Aligning the Visit Priorities of Complex Patients and Their Primary Care Providers
Phase: NA
Conditions: Primary Health Care, Quality of Health Care, Comorbidity, Communication, Medical Informatics Applications
Sponsor: Kaiser Permanente

 
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1. Protocol  
Protocol Title 
Aligning the Visit Priorities of Complex Patients and their Primary Care Providers – PCORI 1403-11992 
 
Principal Investigator  
Richard W. Grant, MD MPH 
 
Version Date 
7/12/18 
 
Form Author 
Karen R. Estacio 
 
Objectives 
 
For Aim 1 our study objectives were to obtain patient and provider views of their priorities for primary 
care visits and how to format a PC tablet based tool designed to help complex patients determine their top 
priorities for their upcoming primary care appointment. In Aim 1, we conducted an iterative series of 
separate one-on-one interviews with complex patients and their PCPs to characterize the process of 
prioritization, understand how patients and their providers differ in setting priorities, and create a process 
for how these differences can be negotiated during time-limited primary care visits.  
 
In Aim 2 we developed a simple web-based application that can be loaded onto a Tablet PC to be used in 
the waiting room prior to the visit. This tool was designed to guide patients to define and discuss their top 
priorities for the visit. IRB approval was not required for this aim as it did not involve human subjects. 
In Aim 3, we examined the impact of this tool on both patient-centered and clinical care outcomes. We 
compared complex patients in intervention vs. control arms to test the following hypotheses: 
H1: The intervention increases patient satisfaction, autonomy, perceived patient-centeredness, 
and quality of communication (patient-centered outcomes). 
H2: The intervention reduces quality care gaps (clinical outcome). 
H3: The intervention improves collaboration (patient/provider outcomes). 
 
 
2. Background 
a. Scientific Background 
Patients are Increasingly Complex: The aging of the US population coupled with better disease 
prevention and treatment efficacy means that more patients are living with multiple comorbidities that 
require complicated medical regimens.1,2 By 2020 there will be an estimated 130 million Americans with 
one or more chronic conditions.3,4  Patients with multiple chronic conditions have more outpatient visits 
per year, are often prescribed up to 20 medications, generate more health care costs, have more adverse 
events, and have lower health-related quality of life.5 For this proposal, we define “complex patients” as 
patients with two or more chronic conditions who are not receiving the full potential benefit of health 

