|Home | About | Journals | Submit | Contact Us | Français|
Clinicians are caring for an increasing number of older patients with multiple diseases, in the face of uncertainty concerning the benefits and harms associated with guideline-directed interventions. Understanding how primary care clinicians approach treatment decision-making for these patients is critical to the design of improving the decision-making process.
Focus groups were conducted with study with forty primary care clinicians (physicians, nurse-practitioners, physician assistants) in academic, community, and VA-affiliated primary care practices. Participants were given open-ended questions about their approach to treatment decision-making for older persons with multiple medical conditions. Responses were organized into themes using qualitative content analysis.
Participants were concerned about their patients’ ability to adhere to complex regimens deriving from guideline-directed care. There was variability in beliefs regarding and approaches to balancing the benefits and harms of guideline-directed care. There was also variability in how they involved patients in the process of decision making, with clinicians describing conflicts between their own and their patients’ goals. Participants listed a number of barriers to making good treatment decisions, including lack of outcome data, the role of specialists, patient and family expectations, and insufficient time and reimbursement.
The experiences of practicing clinicians suggest that they struggle with the uncertainties of applying disease-specific guidelines to their older patients with multiple conditions. To improve decision making, they need more data, alternative guidelines, approaches to reconciling their own and their patients’ priorities, the support of their subspecialist colleagues, and an altered reimbursement system.
Optimizing the care of older persons with multiple medical conditions is a complex task, with clinicians receiving potentially contradictory recommendations for how to tailor care for these patients from the medical literature. On the one hand, there is a growing evidence base that older persons with multiple conditions have poorer outcomes when treated according to disease-specific guidelines compared to other patients.1–6 There are several reasons for these poorer outcomes. First, the presence of comorbid conditions may result in persons receiving less benefit from therapy directed at a particular condition.1, 2 Second, the presence of these conditions may also increase the likelihood that the individual will experience adverse effects with any given intervention.3, 4 Finally, the polypharmacy that generally accompanies multimorbidity confers an increased risk of adverse drug events, independent of the chronic conditions.5, 6 On the other hand, editorials and clinical studies remind readers that the clinical trials providing evidence base underlying these guidelines demonstrates that patients have improved outcomes with the medications recommended by these guidelines,7, 8 and multiple studies have examined medication underuse and the failure to apply clinical guidelines to individual patients as a problem of poor quality care.9–11 Clinicians are therefore charged with caring for an increasing number of older patients with multi-morbidity in the face of seemingly contradictory evidence of harms and benefits of following disease guidelines.
In the face of this complexity, new approaches are needed to guide the care of older persons with multiple conditions. Ideally, the design of these approaches will not only incorporate the best evidence regarding how multimorbidity influences the outcomes of treatment but also be responsive to the needs and perspectives of the clinicians who provide the care for these patients. Little is known about how clinicians approach the care of older persons with multiple medical conditions. Understanding clinicians’ experiences with these patients and their views on the challenges inherent to their care can help to inform the development of approaches that are acceptable to clinicians and are congruent with their practice patterns. The purpose of this study was to explore clinicians’ perspectives of and experiences with therapeutic decision making for older persons with multiple medical conditions. Because we were interested in understanding how clinicians think about the care they provide, we utilized qualitative methods in order to allow participants to articulate the reasoning and strategies they use.
Participants were clinicians who had completed training and who belonged to general internal medicine primary care practices. We purposefully sampled practices from academic, community, and Veterans Affairs (VA) settings in the greater New Haven area in order to ensure the inclusion of participants practicing medicine under different care systems and who had a diverse set of constraints informing their approach to the care of older persons with multiple conditions. Five focus groups were conducted. Of these, two were conducted with community primary care practices, one of which consisted of three physicians and a nurse practitioner; the second group consisted of three physicians. There were two focus groups conducted with the primary care practices of the VA Connecticut Healthcare System. The first of these consisted of seven physicians and one pharmacist, nurse practitioner, and physician assistant, and the second of three physicians. The final focus group was conducted with the full-time general medicine faculty at the Yale School of Medicine. This group consisted of twenty physicians who had widely varying distributions in the time they spent performing clinical work, administration, and research; and whose practice sites included primary care clinics at several urban hospitals and the VA. Participants received a meal but no other reimbursement. The study protocol was approved by the Human Investigation Committee of the Yale School of Medicine and the Human Subjects Subcommittee of VA Connecticut Healthcare System.
Focus groups were moderated by a single investigator (TRF) and were conducted with the use of a discussion guide. The guide began with an opening statement informing participants that they were asked to participate because of their experience caring for older persons with multiple medical conditions and that they would be asked to talk about the approaches they took in caring for this population of patients. The first questions asked participants to think broadly about treatment decision making for these patients. Participants were asked to think about their patients who had multiple medical conditions and were potentially taking multiple medications and to reflect on how their approach to treatment decision making compared to their approach for younger patients and patients without multiple conditions. Participants were also asked to think about how they applied clinical guidelines to these patients and whether there were patient factors that influenced the way in which they used the guidelines.
