Article
What to Do When Chronic Conditions Add Up
The HHS is aiming to bolster interprofessional education and training materials on multiple chronic conditions designed specifically for health...
Discussion
High-risk patients with DM enrolled in this primary care academic clinic and discussed at interprofessional case conferences did not have a statistically significant change in A1c values following the case conferences. There was also no statistically significant change in systolic and diastolic BP measurements following PACT ICU case conferences in high-risk patients with hypertension. The relationship between PACT ICU presentations and patient outcomes may not be direct, but the potential to decrease A1c values by 0.6% may be of clinical benefit to patients enrolled at the Boise VAMC academic clinic.
The results of this study are comparable with other studies where the impact of interprofessional forms of care on patient outcomes such as A1c and BP is not as apparent.3-5 The patients included in this study were high-risk compared with other patients, and patient outcome goals for DM and hypertension management according to clinical practice guidelines may be less stringent for these patients.9-11
Interprofessional case conferences are being used at the Boise VAMC academic clinic to teach primary care trainees how to improve care for patients by working on teams, with a goal of promoting alternate forms of health care. Referrals of patients to pharmacy services for chronic disease management may result from these case conferences, and patients could benefit from pharmacy review and management of medications for the treatment of DM and hypertension. There may be other advantages to patients and to the health system in the form of more appropriate health care use, increased contact with providers, and use of other health care resources to decrease costs and medication burden, although these are speculative at this time.
Limitations
This study had several limitations. The patients included in this study were high-risk patients seen by primary care trainees at the Boise VAMC academic clinic, and a small number of patients were included in the final analysis, limiting the generalizability of the results to other patient populations. Finding a difference in A1c and BP values before and after PACT ICU case conferences was also limited by the small number of patients who met inclusion criteria. Many patients included in the study also had reasonably controlled A1c and BP levels prior to PACT ICU case conferences; therefore, a difference would be more difficult to determine.
The PACT ICU case conferences occur at one point in time, but the impact of the intervention and recommendations may take longer to appreciate. A longer study duration may be needed to determine differences in A1c and BP values over time. Regression to the mean is also a possibility given the type of data collected. As each primary care trainee selects the patient to be discussed at a PACT ICU case conference, bias could also be present, because the provider may focus on patients with recent clinic visits or on patients who are the most difficult for the provider to manage or contact.
The Boise VAMC PACTs include many different health care disciplines; therefore, the institution may foster interprofessional, team-based care more easily compared with that of other health care systems. Trainees in the CoEPCE also are aware of other team members’ roles, and clinical pharmacists are currently part of PACTs at the institution. The idea of interprofessional case conferences may be simple, but the process at this institution requires time and effort from a nurse care manager who coordinates patient selection and information distribution and an attending physician supervisor who facilitates each case conference. The Boise VAMC also supports pharmacy chronic disease management services, and several of these patients with uncontrolled DM or resistant hypertension may have been seen by the pharmacy-managed insulin titration or hypertension clinics. Finally, there is also limited documentation of whether DM or hypertension management was discussed at the case conferences.
Despite the medical complexities seen in these patients, discussions during PACT ICU presentations may involve many social and behavioral interventions, and DM and hypertension issues may not be significant enough for review at a case conference. However, the intervention of PACT ICU case conferences encompassed a variety of care plans, and this study evaluated the impact of the entire discussion and recommendations and not any individual component. Other recommendations were not evaluated due to the wide variety of interventions that were potentially discussed, and a process for tracking these was not in place.
The results of this study did not show that the care plans that develop at PACT ICU case conferences impacted high-risk patients with DM or hypertension, likely due to small sample sizes (2 patient cases were discussed per week). The impact could be better determined through a larger sample size, longer duration, or assessment of patients whose disease was not controlled. The impact may also be more significant for individuals who benefit from the increased review and assessment of their chronic medical conditions and increased access to care.