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Micro Level Priority Setting for Elderly Patients with Acute Cardiovascular Disease and Complex Needs: Practice What We Preach or Preach What We Practice?
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Demographic trends and other factors are expected to continue widening the gap between health care demands and available resources, especially in elder services. This growing imbalance signals a need for priority setting in health care. The literature has previously described problems in constructing useable means of priority setting, particularly when evidence is sparse, when patient groups are not satisfactorily defined, when interpretation of the term patient need is unclear, and when uncertainty prevails on how to weigh different ethical values. The chosen study object illustrates these problems. Moreover, the Swedish Government recently stated that care for elderly persons with complex health care needs remains underfunded. The general aim of this thesis is: to study micro-level priority setting for elderly heart patients with complex needs, as illustrated by those with non-ST-elevation myocardial infarction (NSTEMI); to relate the findings to evidence-based priority setting, e.g. guidelines for heart disease; and to analyse how complex needs could be appropriately categorised from a perspective of evidence-based priority setting.

Paper I presents a register study that uses data from the Patient Register to describe inpatient care utilization, costs, and characteristics of elderly patients with multiple diseases. Paper II presents a confidential survey study from a random sample of 400 Swedish cardiologists. Paper III presents a prospective, clinical, observational multicentre-study of elderly patients with myocardial infarction (NSTEMI). Paper IV presents a questionnaire study from a purposeful, stratified sample of Swedish cardiologists.

The results from Paper I show that elderly patients with multiple diseases have extensive and complex needs, frequently manifesting chronic and intermittently acute disease and consuming health care at various levels. A large majority have manifested cardiovascular disease. Results from Paper II indicate that although 81% of cardiologists reported extensive use of national guidelines in their clinical decision-making generally, the individual clinician’s personal clinical experience and the patient’s views were used to a greater extent than national guidelines, when making decisions about elderly multiple-diseased patients. Many elderly heart disease patients with complex needs manifest severe, acute or chronic, comorbid conditions that constitute exclusion criteria in evidence-generating studies, thereby limiting the generalisability of evidence and applicability of guidelines for these patients. This was indicated in papers I-IV. Paper III reports that frailty is a strong independent risk factor for adverse, short-term, clinical outcomes, e.g. one-month mortality for elderly NSTEMI patients. Particularly frail patients with a high comorbidity burden manifested a markedly increased risk.

In the future, prospective clinical studies and registries with few exclusion criteria should be conducted. Consensus-based judgments based on a framework for priority setting as regards elderly patients with complex needs may offer an alternative, estimating the benefitrisk ratio of an intervention and the time-frame of expected benefits in relation to expected life-time. Such a framework, which is tentatively outlined in this thesis, should take into account comorbidity, frailty, and disease-specific risk.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2011. , 106 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1240
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-67639ISBN: 978-91-7393-188-5OAI: oai:DiVA.org:liu-67639DiVA: diva2:412159
Public defence
2011-05-13, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2011-05-11 Created: 2011-04-20 Last updated: 2011-07-05Bibliographically approved
List of papers
1. Characteristics of multiple-diseased elderly in Swedish hospital care and clinical guidelines: Do they make evidence-based priority setting a "mission impossible"?
Open this publication in new window or tab >>Characteristics of multiple-diseased elderly in Swedish hospital care and clinical guidelines: Do they make evidence-based priority setting a "mission impossible"?
2008 (English)In: International Journal of Ageing and Later Life, ISSN 1652-8670, Vol. 3, no 2, 71-95 p.Article in journal (Refereed) Published
Abstract [en]

In Sweden, an expected growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines and priority setting into focus. There are problems, however, in areas where the evidence base is weak and underlying ethical values are controversial. Based on a specified definition of multiple-diseased elderly patients, the aims of this study are: (i) to describe and quantify inpatient care utilisation and patient characteristics, particularly regarding cardiovascular disease and co-morbidity; and (ii) to question the applicability of evidence-based guidelines for these patients with regard to the reported characteristics (i.e. age and co-morbidity), and to suggest some possible strategies in order to tackle the described problem and the probable presence of ageism. We used data from three sources: (a) a literature review, (b) a register study, based on a unique population-based register of inpatient care in Sweden, and (c) a national cost per patient database. The results show that elderly patients with multiple co-morbidities constitute a large and growing population in Swedish inpatient hospital care. They have multiple and complex needs and a large majority have a cardiovascular disease. There is a relationship between reported characteristics, i.e. age and co-morbidity, and limited applicability of evidence-based guidelines, and this can cause an under-use as well as an over-use of medical interventions. As future clinical studies will be rare due to methodological and financial factors, we consider it necessary to condense existing practical-clinical experiences of individual experts into consensus-based guidelines concerning elderly with multi-morbidity. In such priority setting, it will be important to consider co-morbidity and differens degrees of frailty.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2008
Keyword
priority setting, evidence-based guidelines, elderly, co-morbidity, cardiovascular disease, ageism
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-56241 (URN)10.3384/ijal.1652-8670.083271 (DOI)
Available from: 2010-05-04 Created: 2010-05-04 Last updated: 2011-05-11Bibliographically approved
2. Elderly people with multi-morbidity and acute coronary syndrome: Doctors' views on decision-making
Open this publication in new window or tab >>Elderly people with multi-morbidity and acute coronary syndrome: Doctors' views on decision-making
2010 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 38, no 3, 325-331 p.Article in journal (Refereed) Published
Abstract [en]

