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Patient Complexity and Risk Factor Control Among Multimorbid Patients With Type 2 Diabetes

Results From the R2D2C2 Study

Malik, Shaista, MD, PhD, MPH*; Billimek, John, PhD; Greenfield, Sheldon, MD; Sorkin, Dara H., PhD; Ngo-Metzger, Quyen, MD, MPH; Kaplan, Sherrie H., PhD, MPH

doi: 10.1097/MLR.0b013e318273119b
Brief Report

Background: Among patients with type 2 diabetes, it is not known whether risk factor control is better or worse for those who also have heart disease, depression, multiple other comorbidities, and associated management challenges.

Objective: To examine the relationship between this complex constellation of multimorbidities, adherence to treatment and risk factor control among patients with type 2 diabetes, independent of regimen intensity.

Research Design: Observational cross-sectional study.

Subjects: A total of 1314 patients with diabetes from the Reducing Racial Disparities in Diabetes Coached Care (R2D2C2) Study.

Measures: A composite cardiometabolic risk factor profile was the dependent variable. Independent variables included a composite measure of patient complexity, patient-reported adherence to treatment, history of coronary heart disease (CHD), and intensity of medication regimen.

Results: A higher proportion of the most complex patient-reported problems with adherence compared with the least complex patients (83.5% vs. 43.3%, P<0.001). Compared with those without a history of CHD, fewer patients with CHD-reported problems with medication adherence (59.3% vs. 69.3%, P<0.01) and had better risk factor control, independent of complexity and regimen intensity. Better risk factor control was independently associated with less patient complexity (P=0.003) and to history of CHD (P=0.01).

Conclusions: The presence of a complex illness profile was associated with poorer control of risk factors. Those with CHD were more adherent to treatment and had better risk factor control. The occurrence of CHD may present an opportunity for physicians to emphasize risk factor management. Diabetes patients with a complex illness profile may be at highest risk for cardiovascular events and in greatest need of prevention of cardiac disease.

Trial Registration: identifier: NCT01123239.

*Department of Medicine, Division of Cardiology

Department of Medicine, Health Policy Research Institute, University of California, Irvine, CA

Office of Quality and Data, Bureau of Primary Health Care, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, MD

Supported by the National Institute of Diabetes, Digestive and Kidney Diseases (R18DK69846 and K01DK078939), the Robert Wood Johnson Foundation (Generalist Physician Faculty Award #1051084 and Finding Answers: Disparities Research for Change #59758), the NovoNordisk Foundation, and Lilly Research Laboratories. S.M., J.B., S.G., D.H.S., Q.N.M., and S.H.K. had full access to the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. S.G. and S.H.K. received funding for research grants from Lilly Research Laboratories and NovoNordisk Foundation (modest). S.M. received funding for research grant from Lilly Research Laboratories.

The authors declare no conflict of interest.

Reprints: Shaista Malik, MD, PhD, MPH, Department of Medicine, Division of Cardiology, 333 City Blvd. West, Suite 400, Irvine, CA 92868-3298. E-mail:

© 2013 Lippincott Williams & Wilkins, Inc.