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    The impact of multiple chronic conditions
Introduction                                               Figure 1
           According to a 2001 survey by the Center        Percent of Population with Asthma and Other Chronic
    for Disease Control and Prevention, there are          Conditions
    approximately 31.3 million Americans
    diagnosed with asthma at some point during                            17.9%
                   1                                                                                            32.2%
    their lifetime. Among all the age groups,
    children 5-17 years of age have the highest                   7.9%
    prevalence rates. “Asthma is the leading
    cause of school absences from a chronic
    illness. It accounts for an annual loss of more               10.6%
    than 10 million school days per year and more                                                   17.7%
    hospitalizations than any other childhood
    disease. Children with asthma spend an
                                                           Source: Large Private Insurer, CY 2001   0   1   2     3     4   5+
    estimated 7.3 million days per year restricted to
                                                           Table 1
Most People With Asthma have                               Conditions                                   Percent of Asthma
other Chronic Conditions
                                                                                                         Patients Affected
           According to Figure 1, over two thirds of       Hypertension                                             25.9%
    people with asthma have one or more other
                                                           Hyperlipidemia, hyperglyceridemia,
    chronic conditions, and more than half of the
                                                           hypercholesterolemia and other
    asthmatics have two or more in addition to
                                                           disorders of lipid metabolism                                18.4%
    asthma. However, little attention has been paid
    to the issue of co-morbidities among asthmatic         COPD                                                         16.1%
    patients. The most common co-morbidities are           Diabetes                                                     10.4%
    shown in Table 1.                                      Coronary atherosclerosis                                      9.4%
           As seen in Figure 2, more than 80 percent         Source: Large Private Insurer, CY 2001
    of asthmatics age 0-17 have no co-morbidities.
    However, the prevalence of co-morbidities
    increases with age. By the time the population
    has reached age 65, only 6% of people have
    asthma only. The number of people

  Trends in Asthma Morbidity and Mortality American Lung
Association, Accessed July 2003,
<> p.5
  Asthma Facts and Figures Asthma and Allergy Foundation
of America, Accessed July 2003,
    with 5 or more chronic conditions in addition to
    asthma also increases with age. One percent of
    children seventeen or less have five or more
    other chronic conditions, by the time the
    population has reached 65, more than one third
    of the population have more than five other
    chronic conditions in addition to asthma.
           There’s some limited clinical research
    discussing the impact of co-morbidities on
    treating asthmatics. As shown in Table 1,
    slightly more than a quarter of asthma patients
    have hypertension, and some studies have
    suspected the possibility of a positive
    correlation. Other studies have shown a
    positive correlation between asthma and type 1
    diabetes. The presence of these co-morbidities
                                                                  Hospitalization Rates Increase as
    may complicate treatment; however, information                the Number of Chronic Conditions
    on treating asthma patients with other chronic                Increases
    conditions is limited. Nevertheless, improving
                                                                 Table 2
    the quality of treatment remains an important
    issue, since research has already shown that                 Number of Chronic                    Hospitalizations for
    co-morbidities, especially cardiac disease and               Conditions in                        ACSC Admissions
    hypertension, result in poor health-related                  Addition to Asthma                             per 1000
    quality of life (HRQoL) in asthma patients.
                                                                 0                                                    11.1
Health Care Spending Increases                                   1                                                    18.8
                                                                 2                                                    33.0
With Number of Chronic Conditions
           Figure 3 shows that spending on people                3                                                    58.2
    with asthma increases with the number of                     4                                                    93.1
    chronic conditions. People with asthma and five              5+                                                  258.7
    or more chronic conditions have approximately                 Source: Large Private Insurer, CY 2001
    eight times more expenditures per enrollee
    compared to enrollee with only asthma.                                 Many asthmatics have one or more
                                                                  ambulatory care-sensitive conditions, or ACSCs.
                                                                  ACSCs are defined as conditions for which
                                                                  “diagnoses for which timely and effective
                                                                  outpatient care can help to reduce the risks of
                                                                  hospitalization by either preventing the onset of an
                                                                  illness or condition, controlling an acute episodic
                                                                  illness or condition (such as bacterial pneumonia),
                                                                  or managing a chronic disease or condition (such
  Salako BL, Ajayi SO. (2000) Bronchial asthma: a risk            as asthma and hypertension.)”
factor for hypertension? Afr J Med Med Sci. 29(1): 47-50
 Stene LC, Nafstad P.(2001) Relation between
occurrence of type 1 diabetes and asthma. Lancet.
24;357(9256):607-8.                                                 Billings J, Zeitel L, Lukomnik J, Carey TS, Blank AE,
 HA Wijnhoven et al. (2003) The influence of co-morbidity         Newman L. Impact of socioeconomic status on hospital use
on health-related quality of life in asthma and COPD patients.    in New York City Health Affairs(Millwood). 1993:12:p.163-
Respir Med. 97(5): 468-75                                         166
         It has been observed that “better primary
care, especially coordination of care, could reduce
avoidable hospitalization rates, especially for
individuals with multiple chronic conditions.”
         Hospitalization for conditions (ACSCs)
that are preventable can be used to indicate
whether the patient is receiving adequate and
quality outpatient care.

