title: Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management?
abstract: BACKGROUND
  The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three.
  
  
  OBJECTIVE
  We sought to understand how the number, type, and severity of comorbidities influence diabetes patients' self-management and treatment priorities.
  
  
  METHODS
  Cross-sectional observation study.
  
  
  METHODS
  A total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey.
  
  
  METHODS
  We constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF).
  
  
  RESULTS
  40% of respondents had at least 1 microvascular comorbidity, 79% at least 1 macrovascular comorbidity, and 61% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores.
  
  
  CONCLUSIONS
  The type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients' self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.
authors.affiliation: VA HSR&D Center of Excellence, VA Ann Arbor Health Care System, Ann Arbor, MI, USA. ekerr@umich.edu
authors.forename: Eve A
authors.initials: EA
authors.lastname: Kerr
authors.forename: Michele
authors.initials: M
authors.lastname: Heisler
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Krein
authors.forename: Mohammed
authors.initials: M
authors.lastname: Kabeto
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Langa
authors.forename: David
authors.initials: D
authors.lastname: Weir
authors.forename: John D
authors.initials: JD
authors.lastname: Piette
mesh_terms: D000368:Aged; D001294:Attitude to Health; D015331:Cohort Studies; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003920:Diabetes Mellitus / Q000453:epidemiology* / Q000628:therapy; D005260:Female; D006292:Health Priorities; D006333:Heart Failure / Q000453:epidemiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012648:Self Care; D012720:Severity of Illness Index; D014481:United States / Q000453:epidemiology