Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians
2012; Wiley; Volume: 60; Issue: 10 Linguagem: Inglês
10.1111/j.1532-5415.2012.04188.x
ISSN1532-5415
Tópico(s)Pharmaceutical Practices and Patient Outcomes
ResumoOne of the greatest challenges in geriatrics is providing optimal care for older adults with multiple chronic conditions, or "multimorbidity."1-4 More than 50% of older adults have three or more chronic diseases. The heterogeneous patterns and severity of conditions produce distinctive cumulative effects for each individual.5 Multimorbidity is associated with many adverse consequences, including death, disability, institutionalization, greater use of healthcare resources, poorer quality of life, and higher rates of adverse effects of treatment or interventions.1 Comprehensive strategies for healthcare delivery that are not disease specific, as well as interventions that target geriatric syndromes common in older adults with multimorbidity, show promise for this population,5-9 although the best approaches to decision-making and clinical management of older adults with multimorbidity remain unclear. Evidence-based clinical practice guidelines (CPGs) exist for many conditions, but the fact that most focus on the management of a single disease remains a barrier to their application in adults with multimorbidity.3, 9-13 Many CPGs do not address the question of how to integrate care for individuals with multimorbidity. Following single-disease CPGs in older adults with multimorbidity may cumulatively result in care that is impractical, irrelevant, or even harmful.3, 9 The source of this deficiency in many current CPGs is not confined to guideline development and implementation.3, 12 At each phase of the translational path, older adults with multimorbidity are often excluded. These omissions occur in the areas of trial and study design and analysis, synthesis of trial and observational study results in meta-analyses and systematic reviews, and the guideline development process. Because each of these generates the information necessary to support evidence-based care, the exclusion or underrepresentation of older adults with multimorbidity must be acknowledged so that appropriate interpretation of results is possible. The full spectrum of clinical management of older adults with multimorbidity includes not only treatments and interventions for their conditions, but also screening and preventive and advanced illness care. The best strategies to determine which aspects of this spectrum of clinical management are of the highest priority in a particular older adult with multimorbidity are unknown. Rather than relying solely on information from the limited evidence-based resources for clinical decision-making, clinicians need a management approach that will consider the multiple problems particular to each individual with multimorbidity. In addition to evidence-based choices, such an approach would reflect an older person's own preferences and goals (in the context of his or her own combination of diseases and conditions), prognosis, and multifactorial geriatric problems and syndromes and the feasibility of each management decision and its implementation. Interactions between treatments or interventions for two different conditions, as well as interactions between treatments or interventions for one condition and coexisting conditions, may factor into decision-making. The American Geriatrics Society (AGS) convened an expert panel with complementary expertise in these topics along with a special interest in older adults with multimorbidity. The goal of the panel was to develop an approach by which clinicians can care optimally for this particular population. It is important to note that this document is not a guideline. A structured literature review was used to inform this work, but unlike a traditional guideline, this document does not issue recommendations based on rigorous evaluation of the quality of evidence for specific clinical questions followed by an assessment of harms and benefits and recommendation statements. By definition, older adults with multimorbidity are heterogeneous in terms of severity of illness, functional status, prognosis, and risk of adverse events even when diagnosed with the same pattern of conditions. Priorities for outcomes and health care also vary. Thus, not only the individuals themselves, but also the treatments that clinicians consider for them will differ. As a result, clinicians must pursue more-flexible approaches to care in these older patients. This document presents a clinical approach to the care of older people with multimorbidity that describes guiding principles for the clinical management of this population. The goal of this work is also to facilitate the development and growth of an evidence base by which clinicians can make sound care decisions for this population, including the testing of better processes for decision-making. For example, not only must the healthcare community generate better evidence about whether a specific intervention is beneficial, it must also establish effective methods for determining outcome priorities and for deciding what changes are needed to the healthcare system to allow these methods to be accommodated. This is a consensus document, and it is hoped that evidence-based approaches to the care of older adults with multimorbidity will replace it in the future. A summary of this document, "Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society," is also published in the Journal of the American Geriatrics Society and is available online at www.ags-online.org. There are many relevant clinical concerns that are outside the scope of this project. Questions regarding costs of care, acute care, transitions of care, and the imminently dying are not specifically addressed; instead, the project focuses on older people with life expectancies of months to many years.14, 15 In addition, multimorbidity is associated with high symptom burden and poor quality