Utilization Increases with Number
of Chronic Conditions

                                                                        The American Academy of Pediatrics
                                                               (AAP), defines medical home as a place where
                                                               medical care is accessible, continuous,
                                                               comprehensive, family-centered, coordinated ,
                                                               compassionate and culturally effective . Lack of a
                                                               medical home may cause unnecessary
                                                               hospitalizations; in fact, research has
                                                               demonstrated that “hospitalization due to acute
                                                               severe asthma represents a failure in the
                                                               preventive, long-term as well as home care of
                                                               asthma.” Care in the context of a medical home
                                                               is also more cost-effective, as the AAP points out:
                                                               “care provided through emergency departments,
                                                               walk-in clinics, and other urgent-care facilities…is
                                                               more costly and often less effective.”
         People with multiple chronic conditions in
addition to asthma utilize more healthcare
resources. As Figure 4 shows, patients with more               Conclusion:
chronic conditions visit doctors more often. As                          Treatment has become increasingly
shown in Figure 5, patients with five or more                  difficult when asthma patients have other chronic
chronic conditions in addition to asthma see                   conditions. Research suggests that patients have
nearly three times as many doctors as does a                   better outcomes at lower cost when care is
patient with asthma alone.
                                                                  American Academy of Pediatrics, Committee on Children
Coordination of Care: The Concept                              With Disabilities. Care coordination: integrating health and
of “Medical Home”                                              related systems of care for children with special health care
                                                               needs. Pediatrics. 1999; 104:978-981
                                                                  American Academy of Pediatrics, Committee on Pediatric
                                                               Workforce. Culturally effective pediatric care: education and
                                                               training issues. Pediatrics. 1999;103:167-170
                                                                  Singh M. (2001) Management of acute asthma. Indian J
  Anderson G., Starfield B, and Wolff J. (2002) Prevelence,    Pediatr. 68 Suppl 4: S23-30
Expenditures, and Complications of Multiple Chronic               American Academy of Pediatrics, Medical Home
Conditions in the Elderly Arch Intern. Med. 162(20): 2269-76   Initiatives for Children With Special Needs Project Advisory
  Millman M. Access to Health Care in America Washington,      Committee. The Medical Home. Pediatrics. 2002;110:184-
DC: National Academy Press; 1993                               186
coordinated . Care coordination becomes
essential to improvements in care for patients with
lung cancer.

About Partnership for Solutions
         Partnership for solutions, led by Johns
Hopkins University and the Robert Wood Johnson
Foundation, is an initiative to improve the care
and quality of life for the estimated 125 million
Americans with chronic health conditions. The
Partnership is engaged in three major activities
conducting original research and identifying
existing research that clarifies the nature of the
problem; communicating these research finding to
policymakers, business leaders, health
professionals, advocates, and others; and working
with public and private programs to identify
promising solutions to the problems faced by
people with chronic conditions.

  Anderson G, Starfield B, and Wolff J. Prevalence,
Expenditures, and Complications of Multiple Chronic
Conditions in the Elderly Arch Intern. Med. Vol. 162,
Nov. 2002, p. 2275

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