 
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care, often due to competing health concerns such as active symptoms, cost or other access barriers, 
medication side effects and adherence, and treatment preferences.6,7 Effective management of these 
complex patients presents a major challenge in our current primary care system.8-11  
Physicians Have More to Do: In parallel with increasing patient complexity, there has been a substantial 
rise in guidelines and quality metrics that primary care providers (PCPs) must address at each visit.12,13 
For example, the number of tasks addressed during a typical primary care visit increased from 5.4 in 1997 
to 7.1 in 2005 (p<0.001).12 Ostbye et al estimated it would require up to 10.6 hours per day for a primary 
care physician (PCP) to deliver high quality care for a typical patient panel if chronic diseases were not 
already under good control.14 This confluence of increasing patient complexity and increasing primary 
care tasks despite unchanging (or even decreasing) visit lengths places significant stress on the traditional 
primary care visit and creates barriers to productive interactions. Without new tools to improve the 
primary care of complex patients, millions of Americans will continue to receive sub-optimal care despite 
the availability of effective therapies and interventions that reduce health risks and improve health.15 
Optimizing care for this growing patient population is a national priority.15,16   
The Solution to Competing Demands is Effective Prioritization: While team care and non-visit based 
interactions are increasingly common for managing complex patients, the primary care visit remains a 
critical opportunity for patients and providers to directly engage in shared decision making. For patients 
with multiple concurrent conditions, however, a critical and often underappreciated first step in this 
process is the decision about which issues to discuss first. Prior research using videotaped encounters has 
shown that the first item addressed during the primary care visit receives the bulk of the attention (5 
minutes vs. 1.1 minutes for the next 5 of six total topics addressed during the typical 15 minute visit).17 
Neglecting this critical aspect of patient-provider communication and collaboration may have important 
negative consequences for complex patients with multiple health-related (and non-health-related) 
concerns. Indeed, other visit content analyses have found that more complex patients are less likely to 
have medication changes compared to less complex patients,18  and the likelihood of preventive screening 
declines with each additional concern brought up by patients.19  
While the basic concept of encouraging patients to prepare for their physician appointments and to ask 
questions during the visit is not new,20 there is a paucity of data demonstrating the clinical impact and the 
optimal implementation of this approach for complex patients.21,22 Truly patient-centered care requires 
that care interactions include consideration of patient priorities. For example, pain symptoms in older 
patients have been associated with a 3-fold greater difficulty taking medications prescribed for other 
chronic conditions, and thus addressing a patient’s pain would likely lead to more effective medication 
management for these other conditions.23 Research by our group and others has demonstrated that it is not 
simply the number of concurrent diagnoses, but the influence of behavioral, emotional, and social factors 
that create substantial barriers to effective clinical care.24,25 
Defining and Aligning Priorities: While it is certain that health issues need to be prioritized, it is less 
clear how to align the potentially different priorities of patient and provider. Physicians are trained to 
address disease prevention and risk reduction and evidence suggests that their priorities may be 
influenced by quality metrics. For example, one study found that PCPs may place relatively higher 
priority on lower impact interventions (e.g. microalbuminuria screening) when these are used as 
performance measures,26 whereas patients often have other concerns that outweigh these treatment 
goals.27 For example, older patients report valuing functional ability 28 and place a high priority on 

 
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avoiding drug side effects.29 Research by our group and others has found only modest concordance in 
how patients and their providers prioritize health issues.30,31   
The Figure shows our conceptual model for how recognizing and aligning patient and provider priorities 
can lead to more productive interactions. In our intervention, we will facilitate the process for patients to 
identify their top priorities prior to the time-limited visit. Studies have shown that PCPs can substantially 
improve their assessments when 
patients more effectively and pro-
actively communicate their 
preferences.32,33 Indeed, current 
research suggests that patient-provider 
interactions could become more 
effective if providers better understood 
the patient’s current priorities34-38 and 
were more aware of “unvoiced” 
agendas.39,40 This supports the 
hypothesis that supporting patients in identifying and articulating their care priorities will improve 
provider knowledge and lead to more productive visit interactions.  
System-level change: The key conceptual innovation of this study is to focus on creating an effective, 
easy-to-use tool for patients with multiple concurrent conditions to identify and discuss their top care 
priorities for their upcoming primary care visit. We will conduct foundational work to better understand 
the different goals and values of patient and providers as they relate to setting priorities (Aim 1); apply 
this knowledge to design a simple web-based tool that can be used in the waiting room (Aim 2); and then 
test the impact of this approach in a rigorous randomized trial that will measure both patient-relevant and 
clinical care outcomes (Aim 3). The intervention follows the framework of the Chronic Care Model 
(CCM), with a specific focus on creating “informed, activated patients” through delivery system re-design 
that enables patients preparing for primary care visits to identify which items are of greatest priority for 
them at that time.41  We have successfully applied the CCM in prior research.42-59 By providing complex 
patients with both the opportunity to identify their priorities prior to their visit and the tools to more 
effectively discuss these priorities with their PCPs, this intervention seeks to improve patient-centered 
care by optimizing patient-provider visit interactions. 
 
b. Preliminary Data 
Eligible PCPs are primary care physicians who plan on remaining in their current practice for at least 
another two years with at least 40 potentially eligible patients in their patient panels. There are over 300 
PCPs managing ~250,000 adult patients at primary practices within these 3 centers. Based on our 
preliminary analyses, there are at least 30,000 patients meeting study eligibility criteria (103 eligible 
patients/PCP). 
 
