The treatment of unrelated disorders in patients with chronic medical diseases

N Engl J Med. 1998 May 21;338(21):1516-20. doi: 10.1056/NEJM199805213382106.


Background: Patients can have several illnesses concurrently, yet some of these diseases may be neglected if one problem consumes attention. We conducted a population-based analysis in Ontario, Canada - where universal health insurance is provided - to determine whether unrelated disorders are less likely to be treated in patients with chronic diseases.

Methods: We studied the 1,344,145 residents of Ontario in 1995 who were 65 or older and eligible to receive prescription medications free of charge as part of the Ontario Drug Benefit program. Patients with diabetes mellitus were identified by prescriptions for insulin, pulmonary emphysema by prescriptions for ipratropium bromide, and psychotic syndromes by prescriptions for haloperidol. For each chronic disease, we selected an unrelated treatment: estrogen-replacement therapy for patients with diabetes mellitus, lipid-lowering medications for those with pulmonary emphysema, and medical treatment of arthritis for those with psychotic syndromes.

Results: The 30,669 patients with diabetes mellitus were less likely to receive estrogen-replacement therapy than the other subjects in the study (2.4 percent vs. 5.9 percent, P<0.001). The disease was associated with a 60 percent reduction in the odds of estrogen treatment (odds ratio, 0.40; 95 percent confidence interval, 0.37 to 0.43). Findings were similar for the 56,779 patients with pulmonary emphysema, who were less likely to receive lipid-lowering medications (odds ratio, 0.69; 95 percent confidence interval, 0.67 to 0.72; P<0.001), and the 17,336 patients with psychotic syndromes, who were less likely to receive medical treatments for arthritis (odds ratio, 0.59; 95 percent confidence interval, 0.57 to 0.62; P<0.001).

Conclusions: In patients 65 or older who have chronic medical diseases and who receive prescription medications free of charge, unrelated disorders are undertreated. Clinicians caring for patients with chronic diseases should remain alert to other disorders and minimize the number of missed opportunities for treating them.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Arthritis / complications
  • Arthritis / drug therapy*
  • Chronic Disease*
  • Diabetes Mellitus / drug therapy
  • Estrogen Replacement Therapy*
  • Female
  • Humans
  • Hyperlipidemias / complications
  • Hyperlipidemias / drug therapy*
  • Male
  • Ontario
  • Polypharmacy*
  • Psychotic Disorders / complications
  • Psychotic Disorders / drug therapy
  • Pulmonary Emphysema / complications
  • Pulmonary Emphysema / drug therapy