Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois 60637, USA.
Ann N Y Acad Sci. 2011 Dec;1243:69-87. doi: 10.1111/j.1749-6632.2011.06316.x.
Approximately half of adults with diabetes have at least one comorbid condition. However, diabetes care guidelines focus on diabetes-specific care, and their recommendations may not be appropriate for many patients with diabetes and comorbidity. We describe Piette and Kerr's typology of comorbid conditions, which categorizes conditions based on if they are clinically dominant (eclipse diabetes management), symptomatic versus asymptomatic, and concordant (similar pathophysiologic processes as diabetes) versus discordant. We integrate this typology with clinical evidence and shared decision-making methods to create an algorithmic approach to prioritizing care in patients with diabetes and comorbidity. Initial steps are determining the patient's goals of care and preferences for treatment, whether there is a clinically dominant condition or inadequately treated symptomatic condition, and the risk of cardiovascular disease. With these data in hand, the clinician and patient prioritize diabetes treatments during a shared decision-making process. These steps should be repeated, especially when the patient's clinical status changes. This patient-centered process emphasizes overall quality of life and functioning rather than a narrow focus on diabetes.
约一半的糖尿病患者至少有一种合并症。然而，糖尿病护理指南侧重于糖尿病的特定护理，其建议可能并不适用于许多患有糖尿病和合并症的患者。我们描述了 Piette 和 Kerr 的合并症分类法，该分类法根据合并症是否具有临床主导性（影响糖尿病管理）、有症状还是无症状以及与糖尿病是否一致（具有相似的病理生理过程）还是不一致来对合并症进行分类。我们将这种分类法与临床证据和共同决策方法相结合，为患有糖尿病和合并症的患者创建了一种优先考虑护理的算法方法。初始步骤是确定患者的护理目标和治疗偏好，是否存在具有临床主导性的疾病或未得到充分治疗的有症状疾病，以及心血管疾病的风险。有了这些数据，临床医生和患者在共同决策过程中优先考虑糖尿病治疗。应重复这些步骤，尤其是当患者的临床状况发生变化时。这个以患者为中心的过程强调整体生活质量和功能，而不是狭隘地关注糖尿病。
