Skip to main content
NCBI home page
Journal of the National Medical Association logoLink to Journal of the National Medical Association
. 2007 Apr;99(4):377–383.

Facilitating quality improvement in physician management of comorbid chronic disease in an urban minority practice.

Linda S Kahn 1, Chester H Fox 1, Adefunke Olawaiye 1, Timothy J Servoss 1, Elizabeth McLean-Plunkett 1
PMCID: PMC2569643  PMID: 17444426

Abstract

CONTEXT: Increasing numbers of patients with multiple chronic conditions present in the primary care setting and pose a challenge to physicians who must cope with competing demands while adhering to clinical practice guidelines. PURPOSE: We tested a chart audit tool to assess how physicians are managing patients with multiple comorbidities in an inner-city family medicine practice serving minority patients. METHODS: We developed an evidence-based comorbidity chart audit tool that captures the number of diagnosed, coexisting general medical conditions and adherence to key clinical practice guidelines for each condition. A randomized chart audit was undertaken, with one in every five charts selected, yielding a total of 314 patient charts. FINDINGS: The majority of patients (59%) had > or = 2 comorbid chronic conditions, and 32% had > or = 3 comorbid chronic conditions. The highest overall adherence to guidelines was for chronic obstructive pulmonary disease (90%) and asthma (80%), followed by congestive heart failure (75%) and coronary artery disease (58%). For all other conditions, overall adherence to guidelines was < or = 50%. CONCLUSIONS: The chart review tool identified inconsistencies in adherence to guidelines across multiple diagnosed conditions, suggesting the importance of adopting a patient-centered approach to management as well as prevention.