of life. Management of cumulative illness and symptom burden in multimorbidity is not specifically discussed, although many principles related to patient preferences and treatment complexity can relate to management of symptoms in multimorbid patients. The management of chronic conditions in primary care is the primary focus, although older adults with multimorbidity frequently transition through many care settings, and a variety of provider types, referred to hereafter as clinicians, care for them. The method is relevant across settings and types of clinicians. Many of the principles and literature discussed here may have relevance to younger people with multimorbidity, but this population, and problems unique to younger people with multimorbidity, are not specifically considered. Any healthcare professional clinically managing an older person with multimorbidity can use this approach, but a primary provider or medical home, with an associated healthcare team, is central to implementation. Clinical management is defined as representing all types of care for chronic conditions provided by clinicians, including pharmacological treatment, nonpharmacological interventions (e.g., referral to specialists, physical and occupational therapy, use of pacemakers), and screening and diagnostic tests and follow-up. Clinicians are the primary intended audience for this document. This work will also inform researchers, public health professionals, payers, policy-makers, and others interested in the care of older adults, because it addresses controversies and challenges to implementing the approach, offers a relevant research agenda, and describes barriers to its adoption. The AGS Clinical Practice and Models of Care Committee convened the expert panel with funding from the AGS. Members of the interdisciplinary panel were selected on the basis of their expertise in different areas relevant to older adults with multimorbidity, with a focus on geographic and training diversity. To ensure that potential conflicts of interest were clarified and addressed appropriately, each member disclosed his or her potential conflicts of interest to the expert panel at the onset. The panelists' potential conflicts of interest are listed at the end of the paper. Through a one day in-person meeting and a series of conference calls, the panel proposed that the document contain five domains relevant to the care of older adults with multimorbidity: Patient Preferences, Interpreting the Evidence, Prognosis, Clinical Feasibility, and Optimizing Therapies and Care Plans. These domains were used to organize the report, although there is inherent overlap among them. Some of the individual domains apply to multiple steps of the flowchart (Figure 1). In addition to the five domains, a section on Barriers focuses on real-world challenges to implementing this approach in older adults with multimorbidity. Two distinct literature review strategies were used for this project. The first used a structured PubMed literature search strategy. The second consisted of a citation search of relevant articles. This is not a systematic review. Four separate literature searches were conducted: one each for the Patient Preferences, Interpreting the Evidence, Prognosis, Clinical Feasibility, and Optimizing Therapies and Care Plans. A separate search was not conducted for the Barriers section. Instead, panel members were asked to look for, and identify, articles that addressed potential barriers and challenges in relation to any of the aforementioned domains. Panel members recommended a list of domain-specific search terms based on their knowledge of the subject matter, their experience with the literature, and key words found in articles considered to be highly representative of the domain topic. An informationist from the Johns Hopkins Welch Library was consulted on construction of the search strategy. First, all of the appropriate Medical Subject Heading (MeSH) terms that aligned with each of the proposed search terms were identified. Terms without appropriate MeSH headings were added to the search strategy in quotation marks. The overall strategy of the PubMed literature search was to cross the domain-specific concepts with the general concept of multiple chronic conditions, or multimorbidity. Because there are no specific MeSH terms for the concept of "multimorbidity" or "multiple chronic conditions," a list of possible terms related to this concept was created. For each of the four searches, the domain-specific search terms were combined with the search terms related to the concept of multiple chronic conditions through use of the Boolean operator "AND" (Table 1). Only articles published in English since January 2000 were included. The panel members were provided with the title and abstracts of all of the articles identified using the searches. Each was instructed to reject articles that were not related to the domain topic, not related to patients with multimorbidity, not related to adults, or not relevant for any other reason. Panel members retained articles that were pertinent to any or all of the project domains (regardless of the domain to which they were assigned). They were then provided with the full text of all articles retained for their review and consideration. In addition to the literature search described above, a search was conducted of articles that panel members determined to be highly relevant to each domain. For each of the relevant articles, we conducted a cited reference search using the Web of Science to find the articles that cited each relevant article. The number of relevant articles per domain, the number of unique citations arising from those articles, and the number of articles retained for review are provided in Table 2. In addition to both of these methods, panelists also reviewed the list of references at the end of each relevant article to capture any additional articles that might have been missed. Major areas of uncertainty or areas where relevant