title: Burden of comorbid medical conditions and quality of diabetes care.
abstract: OBJECTIVE
  With performance-based reimbursement pressures, it is concerning that most performance measurements treat each condition in isolation, ignoring the complexities of patients with multiple comorbidities. We sought to examine the relationship between comorbidity and commonly assessed services for diabetic patients in a managed care organization.
  
  
  METHODS
  In 6,032 diabetic patients, we determined the association between the independent variable medical comorbidity, measured by the Charlson Comorbidity Index (CCI), and the dependent variables A1C testing, lipid testing, dilated eye exam, and urinary microalbumin testing. We calculated predicted probabilities of receiving tests for patients with increasing comorbid illnesses, adjusting for patient demographics.
  
  
  RESULTS
  A1C and lipid testing decreased slightly at higher CCI: predicted probabilities for CCI quartiles 1, 2, 3, and 4 were 0.83 (95% CI 0.70-0.91), 0.83 (0.69-0.92), 0.82 (0.68-0.91), and 0.78 (0.61-0.88) for A1C, respectively, and 0.82 (0.69-0.91), 0.81(0.67-0.90), 0.79 (0.64-0.89), and 0.77 (0.61-0.88) for lipids. Dilated eye exam and urinary microalbumin testing did not differ across CCI quartiles: for quartiles 1, 2, 3, and 4, predicted probabilities were 0.48 (0.33-0.63), 0.54 (0.38-0.69), 0.50 (0.34-0.65), and 0.50 (0.34-0.65) for eye exam, respectively, and 0.23 (0.12-0.40), 0.24 (0.12-0.42), 0.24 (0.12-0.41), and 23 (0.11-0.40) for urinary microalbumin.
  
  
  CONCLUSIONS
  Services received did not differ based on comorbid illness burden. Because it is not clear whether equally aggressive care confers equal benefits to patients with varying comorbid illness burden, more evidence confirming such benefits may be warranted before widespread implementation of pay-for-performance programs using currently available "one size fits all" performance measures.
authors: Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. jhalanych@uab.edu
authors: Jewell H
authors: JH
authors: Halanych
authors: Monika M
authors: MM
authors: Safford
authors: Wendy C
authors: WC
authors: Keys
authors: Sharina D
authors: SD
authors: Person
authors: James M
authors: JM
authors: Shikany
authors: Young-Il
authors: YI
authors: Kim
authors: Robert M
authors: RM
authors: Centor
authors: Jeroan J
authors: JJ
authors: Allison
mesh_terms: D000368:Aged; D000407:Alabama; D015897:Comorbidity; D017281:Cost of Illness; D048909:Diabetes Complications / Q000097:blood / Q000628:therapy*; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D008055:Lipids / Q000097:blood; D006278:Medicare; D011785:Quality Assurance, Health Care; D012051:Reimbursement Mechanisms; D014481:United States
chemical_list: D006442:Glycated Hemoglobin; D008055:Lipids