How clinical data helps improve outcomes for patients with multiple chronic conditions

Suboptimal health outcomes and rising healthcare expenditures for those with multiple chronic conditions have been identified by the US Department of Health and Human Services as a major public health challenge.

This comes as no surprise to healthcare organizations who have taken accountability for Medicare Advantage patient populations, as the large majority of these patients are high-risk patients with chronic conditions. More than two-thirds of Medicare beneficiaries have multiple chronic conditions, the most common of which are diabetes, lung disease, cancer, heart disease and kidney disease. Many of these organizations have embraced the transition to value-based models to combat rising healthcare costs and focus on preventative care for these conditions. Fulfilling the goal of improving outcomes at lower costs requires a comprehensive understanding of a population's current and rising risk, so that prevention and outreach efforts can be directed towards patients most in need of intervention and disease management. Accomplishing this presents particular challenges as the most vulnerable patients in need of early intervention and precision care also typically generate the largest volumes of data across the fragmented and siloed spectrum of care.

Patients with chronic conditions are more at risk for poor outcomes and high utilization

The presence of a chronic condition increases the risk of poor outcomes, such as mortality and functional limitations, and high-cost services, including hospitalizations and emergency room visits. Multiple chronic conditions, and the associated clinical complexity of co-existing conditions, compounds that risk. Plans and physicians who care for complex populations know that getting these patients on a more targeted treatment plan as soon as possible is essential. Preventing poor outcomes for high-risk patients starts with a population-level view to determine which patients to prioritize for disease and utilization management programs. Each patient profile should include previously documented, new and suspect diagnoses for an accurate depiction of rising risk as well as existing conditions. Once patients' true risk are clearly defined, analytics can be applied to identify, stratify and assess patient populations. The results can be used to inform outreach initiatives and to focus efforts more precisely based on the needs of patients within each subgroup.

Chronic disease comes with increased risk of more chronic disease Multiple chronic conditions have associated comorbidities that can lead to long-term complications and increase treatment costs. A leading McKinsey research study suggests that, for example, 71% of patients with heart failure also have hypertension, 37% have diabetes, and 53% have hyperlipidemia.

Given this reality, treating a patient's primary condition is not enough particularly in value-based medicine where the goal is to focus on patients at risk for developing a chronic condition, not just managing existing conditions. As patients with chronic conditions are at increased risk of developing comorbidities in the future, they must be monitored closely. Addressing comorbidities in time will ensure that the patient remains stable in the long run and cuts down the risk of emergency visits.

An analysis of the full scope of data can reveal clinical indicators of possible comorbidbities which can receive early attention, preventing them from becoming more serious problems later. Predictive analytics can even detect the statistical probability of additional diagnoses without specific clinical indicators, based on a comparison to patients with similar backgrounds and conditions. Analytics can also handle the complexity and probabilistic nature of potential outcomes for patients with multiple chronic conditions more quickly and accurately than human analysis alone would allow. Of course, like any analysis, the reliability of results depends on the quality and completeness of the underlying data.

Chronic disease treatment accounts for the majority of healthcare expenses

According to the Agency for Healthcare Research & Quality (AHRQ), chronic conditions account for nearly 70% of all healthcare expenses, which equates to more than $3.5 trillion. The five chronic diseases that account for most of the cost are cancer, cardiovascular disease, diabetes, obesity, and kidney disease.

Given the fact that chronic disease treatment occupies a large chunk of the nation’s average healthcare spending, proactive management of these diseases should be the priority. Investing in prevention and disease management will save lives and money now and well into the future. But plans often overlook many highly preventable conditions due to lack of access to clinical data.

Patients with chronic conditions require collaborative care

Patients with chronic conditions often require engagement with a team of primary, specialty, and acute care providers, who work together towards the common goal of achieving the best possible outcomes. The more complex and serious the condition, the more likely several specialists are involved and the more paperwork that is generated. Care team members sometimes work within the same health system, but more often than not, they are spread across different locations along the spectrum of care, including the patient’s home.

To facilitate high-quality care for these patients, the findings and data from each care team member should be succinctly and properly communicated to fellow providers. Application of single-disease guidelines to patients with multiple chronic conditions without a full understanding of the patient's health may lead to conflicting treatment recommendations and interactions resulting in adverse events. It is crucial, for example, that all medications are known and understood before making any adjustments to a patient's care. Side-effects and reactions to multiple medications can be life threatening or lower quality of life.

Shared data is imperative for these patients not only to keep the team abreast of changes, progress and decline, but also to enable collaborative care. With chronic disease, it is common that the best option for treatment will not be clear, and it takes the dedication of an interdisciplinary team to evaluate and monitor for the best possible outcome. Management of a patient's multiple chronic conditions must also be frequently re-visited by an interdisciplinary team as adjustments are made according to the patient's individual response.