Keirns CC (University of Michigan, Robert Wood Johnson Clinical Scholars Program), Frankel RM
(HSR&D Center of Excellence on Implementing Evidence-Based Practice, Indianapolis, Indiana), Robinson C
(HSR&D Center for Clinical Management Research (CCMR), Ann Arbor VA Medical Center), Kerr EA
(CCMR, Ann Arbor VA Medical Center), Forman J
(CCMR, Ann Arbor VA Medical Center)
There is great interest in understanding how comorbid conditions influence patients’ chronic disease self-management (SM). Researchers have done this quantitatively by examining the role of concordant (sharing pathophysiology and/or clinical management) and discordant comorbid conditions. This disease-based approach does not consider how patients perform SM tasks in their daily lives. We used qualitative methods to explore how the characterization of comorbid conditions as concordant and discordant compared with patients’ views and actions related to SM for hypertension (HTN).
As part of a larger study of HTN management among 1169 patients with diabetes in nine VA facilities, we conducted structured, open-ended phone interviews with a purposeful sample of 37 patients. Interviews covered comorbidities, disease prioritization, medication management, and self-management. We analyzed the data using two different qualitative techniques: content coding and a case-based approach.
Content coding was useful in exploring barriers and facilitators of HTN control, while the case-based approach offered richer insights into the complexities of overall management burden and conflicting priorities. We found that some patients viewed particular SM tasks for diabetes and cardiovascular disease as discordant with HTN, even though they are clinically concordant. For example, several patients focused on sugar and carbohydrates to control diabetes to the detriment of reducing saturated fat, cholesterol, calories, and salt important for HTN. Stroke and heart disease were often concordant with HTN SM in patients early in their course; while for patients with more severe stroke or heart disease, these eclipsed HTN. HTN medication management was made more difficult by the presence of both concordant and discordant comorbidities, due to large numbers of medications, complex regimens, and side effects.
The current characterization of comorbid diseases as clinically concordant or discordant does not adequately describe the complex ways that comorbidity influences SM. The disease-by-disease approach commonly used by physicians leaves the patient to translate clinical recommendations into workable self-management regimens, with little guidance on how to combine management of different diseases.
Physicians and patients need to work together to triangulate clinical recommendations into self-management plans organized around patients’ understanding of their diseases and daily tasks such as diet, medications, and exercise.