Technical Report on Psychiatric Polypharmacy, 2001. Available at: www.nasmhpd.org/general_files/publications/med_directors_pubs/Polypharmacy.PDF. Accessed October 18, 2005.
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;">12. Black F. Teaching rational prescribing. <em>Aust Fam Phys.</em> 1996;25:1097-1099.</span></span>
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;">13. Hogerzeil HV. Promoting rational prescribing: an international perspective. <em>Br J Clin Pharmacol. </em>1995;39(1):1-6.</span></span>
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;">14. Stevenson J, Abernethy AP, Miller C, Currow DC. Managing comorbidities in patients at the end of life. <em>BMJ.</em>2004;329:909-912.</span></span>
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;">15. Avorn J, Soumerai SB. Improving drug-therapy decisions through educational outreach: a randomized controlled trial of academically based "detailing." <em>N Engl J Med.</em> 1983;308:1457-1463.</span></span>
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;">16. Berbatis CG, Maher MJ, Plumridge RJ, Stoelwinder JU, Zubrick SR. Impact of a drug bulletin on prescribing oral analgesics in a teaching hospital. <em>Am J Hosp Pharm.</em> 1982;39:98-100.</span></span>
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;">17. Denig P, Haaijer-Ruskamp FM, Zijsling DH. Impact of a drug bulletin on the knowledge, perception of drug utility, and prescribing behavior of physicians.</span></span>
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;"><em>DICP.</em>1990;24:87-93.</span></span>
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;">18. Soumerai SB, Avorn J, Gortmaker S, Hawley S. Effect of government and commercial warnings on reducing prescription misuse: the case of propoxyphene. <em>Am J Public Health. </em>1987;77:1518-1523.</span></span>
<span style="font-size:11px;"><span style="font-family: arial,helvetica,sans-serif;">19. Stafford RS, Furberg CD, Finkelstein SN, Cockburn IM, Alehegn T, Ma J. Impact of clinical trial results on national trends in alpha-blocker prescribing, 1996-2002. <em>JAMA.</em>2004;291:54-62. </span></span>
20. Tamblyn R, Huang A, Perreault R, et al. The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care. CMAJ. 2003;169:549-556.