3. Study Design 
 
Aim 1 consists of patient and provider interviews. 
In Step 1 we interview up to 25 complex patients who have had a visit with their PCP within the prior 6 
months. For this proposal we define complex patients as patients with 2 or more chronic conditions and 
 
Patient Priorities 
may be driven by: 
1. Symptoms 
2. Concerns 
3. Frustrations  
 
Provider Priorities 
may be driven by: 
1. Disease Risk 
2. Quality Measures  
3. Prior visit plan  
 
Time-limited Visit 
Recognize  
and align 
priorities 
Focused 
Discussion &  
Mutual Goals 
More  
Productive 
 interaction 
Different Approaches to Priorities 
“I never think about the medical conditions I have. I 
focus on symptoms” –  
Patient Advisor for Current Proposal 

 
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not meeting one or more evidence-based primary care management outcomes related to preventive 
screening [e.g. cancer screening], disease management [i.e. risk factor testing or control], or medication 
taking [evidence of non-adherence based on pharmacy dispensing or self-report]). In these Step 1 
interviews, we focus on understanding whether and how patients prepare for upcoming visits and how 
they conceptualize the relative importance of different health issues. For each participant, we also elicit a 
specific list of their current health care priorities that they want to discuss with their physician. With each 
patient’s prior consent, in Step 2 we interview each participant’s physician. In the Step 2 interviews we 
elicit the physician’s priorities for the patient, compare the physician and patient listed priorities, and 
investigate how each physician would seek to balance any differences between the two sets of priorities. 
Finally, in Step 3 we close the loop by returning to the patient. In the Step 3 interviews, we present 
patients with physician priorities and investigate how the patient perceives any differences between 
his/her priorities and PCPs. 
 
Aim 2 is the IT development of the tablet application and does not involve human subjects. 
Aim 3 Clinical Trial  
We conducted a 2-arm parallel group clinical trial with random, concealed allocation at the level of PCP. 
Both PCPs and patients provided informed written consent. Patients, providers, and waiting room 
research assistants cannot be blinded to randomization status because treatment patients are given the 
Visit Planner tool in the waiting room while control patients are not. However, collection of post-visit 
survey data and assembly of analytic datasets is masked to randomization status. For Aim 3, we enroll 
PCPs and their patients from KPNC primary care practices in Oakland and San Francisco. PCPs are 
recruited via their weekly practice meetings and through individual in-person contacts.  
Intervention 
Intervention patients are provided the Visit Planner on a tablet tool in the waiting room. The tool starts off with a 
video that explained the purpose of the application and educated patients about the importance of bringing up 
their concerns early rather than later in the visit.  Then, the tool prompts them to choose their top 1 or 2 concerns 
for the visit from 6 categories (New Problem, Medicines, Need something from the doctor, Old Problem, Stress at 
home or at work, A personal concern or other). Within each category, patients have the option of choosing 3-4 
sub-categories and of inputting additional comments in a free-text field. After identifying their top visit priorities, 
patients are then prompted to identify how they would use their time during or after the visit to stay involved with 
their care (e.g., Take notes during the visit, Ask my doctor questions during the visit, Review with a friend or 
loved one, Check online patient portal after the visit). All patient responses are subsequently printed out as a Visit 
Planner Summary for the patient to bring into their visit.  
 
Control 
Control patients are also met in the waiting room before eligible visits. Control patients are given a 1-page healthy 
lifestyle education handout.  
 
Patients in both study arms otherwise receive usual care throughout the clinical trial period.  
 
