"Whole patient" approach needed in diabetes care

Older patients often have more than one chronic condition and need guidance to prioritize self-care, according to a new study.

By Susan J. Landers — Posted Dec. 24, 2007

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Diabetes by itself is hard enough to manage effectively, but try adding another one, two or three chronic diseases, and the complexities escalate.

Plus, ineffective management of some of these other diseases may be standing in the way of good diabetes control. Researchers in a recent study recommended physicians consider the "whole patient" when devising treatments and advise patients that their chronic conditions may, in fact, be related.

The study, which is in the December Journal of General Internal Medicine, found that 92% of 1,900 older patients queried had at least one other chronic disease in addition to their diabetes, and half had three or more additional diseases. One researcher also speculated that those high numbers are probably underestimates.

The study concluded that patients may neglect their diabetes care and increase their risk for stroke because of the competing demands posed by these simultaneous chronic diseases. The likelihood of this scenario went up with the number and severity of co-existing diseases.

The findings underscore the need to treat the whole patient, because successfully managing one chronic disease, in this case diabetes, could depend on how effectively a patient is managing another. If a patient had arthritis, for example, he or she can continue to exercise, researchers said.

Determining how best to meet these overlapping needs was a driving force behind the research, said the principal investigator, Eve Kerr, MD, MPH, associate director for the VA Ann Arbor Health Services Research and Development Center for Clinical Management Research and associate professor of internal medicine at the University of Michigan Medical School in Ann Arbor.

The study is an extension of the challenges in her practice.

"Many of my older patients are dealing with these same issues. They are patients who have multiple chronic conditions, and they look to me to help them prioritize and figure out how to improve their quality of life."

Helping with self-care

But how to do this in the limited time available in an office visit remains a puzzle. Dr. Kerr believes that most primary care physicians are trying to deliver comprehensive care that touches on their patients' needs, but time -- with a 15-minute visit -- isn't on their side. "So one of the things that I believe the health care system needs to think about is developing systems, mechanisms and methods to help patients to focus on their own self-care needs."

One step toward better self-care could be to help patients understand their diseases are often related. For example, patients may not know their diabetes puts them at higher risk for heart disease and stroke. That lack of awareness may mean they don't put as much emphasis on controlling their blood pressure or cholesterol as they should. Patients need to perceive diabetes as a multisystem disease, Dr. Kerr said.

Using data from the national Health and Retirement Study, which surveys 22,000 older Americans every two years, the researchers were able to focus on diabetes. However, they noted that these findings may apply to other chronic diseases as well.

The research shows how complex patients' health issues have become as life spans have increased, noted Jacqueline A. Pugh, MD, professor of medicine at the University of Texas Health Science Center in San Antonio, in an editorial in the same journal issue. "Clinical practice guidelines, as currently designed in a disease-specific manner, are woefully inadequate for dealing with the intersection of comorbidities and prioritizing among treatments."

"The work reminds us," Dr. Pugh wrote, "that we need to take care of the whole person, not just their heart, knee or pancreas, and to truly let that person be the decision-maker with the care team providing information and support."

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