BACKGROUND/RATIONALE:
This project focuses on the impact of comorbid heart failure (HF) on the health outcomes, health service utilization and medication adherence of patients with diabetes (DM). The study also explores communication, patient engagement and shared decision making (SDM) during patients visits. Most patients with chronic disease have more than one disease (Lee, et al., 2007). The presence of comorbidities was associated with higher 5-year mortality rates (Pogach, et al., 2007). Similar results were found in a cohort study of veteran health care users (Lee, et al., 2007) in which multiple chronic conditions were found to be associated with increased mortality rates in veterans. Comorbidity of DM and HF is common. DM itself is a risk factor for HF (Nichols, Gullion, Koro, Ephross & Brown, 2001; Bell, 2003; From et al., 2006).

The management of a single serious chronic illness can be challenging for patients and providers alike; managing two presents other challenges for both patient and clinician. DM and HF require different types of medical and self-management. Each of these has different short- and long-term clinical manifestations. Much of DM treatment targets prevention of long-term complications can conflict with HF treatment involving management of symptoms such a dyspnea and edema (Kerr et al. 2007). Decisions and tradeoffs must be made. The co-occurrence of multiple illnesses reduces the amount of time, energy and financial resources available for treatment and self-management of each individual illness. In patients with DM, HF can be shift priorities for patients (Kerr et al, 2007). This shift may be an indication that illness factors or symptoms may influence patient decisions. Others issues also arise, e.g, conflicting advice from providers, having to attend multiple appointments, polypharmacy and difficulty accessing urgent care as well as a lack of time, knowledge, skills and motivation (No l, Frueh, Larme & Pugh, 2005).

While many medical professionals believe that patient preference should be considered when making treatment decisions, clinicians may have difficulty eliciting them or may underestimate the patient's desire for being included in the decision process (Coulter, 1997, Kramer et al, 2005). Heisler and colleagues (2003) explored agreement on treatment goals between primary care providers and their patients with DM, including a sample of patients from a VA healthcare system. Findings revealed that when providers engaged in SDM regarding treatment with patients and discussed self-care activities their agreement on strategies for treatment was higher. Higher agreement on strategies and treatment goals was associated with higher patient DM care self-efficacy. Overall agreement between providers and patients on treatment goals and strategies was relative low, however findings illustrate the importance of SDM and the impact it has on patient self-management behaviors which in turn impact patient health outcomes including glycemic control. Priorities for management are best established in a SDM model involving both providers and patients rather than by the provider or patient alone (Street et al. 2007). Engaging in SDM and developing of mutually agreed upon treatment goals should produce higher rates of treatment compliance and better patient health outcomes. SDM creates consensus regarding management of chronic illnesses and patient involvement in efforts to improve their health and quality of life (Coulter, 1997).

OBJECTIVE(S):
This study builds on this prior research by exploring the impact that having HF has on patient medication adherence to DM medications as well as their glycemic control and health service utilization, specifically visits to the emergency room which may be related to areas neglected in medical and self-management. Communication between physicians and patients, including SDM as well as patient engagement during clinical visits will also be assessed. The conceptual model guiding this project illustrates several areas that are hypothesized to contribute to or impact communication and relationships between providers and patients. Several of these relationships will be tested as part of the CDA-1 and others will be more appropriate for subsequent, larger studies as part of a CDA-2 or IIRs. Exploring the proposed relationships in this mixed methods study will serve to guide a better developed future research agenda exploring in more depth methods to improve patient health outcomes through SDM and improved self- and medical-management of DM and HF. Gaining an understanding of the impact of comorbidities and communication between providers and patients about treatment priorities as well as patient engagement will lead to a better understanding of what impacts patient health outcomes. Improving understanding will better guide the development of protocols and procedures to improve treatment, SDM, and management of complex multi-morbidity.

METHODS:
Two sets of data are being utilized in this project. First a quantitative data set including over 13,000 patients with diabetes from the Cleveland VAMC was compiled from patient electronic medical records. The following research questions were explored: What are the differences in health outcomes and health service utilization for patients with DM compared with patients with comorbid DM and HF? What are the differences in adherence to DM medication (antihyperglycemic) for patients with DM compared to patients with comorbid DM and HF?

Survival analytic models will be constructed to answer the first research question. Separate models will be employed to address the differences in health outcomes (measured by glycemic deterioration) and health service utilization (measured by ER visits). A linear regression model will be used to assess question two, the differences in medication adherence between patients with DM and those with comorbid DM and HF based on the continuous measure of medication possession ratio (MPR).

A second qualitative data set includes 65 transcribed audio recorded patient appointments following a hospital admission related to heart failure. Analysis focused on answering the following questions: How do physicians and patients (with comorbid DM and HF) verbally communicate about priorities for treatment and management of their chronic illnesses? Do they engage in SDM? Are patients engaging or attempting to engage during their appointments?

Transcripts were analyzed in Atlas.ti utilizing a grounded theory technique. Themes and codes were developed on a continuous basis. The OPTIONS scale was also used to assess shared decision making in each physician-patient encounter.

FINDINGS/RESULTS:
To date only the qualitative data has findings to report. The quantitative data is currently being analyzed. Based on Analysis of 65 transcripts included 47 patients and 41 physicians several major themes were identified across the patient appointments: Medication review and refill, education, medical complications, rapport, informed decision making, changes in provider, caregiver involvement and patient engagement. The OPTION scale and thematic analysis revealed little shared decision making during appointments, although some appointments involved minimal or baseline level use of some of the methods to engage patients in shared or informed decision making. Patient appointments were interrupted a great deal by phone calls, pages, nurse and other patient interruptions that caused disruption in the flow of the patient's visit.

IMPACT:
Findings from this project will inform future intervention projects aimed at improving patient engagement in their medical appointments. The goal for patient engagement is improved patient health outcomes through shared or informed decision making where patients and physicians agree on appropriate treatment and self-management plans. This project has and will lead to additional knowledge about the impact of multiple chronic illnesses and communication between physicians and patients. Personally this project has helped me improve my research skills, gain knowledge of the research procress at the VA and increaes my understanding of patients with chronic illnesses.

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External Links for this Project

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PUBLICATIONS:

None at this time.

DRA: Aging, Older Veterans' Health and Care, Cardiovascular Disease, Diabetes and Other Endocrine Disorders
DRE: none
Keywords: none
MeSH Terms: none