 
 
4. Study Population 
a. Number of Subjects 

 
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Aim 3 clinical trial = 750 patients (modified) 
 
b. Inclusion and Exclusion Criteria 
 
PCP Eligibility: Providers are eligible for inclusion if they have at least 5 potentially study-eligible 
patients within their patient panel and plan to remain at their current practice for the following year. 
Patient Eligibility: We use the KPNC electronic clinical data repository to identify a broad spectrum of 
potentially eligible patients within each participating PCP’s patient panel. Patient eligibility is defined as 
having 2 or more chronic conditions (defined using our validated clinical data algorithms for the 
following common chronic conditions: type 2 diabetes, hypertension, cardiovascular disease, 
dyslipidemia, chronic obstructive pulmonary disease/asthma, depression, renal insufficiency, cancer, and 
symptomatic arthritis) and 1 or more Quantitative Clinical Care gaps defined using KPNC-
implemented quality metric algorithms (e.g. preventive cancer screening for breast, cervical, and/or 
colorectal cancer screening among screen-eligible patients; and to chronic disease management including 
annual HbA1c testing and result < 8.0% for patients with diabetes; annual blood pressure measurement 
and systolic blood pressure (SBP) < 140 mg Hg for patients with diabetes, hypertension, or cardiovascular 
disease (CVD); annual cholesterol measurement and LDL < 100 mg/dL for patients with diabetes or 
CVD). We exclude patients with psychosis or dementia or other deficits that significantly impair 
communication or use of computers. Screening is conducted via electronic record review and patient 
phone calls. We retain information from decliners so that subjects are not re-contacted after declining. 
 
c. Vulnerable Populations 
 
 
 We do not make any special effort to include or exclude vulnerable populations, however our study only 
includes adult members with at least two complex conditions who can participate in an English or Spanish 
language interview.  Each subject, including those in a vulnerable population listed above who may be 
randomly selected into our study sample, have the opportunity to decline participation and avoid further 
contact by study staff by returning the mailed reply postcard or by phoning the study coordinator. Given 
the very low-risk nature of study participation, i.e. survey completion on a PC tablet or interview 
participation, no additional safeguards, beyond standard confidentiality safeguards, are employed. TPMG 
physicians are assured that no individual identifiable responses gathered during interviews will be shared 
with others outside of the study team. 
Decisionally Impaired Adults   
a. If you will obtain surrogate consent, describe detailed research plan to the surrogate, including present 
and future decisions to be made. A documented assessment of decisional capacity as part of the 
procedures for obtaining surrogate consent should be included. 
 
N/A 
 
Other Populations Targeted for Recruitment 
N/A 

 
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d. Setting 
 
The clinical trial was conducted within KPNC primary care practices located at Oakland and San 
Francisco – Mission Bay. Study procedures were conducted by research personnel. 
 
 
e. Recruitment Methods 
On 1/22/16, the IRB approved the “Aligning Patient and Providers” clinical trial. Intervention arm patients have 
the opportunity to use the Align Waiting Room Tool (an iPad based application that helps them prepare for their 
visit) while control patients receive a KP-designed handout on healthy lifestyle advice.  
We have the following research protocol for our clinical trial: 
1) As with our procedure for our similar ongoing clinical trial (CN-13-1579 – Pre-Visit Prioritization for 
Complex Patients with Diabetes), Dr. Grant contacts Primary Care Practice Leaders (via e-mail or in-person) 
to request permission to present the “Aligning Patient and Providers” clinical trial at a weekly practice 
meeting. At this meeting, Dr. Grant explains the purpose for his visit, describes the study, and identifies 
providers willing to participate. With help from research staff, Dr. Grant then obtains written informed 
consent from willing physicians. Consenting physicians also review a list of their own potentially eligible 
patients to approve contacts and complete the 5-item baseline questionnaire at this time. This entire process 
takes 20-30 minutes. 
2) PCP-approved patients are then sent a letter explaining the study. The letter includes a phone number and e-
mail address for patients who wish to participate or opt out of the study. After 1 week, we contact patients 
who have not yet responded and – using our phone script – invite patients to participate in our study. 
3) We obtain verbal informed consent during this phone call to administer a brief patient baseline questionnaire 
and arrange with patients to meet ahead of time at their primary care practice on the day of their next 
scheduled visit. For visits that occur > 1 week after the initial phone enrollment, we also make a reminder 
phone call. Our team has previously created an informatics tool that alerts us when study participants have 
scheduled an appointment with their primary care physician. 
4) At the primary care practice prior to their visit, the research assistant obtains written informed consent. 
Patients allocated to the intervention arm are then given the pre-loaded iPad with the Visit Planner Waiting 
Room Tool that helps them prepare for their visit. This tool takes approximately 4 minutes to complete. On 
completion of the program, the research assistant prints out the patient’s answers and the patient can bring this 
page into the exam room to remind themselves of their visit priorities and plans. As is clearly explained to the 
patient, none of the answers entered by the patient become part of the medical record and are only for the 
patient’s own use. Control patients receive the “Healthy Living/Physical Activity - Every Move Matters” KP-
designed 2-page pamphlet. 
5) Patients are called within 2 days after their visit at a previously arranged time and asked to complete the post-
visit survey. All patients completing these surveys receive a $20 gift card mailed to their home. 
 