The follow-up questions were designed to serve as prompts to promote additional discussion related to treatment decision making. Participants were asked: 1) what they believed to be the status of evidence used to inform the care of this group of patients; 2) their approach to polypharmacy in this patient population; 3) their approach to the patient who, after being prescribed a medication as recommended by clinical guidelines, such as a statin for hyperlipidemia, returned with a symptom attributed by the patient to the medication. Focus groups lasted approximately 60 minutes.
Focus groups were audiotaped and transcribed by an experienced medical transcriptionist. Content analysis was used to code small portions of the text representing unique concepts. Initially, the two investigators independently coded two of the focus group transcripts and developed a coding structure. The structure was developed inductively, as codes were assigned based on repeated close readings of the text. The investigators met to compare the structures and their application to the text. Differences in both the identification of codes and the application of codes to text were resolved through discussion. A single investigator coded the remaining transcripts, and the two investigators met to discuss the relationship of the codes to one another within and across transcripts to identify themes arising from the examination of the relationships among the codes.
A number of themes were identified that described clinicians’ approaches to treatment decision making for older persons with multiple medical conditions. These were: 1) Concerns about patients’ ability to adhere to complex medical regimens; 2) Variability in beliefs regarding the harms and benefits of guideline-directed care; 3) Variability in approaches to balancing trade-offs between harms and benefits; 4) Involvement of patients in the decision making process; 5) Barriers to clinicians’ preferred approaches to decision making.
Participants in every focus group cited examples of tailoring their approach to the care of older persons with multiple conditions because of concern that the patient would not be able to adhere to more complex regimens. These concerns stemmed from a consideration of such factors as patients’ cognition and availability of social support, as illustrated in Table 1.
In contrast to the consensus about the need to tailor therapy based on the patient’s ability to adhere, there was substantial variability in beliefs about the likelihood of benefits versus harms of guideline-directed care. Some clinicians cited concerns about the possibility of harms outweighing the benefits of guideline-directed care, whereas other clinicians believed that guideline-directed care would produce the best outcomes, as outlined in Table 2. Clinicians also raised concerns about the lack of data regarding the benefits versus harms of this care and about the focus of guidelines on outcomes that may not be of greatest importance to their patients. Participants who raised issues of trade-offs between benefits and harms or of lack of data spoke of these as reasons to deviate from guideline-directed care.
Those clinicians who were concerned about the trade-offs between the benefits and harms of guideline-directed care had a wide variety of approaches to how they could be balanced. These different approaches and representative quotations are provided in Table 3 and include prioritizing the patient’s problems, stratifying risk for individual diseases, and modifying guidelines in anticipation of certain adverse effects. Clinicians also spoke about the lack of available tools to help them quantify benefits and harms and also about their inability at times to find a strategy for balancing benefits and harms.
Clinicians offered differing descriptions of how they involved their older patients in the process of decision making, as presented in Table 4. Several clinicians spoke of conflicts between what they wanted to do for the patient and what the patient wanted, and they presented different approaches to dealing with these differing goals.
Regardless of how they balanced competing outcomes and attempted to involve patients in the decision-making process, the clinicians cited a number of barriers to making what they identified as being the highest quality decisions for or with their patients, as presented in Table 5. These included unrealistic patient and family expectations, the questionable application of quality measures, involvement of specialists, and lack of time and reimbursement.
Each of the major themes and specific examples arose in both the focus groups composed of academic and community clinicians, with one exception. The issue of quality measures was raised only by clinicians in the focus groups conducted at the VA.
The perspectives of primary care clinicians regarding the management of their older patients who have multiple medical conditions highlight the complexity of caring for this group of patients. Their experiences suggest that they struggle with the uncertainties of applying disease-specific guidelines to their older patients with multiple conditions and creating strategies for optimizing decision making and improving patient outcomes. Many clinicians were concerned about their patients’ ability to adhere to complicated medical regimens. There were variable beliefs regarding the benefits and harms of guideline-directed care. While some clinicians believed the this approach would provide the best outcomes, others were concerned that guidelines were developed based on evidence obtained from younger patients, that they failed to target outcomes of greatest concern to their patients, such as quality of life, and that the application of multiple guidelines could result in adverse events. Participants used a variety of strategies to balance the benefits and harms of guideline-directed care, including prioritizing the patient’s problem list and performing risk stratification for individual diseases, but they also cited the lack of availability of outcome data and noted they sometimes could not figure out how to achieve a balance. Clinicians cited conflicts in their own and their patients’ goals and varied in their approach to resolving them. They identified a number of barriers to caring for older patients with multi-morbidity, including unrealistic patient and family expectations, pressure to adhere to quality measures, and lack of time and reimbursement.
