Comorbidities and Diabetes Care – Impact on Treatment Strategies Dr. Joel Rodriguez-Saldana Multidisciplinary Diabetes Centres Mexico

Prevalence and Multimorbidity Patterns in Australia CategoryNMorbidity≥2≥3≥4 Vascular2, %25.8%16.9%9.1% Muscleskeletal2, %22.5%15.3%8.4% Psychologic2, %18.0%11.7%6.3% Asthma, COPD1, %9.5%6.7%4.5% Gastroesophageal1, %11.9%9.2%5.9% Heart disease %10.4%8.6%5.8% Diabetes7568.3%7.7%5.9%3.9% Cardiovascular disease %3.5%3.1%2.3% Malignancy2803.1%2.6%1.8%1.2% Britt HC et al: MJA 2008;189:72-77

Prevalence of Multimorbidity by Gender and Age Group CategoryN≥1≥2≥3≥4 Men3, %36.4%20.1%10.1% Women5, %37.5%21.1%10.1% Age Group <25 years2, %2.6%0.6%0.2% , %14.7%3.9%1.1% , %46.5%22.7%9.1% %74.6%46.0%22.6% ≥ 751, %83.2%58.2%33.4% Britt HC et al: MJA 2008;189:72-77

Epidemiology of Multimorbidity and Implications Background: health systems are configured for individual diseases, rather than multimorbidity Objective: to examine the distribution of multimorbidity and of comorbidity of physical and mental health disorders, in relation to age and soocioeconomic deprivation Barnett K et al: Lancet 2012;380:37-43

Epidemiology of Multimorbidity and Implications Methods: a cross sectional study on 40 morbidities from a database of 1,751,841 people registered with 314 medical practices in Scotland. Multimorbidity was defined as the presence of two or more disorders Barnett K et al: Lancet 2012;380:37-43

Number of Chronic Disorders by Age Group Barnett K et al: Lancet 2012;380:37-43

Epidemiology of Multimorbidity and Implications Results: 42.2% (CI ) of all patients had one or more morbidities, and 23.2% were multimorbid Multimorbidity ocurred years earlier in people living in the most deprived areas compared with the most affluent Barnett K et al: Lancet 2012;380:37-43

Epidemiology of Multimorbidity and Implications Results: socioeconomic deprivation was particularly associated with multimorbidity that included mental health disorders The presence of a mental health disorder increased as the number of physical morbidities increased, and was greater in the most deprived Barnett K et al: Lancet 2012;380:37-43

Epidemiology of Multimorbidity and Implications Conclusions: the single-disease framework by which most health care, medical research, and medical education is configured must be challenged A complementary strategy is needed to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas Barnett K et al: Lancet 2012;380:37-43

Comorbidity in Males ≥ 65 Years NoHBPLIPCHDDMGERBPHARTCOPDANECVDPrevalence 1XXX37.4% 2XXX32.6% 3XXX22.4% 4XXX21.1% 5XXX20.4% 6XXX20.2% 7XXX19.5% 8XXX19.0% 9XXX16.7% 10XXX15.0% 11XXX14.5% 12XXX14.0% 13X13.8% N= 1,963,810 Steinman MA et al: JAGS 2012;60:

Comorbidity in Females ≥ Years NoHBPLIPCHDDMGEROSTTHYRARTHCOPDANAEMDEPPrevalence 1XXX24.7% 2XXX23.6% 3XXX22.9% 4XXX22.0% 5XX20.5% 6XXX19.3% 7XX17.3% 8XXXX15.5% 9XXX13.8% 10XX12.8% 11XXX12.4% 12XXX12.1% 13XXX12.0% N= 1,963,810 Steinman MA et al: JAGS 2012;60:

Multimorbidity MMD and its Consequences in Primary Care Objective: examine the prevalence, health care utilization and cost of multimorbidity Methods: 3,309 patients >50 years receiving primary care in Ireland Results: MMD prevalence was 66.2% – RR associated with >4 vs 0: diseases – Medical visits: 11.9 vs 3.7, P <0.001 – Hospital admissions: 4.51, P <0.01 – Costs: EU 4, vs EU , P <0.001 Glynn LG et al: Fam Pract 2011;28:

Number of Chronic Diseases and Prevalence of MMD Age groupN° CDPrevalence of MMD Men % % % ≥ % Women % % % ≥ % Glynn LG et al: Fam Pract 2011;28:

Odds Ratio: Primary Care Visits, Hospital Visits and Admissions, and Number of Chronic Diseases N° of CDPrimary Care Visits Hospital Visits Hospital Admission OR 03.72%0.63% %1.17% %1.43% %1.92% %2.42%3.80 >411.86%3.58%4.51 Glynn LG et al: Fam Pract 2011;28:

Costs per Patient Receiving PC, Hospital Visits, Hospital Treatment and Total Care in USD ConceptNumber of Chronic Diseases 01234>4 Primary Care Visit Hospital Visit Hospital admission ,466.5 Total cost per year850.02,2414,2566,1788, ,699 Glynn LG et al: Fam Pract 2011;28:

Multimorbidity in Patients with Type 2 Diabetes Objective: to examine the nature of multimorbidity, and its impact on GP visits, polypharmacy and glycemic control Methods: a cohort of 424 patients with type 2 diabetes enrolled in a RCT in Irish general practice Teljeur C, et al: Eur J Gen Pract 2013;19:17-22

Multimorbidity in Patients with Type 2 Diabetes Results: 90% of the patients had at least one additional chronic condition, and 25% had ≥4 additional chronic conditions: – Hypertension: 66% – Heart disease: 25% – Arthritis: 16% GP visits and polypharmacy increased with increased number of chronic conditions Teljeur C, et al: Eur J Gen Pract 2013;19:17-22

Multimorbidity in Patients with Type 2 Diabetes Results: patients who reported a higher proportion of their conditions had better glycemic control with lower HbA1c scores Conclusions: the prevalence of mulltimorbidity in patients with Type 2 diabetes is very high. Glycemic control is related to patients’ awareness of their chronic conditions Teljeur C, et al: Eur J Gen Pract 2013;19:17-22

Comorbidity: Lines of Action 1.Acknowledge its likelihood: the simultaneous presence of comorbidity and multimorbidity is the norm of populations 2.People should be characterized by their morbidity burden and by the patterns of morbidity that they experience with time 3.Clinical trials should characterize participants according to morbidity burden Starfield B: Ann Fam Med 2006;4:

4. Primary care practitioners and researchers should participate in the design of studies to test about comorbidity 5. Academic departments should be developing guidelines for specialty care of comorbidity Starfield B: Ann Fam Med 2006;4: Comorbidity: Lines of Action