"They are interrelated, one feeds off the other": A taxonomy of perceived disease interactions derived from patients with multiple chronic conditions.

OBJECTIVE: To understand patients' experiences with condition interactions and develop a taxonomy to inform care for patients with multiple chronic conditions. METHODS: We conducted qualitative and quantitative analysis of free-text data from patient surveys in which respondents were asked to indicate their most bothersome chronic condition and describe how their other conditions affect their self-care for that condition. Using standard content analysis, we developed a taxonomy comprising how patients perceive interactions among their conditions, and examined cross-cutting themes that reflect qualities of these interactions. RESULTS: Among 383 eligible survey respondents, the mean (SD) number of chronic conditions was 4 (2); common conditions included hypertension (60%), chronic pain (49%), arthritis (41%), depression (32%), diabetes (29%), and post-traumatic stress disorder (26%). Patients' perceived condition interactions took four broad forms: 1) unidirectional interactions among conditions and/or treatments, 2) cyclical or multidimensional interactions, 3) uncertain or indistinct interactions, and 4) no perceived interaction. Cross-cutting themes included beliefs about causal relationships between conditions, identification of interactions as negative vs. positive, and interactions between physical and mental health. CONCLUSION: This study presents a novel taxonomy of condition interactions from the patient perspective. PRACTICE IMPLICATIONS: Understanding perceived condition interactions may support patient self-management and shared decision-making efforts.

"I had to change so much in my life to live with my new limitations": Multimorbid patients' descriptions of their most bothersome chronic conditions.

Objective To characterize diseases that are described as most bothersome by individuals with multiple chronic conditions and to identify themes that characterize their experiences with their most bothersome condition. Methods In a survey of patients at an academic center and a Veterans Affairs hospital, we asked individuals with multiple chronic conditions to identify their most bothersome chronic condition and describe why it is challenging. Standard content analysis methods were used to code responses and identify themes reflecting characteristics of most bothersome conditions. Results The most commonly cited bothersome conditions were chronic pain (52%), diabetes (43%), post-traumatic stress disorder (25%), heart failure (24%), and lung problems (20%). Conditions were described as most bothersome due to: (a) impact on function and quality of life (e.g. active symptoms, activity limitations), (b) health consequences or sequelae (e.g. risk of complications), and (c) challenges associated with treatment or self-management. Patterns of theme dominance varied for conditions with different characteristics. Discussion The conditions that patients with multiple chronic conditions identify as most bothersome vary depending on individuals' diseases and their health-related preferences and priorities. Ascertaining patients' most bothersome conditions and associated challenges, stress, and frustrations may help ensure that management decisions are aligned with patient preferences and priorities.

Intensive Outpatient Program Effects on High-need Patients' Access, Continuity, Coordination, and Engagement.

OBJECTIVE: The intensive and varied services required by high-need patients have inspired a number of new care delivery models; however, evidence of their effectiveness is mixed. This study evaluated whether augmenting a patient-centered medical home (PCMH) with intensive outpatient management enhances high-need patients' care processes. RESEARCH DESIGN: Retrospective analysis using differences-in-differences and χ tests. SUBJECTS: Of 545 high-need patients receiving PCMH care, 140 were previously randomly selected for the intensive outpatient management program; the remaining received usual care. MEASURES: We evaluated program effects on care continuity (proportion of primary care visits with assigned primary care physician); access (proportion of telephone visits out of all primary care encounters, missed appointment rate); care coordination (rate of follow-up after hospital discharge, new telehealth enrollment); and patient engagement (rates of online personal health record registration, advance directive completion). RESULTS: Compared with patients receiving usual care, patients enrolled in intensive management experienced a 5.9% increase in proportion of primary care visits with an assigned primary care physician (P<0.001) and a 17.9% increase in proportion of telephone-based visits (P<0.001). Patients in the program had 7.5% higher rates of telehealth referral (P=0.01), 17.2% higher rates of advance directive completion (P<0.01), and 9.3% higher rates of personal health record registration (P=0.02). There was no effect on missed appointments or posthospital discharge visit rates. CONCLUSIONS: Augmenting a PCMH with intensive outpatient management may have positive effects on primary care processes related to continuity, access, coordination, and patient engagement.