Journal of General Internal Medicine

, Volume 24, Issue 11, pp 1205–1210 | Cite as

Are Co-Morbidities Associated with Guideline Adherence? The MI-Plus Study of Medicare Patients

  • Anne E. Sales
  • Edmund F. Tipton
  • Deborah A. Levine
  • Thomas K. Houston
  • Yongin Kim
  • Jeroan Allison
  • Catarina I. Kiefe
Original Article



The impact of co-morbid illnesses on adherence to guideline recommendations in chronic illness is of growing concern. We tested a framework [Piette and Kerr, Diabetes Care. 29(3):725–31, 2006] of provider adherence to guidelines in the presence of co-morbid conditions, which suggests that the effect of co-morbid conditions depends on treatment recommendations for the co-morbid conditions and how symptomatic they are.


We conducted an exploratory analysis to assess the framework using chart audit data for 1,240 post-acute myocardial infarction (AMI) Medicare beneficiaries in Alabama. We assessed level of guideline-adherent post-AMI care from chart-based quality indicators and constructed scores reflecting how much care for the co-morbid condition was similar to post-AMI care (concordance) and how symptomatic the co-morbid condition is, based on expert opinion.


Patients had a mean age of 74 years, mean co-morbidities of 2, and 61% were white. Both concordance and symptomatic scores were positively associated with guideline compliance, with correlations of 0.32 and 0.14, respectively (p < 0.001 for each). We found positive correlations between highly concordant co-morbid conditions and post-AMI quality scores and negative correlations between highly symptomatic conditions and post-AMI quality scores; both findings support the framework. However, the framework performed less well for conditions that were not highly concordant or highly symptomatic, and the magnitudes of the associations were not large.


The framework was related to the association of co-morbid conditions with adherence by providers to guideline-recommended treatment for post-AMI patients. The framework holds promise for evaluating and possibly predicting guideline adherence.


acute myocardial infarction guideline adherence co-morbid disease multi-morbidity older patients theory testing 


Acknowledgements and Disclaimers

Drs. Levine, Houston, Allison, and Kiefe were all affiliated with the University of Alabama at Birmingham Division of Preventive Medicine and the UAB Center for Outcomes and Effectiveness Research and Education when the analyses for this paper were completed.

This project was funded in part by grant numbers R01 HL70786 from the National Heart, Lung and Blood Institute and SDR 03-090-1 from the VA Health Services Research and Development (HSR&D)

The analyses upon which this publication is based were performed under contract number 500–02-AL02, entitled "Utilization and Quality Control Peer Review Organization for the State (Commonwealth) of Alabama," sponsored by the Centers for Medicare and Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare and Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor.

Conflict of Interest

None disclosed.


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Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Anne E. Sales
    • 1
    • 5
  • Edmund F. Tipton
    • 2
  • Deborah A. Levine
    • 3
  • Thomas K. Houston
    • 4
  • Yongin Kim
    • 2
  • Jeroan Allison
    • 4
  • Catarina I. Kiefe
    • 4
  1. 1.University of AlbertaEdmontonCanada
  2. 2.University of Alabama at BirminghamBirminghamUSA
  3. 3.VA Ann Arbor Healthcare System and The University of MichiganAnn ArborUSA
  4. 4.University of Massachusetts Medical SchoolWorcesterUSA
  5. 5.Faculty of Nursing and Department of Family MedicineUniversity of AlbertaEdmontonCanada

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