Full text

PDF
377

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. American Diabetes Association Standards of medical care in diabetes. Diabetes Care. 2005 Jan;28 (Suppl 1):S4–S36. [PubMed] [Google Scholar]
  2. Antman Elliott M., Anbe Daniel T., Armstrong Paul Wayne, Bates Eric R., Green Lee A., Hand Mary, Hochman Judith S., Krumholz Harlan M., Kushner Frederick G., Lamas Gervasio A. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004 Aug 4;44(3):671–719. doi: 10.1016/j.jacc.2004.07.002. [DOI] [PubMed] [Google Scholar]
  3. Bayliss Elizabeth A., Bayliss Martha S., Ware John E., Jr, Steiner John F. Predicting declines in physical function in persons with multiple chronic medical conditions: what we can learn from the medical problem list. Health Qual Life Outcomes. 2004 Sep 7;2:47–47. doi: 10.1186/1477-7525-2-47. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Beasley John W., Hankey Terry H., Erickson Rodney, Stange Kurt C., Mundt Marlon, Elliott Marguerite, Wiesen Pamela, Bobula James. How many problems do family physicians manage at each encounter? A WReN study. Ann Fam Med. 2004 Sep-Oct;2(5):405–410. doi: 10.1370/afm.94. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Boyd Cynthia M., Darer Jonathan, Boult Chad, Fried Linda P., Boult Lisa, Wu Albert W. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005 Aug 10;294(6):716–724. doi: 10.1001/jama.294.6.716. [DOI] [PubMed] [Google Scholar]
  6. Chobanian Aram V., Bakris George L., Black Henry R., Cushman William C., Green Lee A., Izzo Joseph L., Jr, Jones Daniel W., Materson Barry J., Oparil Suzanne, Wright Jackson T., Jr Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003 Dec 1;42(6):1206–1252. doi: 10.1161/01.HYP.0000107251.49515.c2. [DOI] [PubMed] [Google Scholar]
  7. Durso Samuel C. Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. JAMA. 2006 Apr 26;295(16):1935–1940. doi: 10.1001/jama.295.16.1935. [DOI] [PubMed] [Google Scholar]
  8. Fortin Martin, Dionne Jonathan, Pinho Geneviève, Gignac Julie, Almirall José, Lapointe Lise. Randomized controlled trials: do they have external validity for patients with multiple comorbidities? Ann Fam Med. 2006 Mar-Apr;4(2):104–108. doi: 10.1370/afm.516. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Fortin Martin, Lapointe Lise, Hudon Catherine, Vanasse Alain. Multimorbidity is common to family practice: is it commonly researched? Can Fam Physician. 2005 Feb;51:244–245. [PMC free article] [PubMed] [Google Scholar]
  10. Fortin Martin, Lapointe Lise, Hudon Catherine, Vanasse Alain, Ntetu Antoine L., Maltais Danielle. Multimorbidity and quality of life in primary care: a systematic review. Health Qual Life Outcomes. 2004 Sep 20;2:51–51. doi: 10.1186/1477-7525-2-51. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Fox C. H., Mahoney M. C. Improving diabetes preventive care in a family practice residency program: a case study in continuous quality improvement. Fam Med. 1998 Jun;30(6):441–445. [PubMed] [Google Scholar]
  12. Fuster V., Rydén L. E., Asinger R. W., Cannom D. S., Crijns H. J., Frye R. L., Halperin J. L., Kay G. N., Klein W. W., Lévy S. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J. 2001 Oct;22(20):1852–1923. doi: 10.1053/euhj.2001.2983. [DOI] [PubMed] [Google Scholar]
  13. Hunt Sharon Ann, Abraham William T., Chin Marshall H., Feldman Arthur M., Francis Gary S., Ganiats Theodore G., Jessup Mariell, Konstam Marvin A., Mancini Donna M., Michl Keith. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 13;112(12):e154–e235. doi: 10.1161/CIRCULATIONAHA.105.167586. [DOI] [PubMed] [Google Scholar]
  14. Jellinger P. S., Dickey R. A., Ganda O. P., Mehta A. E., Nguyen T. T., Rodbard H. W., Seibel J. A., Shepherd M. D., Smith D. A., AACE Lipid Guidelines Committee. The American Association of Clinical Endocrinologists AACE medical guidelines for clinical practice for the diagnosis and treatment of dyslipidemia and prevention of atherogenesis. Endocr Pract. 2000 Mar-Apr;6(2):162–213. [PubMed] [Google Scholar]
  15. Macleod Una, Mitchell Elizabeth. Comorbidity in general practice. Practitioner. 2005 Apr;249(1669):282–284. [PubMed] [Google Scholar]
  16. Ratzan Scott C. Modernizing medicine: demonstrating a policy of prevention. J Health Commun. 2004 Mar-Apr;9(2):89–90. doi: 10.1080/10810730490425204. [DOI] [PubMed] [Google Scholar]
  17. Starfield B. New paradigms for quality in primary care. Br J Gen Pract. 2001 Apr;51(465):303–309. [PMC free article] [PubMed] [Google Scholar]
  18. Starfield Barbara. Threads and yarns: weaving the tapestry of comorbidity. Ann Fam Med. 2006 Mar-Apr;4(2):101–103. doi: 10.1370/afm.524. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Tinetti Mary E., Bogardus Sidney T., Jr, Agostini Joseph V. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004 Dec 30;351(27):2870–2874. doi: 10.1056/NEJMsb042458. [DOI] [PubMed] [Google Scholar]
  20. Tinetti Mary E., Fried Terri. The end of the disease era. Am J Med. 2004 Feb 1;116(3):179–185. doi: 10.1016/j.amjmed.2003.09.031. [DOI] [PubMed] [Google Scholar]
  21. Wright Nat, Smeeth Liam, Heath Iona. Moving beyond single and dual diagnosis in general practice: many patients have multiple morbidities, and their needs have to be addressed. BMJ. 2003 Mar 8;326(7388):512–514. doi: 10.1136/bmj.326.7388.512. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Østbye Truls, Yarnall Kimberly S. H., Krause Katrina M., Pollak Kathryn I., Gradison Margaret, Michener J. Lloyd. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005 May-Jun;3(3):209–214. doi: 10.1370/afm.310. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Journal of the National Medical Association are provided here courtesy of National Medical Association

RESOURCES