evidence is limited are specifically described, with the goal of highlighting the topics that are most critically in need of future research. The document was also circulated for peer review to a number of organizations with special interest and expertise in treating older adults with multimorbidity and was posted to the AGS website for public comment. Organizations that participated in peer review are noted in the Acknowledgments section of this document. All clinicians, including primary care providers (physicians, physician assistants, and nurse practitioners), pharmacists, geriatricians, specialists, and other clinicians who take care of older patients with multimorbidity often find themselves challenged on many levels. Of particular concern are complexities involved in clinical management decisions; inadequacy of good evidence for making informed, shared decisions; and time constraints and reimbursement structures that hinder the provision of efficient quality care.2, 16 One approach is illustrated in Figure 1, a flowchart that presents one sequence of questions and considerations useful in the optimal management of older people with multimorbidity. The steps suggested can be taken in other sequences with equal validity, particularly because the best approaches to addressing this population have not been compared, and few approaches of this type appear in the literature.17, 18 For example, in many instances, patient preferences are best elicited in the context of the patient's prognosis. The five main domains apply at various steps illustrated in Figure 1. These domains represent themes that must be considered when caring for older adults with multimorbidity. Each domain is discussed below, and each merits a formal review in and of itself. The development of this document was undertaken with the premise that bringing these themes together would be of value to clinicians and would highlight areas for future research in this field. After describing the five domains in detail, two clinical scenarios are offered, illustrating how the approach can guide clinical decisions for this population. (See 7.) Guiding Principle: Elicit and incorporate patient preferences1 into medical decision-making for older adults with multimorbidity. CPGs do not routinely search for or include evidence related to patient values or preferences.19, 20 Few references used to construct CPGs address preferences.20 Consequently, care that is provided in accordance with CPGs may not adequately address this important aspect of medical decision-making. Older people with multimorbidity are able to evaluate choices and then prioritize their preferences for care, considering pertinent personal and cultural contexts about health and health care. For example, it has been shown that such patients can weigh the risks and benefits of treatment when deciding to take medications21 and are able to rank health outcomes according to personal health priorities.22 Some recommendations within CPGs are more preference sensitive than others, and clinicians should be particularly aware of patient preference in these types of medical decisions. Preference-sensitive decisions include choices with more than one reasonable treatment option and possible lifelong implications for chronic disease management or decisions about treatments or interventions that have an important risk or offer uncertain benefit.23-25 All clinical decisions require an assessment of patient preferences. The preferences can be elicited according to the degree of complexity of the situation and the importance of preference to the decision being discussed.26 The clinician can customize the elicitation of preferences so that decision-making is abbreviated in less-complex situations and more expansive when many options and preferences need to be considered. For clinical management decisions with multiple options, the process of eliciting patient preferences requires several steps. Recognize when the older adult with multimorbidity is facing a "preference sensitive" decision. In such situations, the clinician must understand what is most important to the patient to determine the best option. Older adults with multimorbidity are more likely to confront these kinds of decisions because of the burdens that the many potential therapies for each condition, the increased risk of adverse events, and the possibility of more limited benefits impose.3, 9 Some examples of "preference sensitive" decisions are therapy that may improve one condition but make another worse (e.g., inhaled corticosteroids to treat chronic obstructive pulmonary disease may exacerbate osteoporosis);27 therapy that may confer long-term benefits but may cause short-term harm (e.g., medications for primary or secondary disease prevention that have adverse effects such as statins, which decrease cardiovascular risk but may cause cognitive impairment or muscle weakness);28, 29 and multiple medications, each with benefits and harms that must be balanced. Many treatments used in this population can improve individual disease-specific outcomes but may be difficult for the patient to take and be associated with greater risk of falls, weight loss, or dizziness.30 Ensure that older adults with multimorbidity are adequately informed about the expected benefits and harms of different treatment options. This step consists of broad consideration of the effects of treatments and interventions on multiple health domains. For example, although clinicians often label adverse medication effects as less important "side" effects than the beneficial outcomes the medications are designed to produce, the individual taking the medication may consider the side effects important outcomes in their own right.31, 32 Therefore, adverse effects in such cases need to be considered as "harms." Although it is a challenging task, numerical likelihoods should be provided to patients if they are available. It has been shown that words used to convey frequencies, such as "rarely" or "frequently," are interpreted highly variably,33 and there continues to be a debate about the best way to present numerical information to patients. Generally well-accepted recommendations include presenting the likelihood of the event occurring and the likelihood of the event not occurring, to avoid framing the outcome positively or negatively;34 presenting absolute rather than relative risks; and providing visual aids, based on evidence that pictographs may be most helpful.35 Older adults have variable levels of "health numeracy" (capacities to access, interpret, and act on numerical and quantitative health information).36 Low numeracy may be associated with greater difficulty in understanding risk information.37 Assessing patients' understanding of the information presented (e.g., using a "teach back" technique) is an important element of this step. Elicit patient preferences only after the older individual with multimorbidity is sufficiently informed. Various decision aids are available to help inform patients and elicit preferences,38 but these may fail to account for the likelihood of different outcomes that may vary greatly with different comorbidity and risk-factor profiles.39 Decision analysis involves the creation of a decision tree, which identifies all potential outcomes of each treatment option. The utilities of each outcome are then calculated, based on preference, and assessed using approaches such as the standard gamble and time trade-off.40-42 Conjoint analysis identifies the characteristics of different treatment options; assigns levels to each characteristic (based on severity of a symptom or likelihood of an outcome); and uses rating, ranking, or discrete choices to determine which characteristics are most important to an individual.43 For busy clinicians, a simpler method of eliciting preferences may be to ask patients to prioritize a set of universal health outcomes that can be applied across individual diseases. Typical outcomes would include living as long as possible, maintaining function, and alleviating pain and other symptoms.44 The individual treatment options are considered in terms of their effects on each of these outcomes, so that a treatment can be selected according to its likelihood of achieving the patient's most-desired outcome or avoiding the least-desired outcome.21, 22 There are several additional considerations for clinicians to keep in mind when attempting to elicit preferences. First, clinicians need to distinguish between eliciting preferences and making a treatment decision.45 The former is the process by which patients voice their opinions about the different treatment options in the context of their values and priorities (the process upon which choice of care is based), whereas the latter is the process by which a specific option is chosen. Patients vary widely in their preferred decision-making style. Some patients prefer to make the decision themselves, whereas others leave the decision to the clinician or choose to share the process of decision-making with the physician. Regardless, virtually all individuals want their opinion to guide the decision.46 Second, patients may want their family, friends, and caregivers to be included in decision-making or even to make the decision for them.47 For patients with cognitive impairment who are unable to understand the implications of different options, these significant others become surrogate decision-makers who work with clinicians to make decisions on behalf of the patient. Individuals who are cognitively intact may also want their family to be involved. Third, preferences may change over time,48 so it is important that they be reexamined, particularly when an older adult with multimorbidity has experienced a change in health status. Fourth, the principle of eliciting preferences and involving patients in the decision-making process does not mean that the patient has the right to demand any and all treatment options if these options do not have a reasonable expectation of some benefit.49 There are challenges involved in some aspects of informing older adults and eliciting their preferences. For example, it is often difficult to convey a clear numerical understanding of benefits and harms.50 Moreover, many studies have demonstrated that the way in which risk information is presented influences patient preferences. Because older adults with multimorbidity may face a large number of preference-sensitive decisions, and the conditions and their clinical management may affect each other, it may not be feasible to use decision tools for each individual choice. Also, data regarding the effects of a given treatment on a range of outcomes, including physical and cognitive function, may not be available. How to communicate uncertainty to patients is challenging in general and is likely to be even more challenging in older people with multimorbidity because the decisions are more complex, and uncertainty may be even greater.51 In addition, patients may feel burdened by the task of participating in decision-making, particularly in situations in which there are no good outcome data. Finally, clinicians struggle to find time to implement CPGs recommendations for a typical panel of patients with chronic conditions in primary care.52 Eliciting preferences may make clinical management of older adults even more time consuming.52 Because the full range of clinical management outcomes shapes preferences, more evidence is needed about the effects of treatment choices on outcomes other than survival, including functional status and quality of life. Risk calculators and other tools may help clinicians inform patients appropriately by providing individualized outcome data according to each person's multimorbidity profile. There have been few studies directly comparing different methods of preference elicitation, and a greater understanding of the feasibility, acceptability, and results of using these methods among persons with multimorbidity is needed. Guiding