 
f. Informed Consent Process 
The study investigator or project manager reviews and presents the consent form before the scheduled 
interview in the waiting room.  We ask if the individual has any questions, provide answers, and obtain 
signed informed consent prior to the interview beginning.     

 
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We do not enroll participants if they cannot provide informed consent due to severe cognitive impairment, 
language issues, or other incapacity.  We screen for these issues during the recruitment telephone call.  
However, any issues of this nature not evident during that call and noted during the consenting process 
are handled on a case by case basis by the person obtaining informed consent. 
Waiver of Informed Consent  
N/A 
 
Waiver of Signed Informed Consent  
N/A 
 
Alteration of Informed Consent  
N/A 
 
Non-English-Speaking Subjects  
 
On 5/25/16, The IRB approved the Spanish version created in close collaboration with the KPNC 
Regional Health Education/Salud Permanente Team responsible for creating all of the Spanish-language 
materials for KPNC members and for creating the Salud Permanente web-site within My Doctor Online.  
 
 
Assent of Children and Parent Permission 
IMPORTANT NOTE: Consent may be obtained in certain situations.  For example, conducting family 
planning or sexually transmitted disease (STD) research.  In addition, for older children ages 16 and up 
who participate in an adult study, the consent document can be used in place of the assent document.   
 
N/A 
 
Adults Unable to Consent/Decisionally Impaired  
If you will obtain surrogate consent, describe detailed research plan to the surrogate, including present 
and future decisions to be made.  
N/A 
 
g. HIPAA Privacy Rule Authorization – if study will use or disclose Protected Health Information (PHI) 
The use and disclosure of PHI for this study presents no more than a minimal risk to the privacy and 
confidentiality of the individuals whose PHI will be accessed, and will be assured by the standard 
protocols in place at DOR that all study staff will follow.  Participant privacy and confidentiality will 
also be ensured by securing storage of physical data (e.g., papers) in locked files, and securing storage of 
digital data (computer files, digital audio) in password-protected files on password protected computers. 
All study staff rated current in HIPAA and IRB training. 
 
Waiver of HIPAA Privacy Rule Authorization  
N/A 
 
 
5. Study Procedures 
Procedures to monitor subjects for safety, including who will review the data and at what frequency for safety 
issues. All patient participants continue with their usual care and are managed medically by their PCPs. The 

 
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intervention is extremely low-risk and is designed to help patients and providers communicate during visits. There 
is no formal safety monitoring. 
 