Background: In most Western countries the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines into focus. However, problems exist in areas where the evidence base is weak, e.g. elderly patients with heart disease and multiple co-morbidities. Objective: Our aim is to evaluate the views of Swedish cardiologists on decision-making for elderly people with multiple co-morbidities and acute coronary syndrome without ST-elevation (NSTE ACS), and to generate some hypotheses for testing. Methods: A confidential questionnaire study was conducted to assess the views of cardiologists/internists (n = 370). The response rate was 69%. Responses were analyzed with frequencies and descriptive statistics. When appropriate, differences in proportions were assessed by a chi-square test. A content analysis was used to process the answers to the open-ended questions. Results: 81% of the respondents reported extensive use of national quidelines for care of heart disease in their clinical decision-making. However, when making decisions for multiple-diseased elderly patients, the individual physician's own clinical experience and the patient's views of treatment choice were used to an evidently greater extent than national guidelines. Approximately 50% estimated that they treated multiple-diseased elderly patients with NSTE ACS every day. Preferred measures for improving decision-making were: (a) carrying out treatment studies including elderly patients with multiple co-morbidities, and (b) preparing specific national guidelines for multiple-diseased elderly patients. Conclusions: In the future, national guidelines for heart disease should be adapted in order to be applicable for elderly patients with multiple co-morbidities.

Keyword
Acute coronary syndrome, co-morbidity, decision-making, elderly, guidelines
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-56309 (URN)10.1177/1403494809354359 (DOI)000277168800014 ()
Note
The final, definitive version of this paper has been published in: Scandinavian Journal of Public Health, (38), 3, 325-331, 2010. Niklas Ekerstad, Rurik Löfmark and Per Carlsson, Elderly people with multi-morbidity and acute coronary syndrome: Doctors' views on decision-making http://dx.doi.org/10.1177/1403494809354359 by SAGE Publications Ltd, All rights reserved. http://www.uk.sagepub.com/ Available from: 2010-05-07 Created: 2010-05-07 Last updated: 2011-05-11Bibliographically approved
3. Frailty as a Predictor of Short-Term Outcomes for Elderly Patients with non-ST-Elevation Myocardial Infarction (NSTEMI)
Open this publication in new window or tab >>Frailty as a Predictor of Short-Term Outcomes for Elderly Patients with non-ST-Elevation Myocardial Infarction (NSTEMI)
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background – For the large and growing population of elderly patients with cardiovascular disease it is important to identify clinically relevant measures of biological age and their contribution to risk. Frailty is an emerging concept in medicine denoting increased vulnerability and decreased physiologic reserves. We analyzed how the variable frailty predicts short-term outcomes for elderly NSTEMI patients.

Methods and Results – Patients, aged 75 years or older, with diagnosed NSTEMI were included at three centers, and clinical data including judgement of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS). Of 307 patients, 150 (48.5%) were considered frail. Frail patients were slightly older and presented with a greater burden of comorbidity. By multiple logistic regression, frailty was found to be a strong independent risk factor for inhospital mortality, one-month mortality (OR 3.8, 95% CI 1.3 to 10.8) and the primary composite outcome (OR 2.2, 95% CI 1.3 to 3.7). Particularly frail patients with a high comorbidity burden manifested a markedly increased risk for the primary composite outcome. By multiple linear regression, frailty was identified as a strong independent predictor for prolonged hospital care (frail 13.4 bed days, non-frail 7.5 bed days; P<0.0001).

Conclusions - Frailty is a strong independent predictor of in-hospital mortality, one-month mortality, prolonged hospital care and the primary composite outcome. The combined use of frailty and comorbidity may constitute an ultimate risk prediction concept regarding cardiovascular patients with complex needs.

Keyword
Elderly, frailty, NSTEMI, co-morbidity, outcomes
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67638 (URN)
Available from: 2011-04-20 Created: 2011-04-20 Last updated: 2013-09-11Bibliographically approved
4. A Tentative Consensus-Based Model for Priority Setting : An Example from Elderly Patients with Myocardial Infarction and Multi-morbidity
Open this publication in new window or tab >>A Tentative Consensus-Based Model for Priority Setting : An Example from Elderly Patients with Myocardial Infarction and Multi-morbidity
2011 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 39, no 4, 345-353 p.Article in journal (Refereed) Published
Abstract [en]

Background: In most Western countries the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines into focus. However, such guidelines are difficult to use when the evidence base is weak. Priority setting for frail elderly patients with heart disease illustrates this problem. We have outlined a tentative model for priority setting regarding frail elderly heart patients. The model takes cardiovascular risk, frailty, and comorbidity into account. Objective: Our aim is to validate the model’s components. We want to evaluate the inter-rater reliability of the study experts’ rankings regarding each of the model’s categories. Methods: A confidential questionnaire study consisting of 15 authentic and validated cases was conducted to assess the views of purposefully selected cardiology experts (n = 58). They were asked to rank the cases regarding the need for coronary angiography using their individual clinical experience. The response rate was 71%. Responses were analysed with frequencies and descriptive statistics. The inter-rater reliability regarding the experts’ rankings of the cases was estimated via an intra-class correlation test (ICC). Results: The cardiologists considered the clinical cases to be realistic. The intra-class correlation (two-way random, consistency, average measure) was 0.978 (95% CI 0.958–0.991), which denotes a very good inter-rater reliability on the group level. The model’s components were considered relevant regarding complex cases of non-ST elevation myocardial infarction. Comorbidity was considered to be the most relevant component, frailty the second most relevant, followed by cardiovascular risk.

Conclusions: A framework taking comorbidity, frailty, and cardiovascular risk into account could constitute a foundation for consensus-based guidelines for frail elderly heart patients. From a priority setting perspective, it is reasonable to believe that the framework is applicable to other groups of elderly patients with acute disease and complex needs.

Place, publisher, year, edition, pages
Sage, 2011
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67637 (URN)10.1177/1403494811405092 (DOI)000290757500002 ()
Available from: 2011-04-20 Created: 2011-04-20 Last updated: 2012-03-26Bibliographically approved

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