Principle: Recognizing the limitations of the evidence base, interpret and apply the medical literature specifically to older adults with multimorbidity. CPGs synthesize evidence from multiple types of studies (augmented, in some cases, by meta-analyses and other secondary analyses of clinical trials and observational studies) to provide guidance for clinicians in managing clinical problems according to the best current evidence. However, most studies of treatment effect and CPGs focus on only one to two clinical conditions at a time and address comorbidities in limited ways, if at all.3, 11-13, 53 Different conditions coexisting within the same patient may interact in a way that changes the risks associated with each condition and its treatments. For example, a person with heart failure, chronic renal insufficiency, diabetes mellitus, depression, and cognitive impairment may be at greater than average risk for a myocardial infarction but may also be at greater than average risk of adverse events from a particular treatment, as well as at greater risk of morbidity and all-cause mortality,54 making determining whether the person will benefit from a particular treatment complicated. The development of thoughtful standardized approaches to interpreting the medical literature,55, 56 known collectively as "evidence-based medicine," provides tools for clinicians to evaluate the applicability of findings reported in the medical literature to each patient. There is increasing consensus about the appropriateness of these methodologies for assessing the quality of evidence supporting GPGs recommendations,57, 58 although one element of such methodologies that must not be neglected is the assessment of applicability of the findings to the specific patient under consideration.55 Significant gaps exist in the current clinical trials evidence base about interactions of conditions and treatments in patients with multimorbidity. To provide patient-centered care, clinicians must evaluate the medical literature in terms of its ability to offer conclusions that pertain to this population of older adults. There are several general principles to consider in evaluating clinical evidence. Reviews of evidence should be based on key clinical questions so that it is possible to determine whether a study informs this question or not. Rigorous methods of reviewing the quality of evidence and its applicability to specific populations have been developed and accepted into common usage.59-63 Although some small differences occur between these approaches, there are a few central concepts in all of them that are consistent and noteworthy. Furthermore, certain questions can be excellent guides to evaluating whether a piece of evidence—regardless of the source—is applicable to an older person with multimorbidity. Although the questions offered below focus on CPGs, they could apply to any piece of scientific evidence. The questions are grouped into five sections: Applicability and Quality of Evidence, Outcomes, Harms and Burdens, Absolute Risk Reduction (ARR), and Time Horizon to Benefit. A fundamental question is whether it is scientifically appropriate to apply the results of a particular study to the population under consideration. In other words, what is the "applicability" of the information? Clinical studies enroll patients drawn from particular populations or subsets of a population. How well the research findings from a particular study apply to older adults with multimorbidity depends upon how closely the individual being considered resembles the research population. Clinicians should try to ascertain whether multimorbid, or even older, people were included in the studies in sufficient numbers to make the study findings applicable to this specific population in a meaningful way. If so, was there evidence of effect modification of intervention effects associated with a factor such as multimorbidity or specific comorbidities?11, 13 Equally important when considering multimorbid patients is an evaluation of the quality of evidence. Published clinical studies vary considerably in their adherence to accepted principles of clinical research. Even a strongly positive result should be viewed with caution if it is from a poor-quality study, because the results may be attributable to flaws in the study design or analysis.59, 60, 63, 64 In this regard, a body of evidence is more helpful than a single positive study. Existing approaches to evaluate the quality of evidence are appropriate for older adults with multimorbidity and will be useful to clinicians. In particular for older adults with multimorbidity, clinicians must seek a balance between other aspects of quality of evidence and applicability. For example, well-designed randomized clinical trials diminish the problems of confounding seen in observational studies but often exclude individuals with multimorbidity. Although results from observational studies are often considered weaker than those from randomized clinical trials, such studies are more likely to include older adults with multimorbidity, and they may provide more information about the adverse events associated with an intervention in this population (Table 3). Clinical trials evaluate many different types of outcomes. For example, trials are often designed to measure intermediate outcomes (surrogates) that are not of immediate importance to patients (e.g., laboratory markers), but there is ample justification in the literature for study designs that evaluate "patient-important outcomes."59, 60, 65, 66 Intermediate outcomes in themselves may not affect patients directly. An individual might not value a high cholesterol result as highly as a patient-important outcome, such as a stroke or myocardial infarction, although such patient-important outcomes may sometimes be tightly linked to the intermediate outcomes. In addition, outcomes relevant to older patients with multimorbidity may not be addressed i
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