For Patients with Many Chronic Problems, More Care Is Better Care

SANTA MONICA, Calif., June 14 -- The higher the number of chronic medical problems patients have, the better the quality of their healthcare tends to be.

The findings suggest that physicians who care for patients with a raft of long-standing problems needn't worry that they might be penalized by quality-of-care watchdogs an international team of investigators wrote in the June 14 issue of the New England Journal of Medicine.

An analysis of data from three large quality-of-care studies showed that as the number of chronic conditions went up, the more likely patients were to get all the elements of care recommended in evidence-based guidelines, wrote Paul G. Shekelle, M.D., Ph.D., of the Rand Corporation here, and colleagues.

The investigators wanted to see whether physicians with a caseload skewed toward more complex patients might be judged unfairly by the arbiters of quality standards.

To do this, they analyzed data from three studies:

• The Community Quality Index study, involving 6,712 adults living in 12 metropolitan areas across the United States.
• The Assessing Care of Vulnerable Elders (ACOVE) study, involving 372 vulnerable older patients, defined as community-dwelling persons ages 65 and older who were at increased risk for death or functional decline; and
• The Veterans Health Administration (VHA) quality-of-care project involving 596 male veterans ages 35 and older who were receiving care at 26 clinical sites in 12 systems of two Veterans Integrated Service Networks.

The authors assessed the relationship between the quality of care patients received, defined as "the percentage of quality indicators satisfied among those for which patients were eligible," and the number of chronic medical conditions each patient had.

They also looked at patient characteristics, numbers of office visits and hospitalization, and the care provided by specialists as factors that might explain the observed relationship.

They found that in each of the studies, each additional condition was associated with an increase in quality score. For example, in the Community Quality Index cohort, each additional condition boosted the quality score by 2.2% (95% confidence interval, 1.7 to 2.7). In both the ACOVE study and the VHA cohort, each condition was associated with a 1.7% increase in quality (95% CI, 1.1 to 2.4 for the ACOVE study, 0.7 to 2.8 for the VHA study).

"This finding suggests that comprehensive, clinically detailed sets of care processes received can be used to assess the quality of care without creating a disincentive for providers to avoid patients with the most prevalent chronic conditions," the investigators wrote.

When the data were adjusted for patient characteristics (e.g., age, gender, race/ethnicity, educational level, income, etc), use of health care, and care provided by specialists, the association between number of conditions and quality of care was weakened somewhat, but remained positive, the authors determined.

"The fact that we found essentially the same relationship in three different data sets, using two different sets of quality indicators, increases the likelihood that this effect is real, rather than an artifact of any one particular study, the investigators wrote.

They noted, however, that the study was limited by its reliance on a count of conditions as the primary value, which, they acknowledged, is a crude measure of complexity.

They also noted that they did not look at the severity of illness for individual conditions, and that there were small samples of patients in two of the studies who seemed to have a decrease in quality associated with seven co-morbidities. These samples were too small, however, to allow for meaningful conclusions, they said.