Procedures performed to lessen the probability or magnitude of risks. The main risk is loss of confidentiality. 
KPNC DOR researchers are accustomed to maintaining processes to ensure confidentiality.  No notations are 
made in the participant’s medical chart.  Subjects are advised that some of the interview questions are of a 
personal nature, but that all data are handled with confidentiality.  Subjects are further assured of their right to 
refuse to answer any questions. Participant privacy and confidentiality is ensured by: 
1. Securing storage of physical data (e.g., papers) in locked files, and securing storage of digital data 
(computer files, digital audio) in password-protected files on password protected computers. 
2. Making data that may contain identifying features accessible only to members of the research team 
working under the direction of the investigators during the duration of the project. 
3. Use of a study ID on all audio files and transcripts. The transcriptionist do not transcribe any identifying 
information.  Study staff review hard copy transcripts and remove any remaining identifying information 
(such as names, place names, etc.).  All audio files are destroyed after transcription. 
4. Ensuring that no data are collected or maintained by investigators which participants do not want to have 
preserved. 
5. Ensuring no participant can be identified in any presentations or publications about this study. 
6. All study staff rated current in HIPAA and IRB training. 
 
All drugs and devices used in the research and the purpose of their use, and their regulatory approval status. NA 
The source records that will be used to collect data about subjects. Data are collected from the medical record and 
via patient and provider surveys. 
What data will be collected including long-term follow-up. Long-term follow-up is based on data from the 
medical record collected as part of routine care. 
The duration of an individual subject’s participation in the study. Physicians were recruited at monthly physician 
meetings where the study was presented. The first eligible patient visit occurred on 3/31/2016 while the last visit 
occurred on 6/30/17.  
The duration anticipated to enroll all study subjects. Enrollment of physicians began 2/2016 and was completed 
by 2/2017. Follow-up was assessed through 12/31/2017— 6 months after the final visit. We chose a 6-month 
follow-up period to balance factors of providing sufficient time for the intervention to make an impact while also 
reducing loss to follow-up. 
 
 
a. Data Analysis  
Study outcomes 
Our primary clinical outcome is the closing of quality care gaps within 6 months of study visits. Individual care 
gaps are measured at baseline and 6-month follow-up as a total count of any care gap at both time periods. 
Change in aggregated care gaps from baseline to follow-up is also assessed in four ways: closure of all baseline 
gaps, closure of any baseline gaps, opening of new care gaps, and presence of no gaps at the end of the study.  
 
Our primary patient-reported outcomes regarding their care experiences are obtained during post-visit telephone 
calls using questions drawn from validated survey instruments. Surveys are conducted within 1 week of the 
eligible primary care visit. We measure outcomes in the domains of patient satisfaction, autonomy, perceived 
involvement in care, and satisfaction with care.29-34 Modeled on the structure of these validated items, we also add 
several study-specific questions to obtain more detailed information about bringing up top concerns at the 
beginning of the visit, taking notes and asking questions during the visit, and following up post-visit with friends 

 
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and loved ones. Finally, we examine responses to a 5-item PCP survey administered at baseline during study 
enrollment.  
 
Statistical Methods 
We examine baseline characteristics of patients and providers by randomization status using chi-square, t-test, and 
non-parametric tests as appropriate. For our clinical trial outcomes, we construct generalized linear mixed models 
(SAS Proc GLIMMIX) with the dichotomized response as a dependent variable (with a logit link), 
treatment/control arm as a fixed effect and PCP as a random effect to adjust for clustering of patients within PCP. 
For secondary survey outcomes, the patient reports are dichotomized and analyzed in the same type of mixed 
models. We also conduct a priori analyses of English vs. Spanish-speaking patients in sub-analyses to determine 
any differential effects by language. We use SAS version 9.3, SAS Institute, Cary NC. 
 
 
b. Sharing of Results with Subjects 
Results will not be directly shared with patients.  
 
c. Data and/or Specimen Banking 
NA 
 
6. Privacy, Confidentiality and Data Security 
Names and other identifying information on study subjects will be retrieved from the KPNC automated 
databases. We will have the link between MRN and original study ID number, and at the end of the study, 
this link will be destroyed. Only KPNC workforce staff directly involved in the study will have access to 
data identifying individual subjects (PI, co-investigators, project manager, & programmer). No 
individuals will be identified in any reports from this study. All data will be presented in aggregate in 
reports and publications; i.e., no identifiers will be shown. Records with any identifying information will 
be kept in locked drawers when not in use. Access to computerized information on the KPNC network 
requires simultaneous knowledge of the databases, programming language, file names, and multiple 
passwords. Therefore, we can ensure data security. All study staff rated current in HIPAA and IRB 
training. 
 
