Care Coordination and Polypharmacy among Working-Age Adults with Multiple Chronic Conditions
Rising prevalence of multiple chronic conditions (MCC) among working-age adults pose enormous challenges to the American economy in heath spending and productivity loss. Despite a large body of research on MCC, critical knowledge gaps remain about the patterns of co-occurring chronic conditions in working-age American population, and how they vary by demographic and community factors. This knowledge deficit further complicates our understanding of associated healthcare delivery related issues in this population, especially the polypharmacy variation, and how care coordination, in terms of continuity of care and physician specialty mix, affects polypharmacy risk. This dissertation study sought to address these gaps using a retrospective cohort analysis of six-years claims data (2008–2013) on 452,834 commercially insured adults, 18–64 years old, living in Texas. Exploratory factor analysis was used on 42 chronic conditions to extract gender-specific MCC patterns; and the propensity to develop these patterns was evaluated across birth-cohorts (younger, and older baby boomers versus generation-X/millennials), and small area communities (defined by zip code tabulation areas) of differing socioeconomic status. For each gender-specific MCC pattern, the association of polypharmacy (above three concurrent medications) risk with care coordination parameters (continuity of care, and physician-specialty mix) was evaluated by estimating a multilevel mixed-effects logistic regression model, adjusting for individual (demographic, and healthcare utilization), and community-level socioeconomic factors. Finally, the effect of concurrent MCC patterns on polypharmacy risk was evaluated using similar regression strategy, adjusting for individual factors (demographic and non-pattern based comorbidity) and community-level socioeconomic factors. Our analysis revealed four patterns each for men [metabolic-urologic, cardiovascular-metabolic, musculoskeletal, and hepatorenal-autoimmune], and women [metabolic, cardiovascular, musculoskeletal, renal- autoimmune] with significant overlapping of member conditions. More than 2 in 3 men and 1 in 2 women had at least one pattern. Most prevalent patterns were cardiovascular-metabolic (34%) and metabolic (25%) pattern for men and women respectively. Further, age and select community factors were associated with propensity to develop each MCC pattern. For example, relative risk to each pattern, except renal-autoimmune for women, was higher in younger and older baby boomers. Further, men living in Hispanic majority areas had higher relative risk for metabolic-urologic and cardiovascular-metabolic patterns, but lower risk for musculoskeletal pattern. For each gender, about 25% of all adults with MCC were on polypharmacy; and within each pattern nearly 36–50% of men and 40–53 % of women were on polypharmacy regimen. In each pattern-specific group, the risk to polypharmacy increases by a factor of 1.15-to-1.23 in men and by 1.14-to-1.22 in women for each 10 percent point increase in continuity of care. However, the evidence on the association of physician- specialty mix with polypharmacy risk was mixed. Finally, the polypharmacy risk increases with additional concurrent MCC patterns, especially for cardiovascular and metabolic related patterns across gender. In summary, this dissertation study makes important contributions to research, and informs practice/policymaking for determining targeted prevention and management strategies to improve healthcare delivery to working-age Americans with MCC.^
Public health|Health care management
Ukhanova, Maria, "Care Coordination and Polypharmacy among Working-Age Adults with Multiple Chronic Conditions" (2017). Texas Medical Center Dissertations (via ProQuest). AAI10690445.