 
Describe the plan for storage of data and/or specimens. 
NA 
 
Collection of data from subjects electronically 
N/A 
 
Does this study involve the disclosure of PHI to a collaborator? 
N/A 
 
7. Provisions to Monitor Data to Ensure the Safety of Subjects 
N/A 
 
8. Risks and Benefits  
a. Risks to Subjects 

 
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We anticipate no physical, social, or economic risks to research participants in this study.  Risks to 
participants in Aim 1 are very small given that participation involves interviews.  Participants will be 
assured they are free not to answer any questions and/or refuse participation at any time, thus guarding 
against the risk of psychological or emotional upset.    
 
b. Potential Benefits to Subjects 
The effective primary care of complex patients remains an important and increasing challenge both for 
KP and nation-wide. There are a wide range of treatments that reduce risk for morbidity and mortality, 
but translating these benefits for all patients has been difficult to achieve. We hypothesize that 
understanding and addressing the issue of prioritization prior to the primary care visit may represent one 
innovative approach to addressing these challenges by making the time-limited primary care visit 
encounter more productive.       
 
9. Economic Burden to Subjects  
N/A 
 
10. Compensation to Participants  
$20 gift card will be provided to study participants completing the post-visit survey. 
 
11. Resources Available 
All study staff rated current in HIPAA and IRB training. 
 
12. Prior Approvals 
N/A 
 
13. Drugs or Devices 
N/A 
 
14. Multi-Site Research  
N/A 
 
15. Community-Based Participatory Research  
N/A 
 
 

 
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References 
 
1. 
Vogeli C, Shields AE, Lee TA, et al. Multiple chronic conditions: prevalence, health consequences, and 
implications for quality, care management, and costs. Journal of General Internal Medicine. 2007;22 
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2. 
Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic 
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3. 
Thorpe KE, Howard DH. The rise in spending among Medicare beneficiaries: the role of chronic disease 
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4. 
Schneider KM, O'Donnell BE, Dean D. Prevalence of multiple chronic conditions in the United States' 
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Field TS, Gurwitz JH, Harrold LR, et al. Risk factors for adverse drug events among older adults in the 
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6. 
Peek CJ, Baird MA, Coleman E. Primary care for patient complexity, not only disease. Families, Systems & 
Health. 2009;27(4):287-302. 
7. 
Reuben DB, Tinetti ME. Goal-oriented patient care--an alternative health outcomes paradigm. N Engl J 
Med. 2012;366(9):777-779. 
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Kalyani RR, Saudek CD, Brancati FL, Selvin E. Association of diabetes, comorbidities, and A1C with 
functional disability in older adults: results from the National Health and Nutrition Examination Survey 
(NHANES), 1999-2006. Diabetes Care. 2010;33(5):1055-1060. 
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Kerr EA, Heisler M, Krein SL, et al. Beyond comorbidity counts: how do comorbidity type and severity 
influence diabetes patients' treatment priorities and self-management? Journal of General Internal 
Medicine. 2007;22(12):1635-1640. 
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Beverly EA, Wray LA, Chiu CJ, Weinger K. Perceived challenges and priorities in co-morbidity 
management of older patients with Type 2 diabetes. Diabetic Medicine. 2011;28(7):781-784. 
11. 
Elliott RA, Ross-Degnan D, Adams AS, Safran DG, Soumerai SB. Strategies for coping in a complex world: 
adherence behavior among older adults with chronic illness. Journal of General Internal Medicine. 
2007;22(6):805-810. 
12. 
Abbo ED, Zhang Q, Zelder M, Huang ES. The increasing number of clinical items addressed during the 
time of adult primary care visits. Journal of General Internal Medicine. 2008;23(12):2058-2065. 
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