The considerations expressed by clinicians in this study reflect the current concerns, debates, and uncertainty in the growing medical literature on the care of older persons with multiple conditions. Their experiences illustrate that apprehensions about the potential adverse consequences of guideline-directed care are not merely theoretical,4 but rather are being observed by clinicians caring for older persons with multiple conditions and are influencing treatment decision-making. These observations corroborate previous reports of the limitations of currently conducted randomized clinical trials to detect the full range of adverse effects of treatments in older adults with multi-morbidity.12 There is growing evidence from cohort studies to suggest that these adverse effects include ones not traditionally associated with medications, as, for example, the association between number of medications taken and weight loss and impaired balance.6 The comments of one clinician also highlighted that traditionally studied outcomes, such as mortality, may not be the outcomes of greatest importance to their patients. This observation is supported by studies of older persons demonstrating the importance of outcomes such as maintaining physical and cognitive function and relief of symptoms.13–15 Clinicians in this study, however, also pointed to guideline-directed care as based on the best available evidence for optimizing outcomes in older persons with multiple conditions. The variability in clinicians’ views on the applicability of disease guidelines to their older patients with multimorbidity and the benefits and harms associated with guideline-directed care reflects the ongoing uncertainty regarding the clinical strategies that will provide the best outcomes.16 In addition to the studies demonstrating risk of adverse outcomes associated with guideline-directed care, evidence also suggests that patients at highest risk of these adverse outcomes may also be most likely to derive benefit from the intervention.17
Clinicians’ descriptions of how they involve patients in the decision-making process illustrate the challenges of implementing the principles of patient-centered care. These descriptions included the negotiation between patients’ and clinicians’ values and goals, which were characterized as sometimes being in conflict. Implicit in the decision-making process for some clinicians was the belief that any amount of risk reduction for a given disease-specific outcome such as myocardial infarction, warranted intervention. However, studies have demonstrated that, when presented with numerical data regarding risk reduction, many patients would be willing to take medication only if the amount of risk reduction exceeded the actual benefit provided by commonly prescribed therapies.18, 19 Moreover, other clinicians noted that the reduction in risk for a disease-specific outcome might not be what was most important to the patient, an observation supported by studies indicating that the adverse effects of medications may be as, if not more, important to patients than their primary effects.20, 21 Disagreement between patients or caregivers and clinicians regarding the goals for the patient’s care has also been demonstrated quantitatively.22, 23 Although the authors of these studies suggest these findings indicate a lack of clinicians’ awareness of the patient’s priorities, the clinicians in the present study present a more complex picture. They cite concern about patients’ and families’ inaccurate understanding of harms and benefits, and they describe performing testing to help patients understand their risk.
The results of the study suggest that clinicians would benefit from a number of tools to assist them in decision making for older persons with multiple conditions. First, the concept of tailoring therapy based on a consideration of patients’ ability to adhere has not received much attention in the medical literature. Such tailoring suggests the need for explicit assessment of the complexity of the interventions recommended by clinical guidelines and for simplified alternatives, so that patients and their families can be provided with treatment plans that are feasible for them to accomplish. Second, the clinicians who discussed the absence of risk calculators for patients with multiple conditions highlight the need for the development of methods to provide individualized assessments of harm versus benefit associated with different treatment strategies, in order to determine optimal therapy depending upon a patient’s comorbidity profile.24, 25 Finally, clinicians’ efforts to inform and involve their patients in the decision-making process suggest that, despite the advances made in risk communication26 and shared and informed decision making,27 further work is required to create and disseminate clinical tools, suitable for use in primary care practice, to elicit priorities and goals in ways that ensure that both clinicians and patients and families feel they have been understood.
The results also highlight the system and health policy challenges that must be met in order to improve the process of decision making. The experience of the clinicians who feel pressure to modify their practice based on their exposure to clinical reminders and quality measures supports efforts for modifying these metrics for persons with multiple conditions.28 The concerns expressed by the primary care clinicians in this study that their subspecialist colleagues may not consider the wider harms and benefits of organ-specific intervention reflect the fragmentation of care for patients who receive care from many physicians for their multiple conditions. Needed is a way to provide patients with a unified approach to decision making that incorporates the perspectives of different clinicians. The final challenge is the limitations imposed by current reimbursement systems, which, as described by several participants, fails to acknowledge the complexities of caring for older persons with multiple conditions.
Because of the qualitative methods used in this study, conclusions cannot be drawn regarding the prevalence of clinicians’ attitudes or regarding differences in these attitudes according to the nature or site of their practice. Although the study population included clinicians practicing in both academic and community settings, it is possible that clinicians agreeing to participate in a focus group may not be representative of all primary care clinicians. In order to decrease the burden on clinicians and to encourage their participation, we did not take additional time to collect descriptive information; therefore, we are unable to characterize our participants in terms of their own characteristics or those of their practices. Several of the probes used in the discussion guide, such as asking clinicians their response to a patient who develops an adverse effect of a medication, were not specific to the care of the older person. Notably, the inclusion of such questions resulted in several participants observing that their approach to balancing benefits and harms of medications in older persons could be appropriate to many other patients in their practice.
The primary care clinicians represented in this qualitative study recognize the complexities of caring for older persons with multiple conditions and the need to provide individually tailored therapy. By their own reports, they need more data, alternative guidelines, approaches to incorporating their patients’ values, the support of their subspecialist colleagues, and an altered reimbursement system to accomplish this task. Addressing these needs will not be easy, but it is essential if we are to evolve a health care system designed to effectively and efficiently care for the ever increasing number of older patents with multiple chronic diseases.
Supported by grant Pioneer 58381 from the Robert Wood Johnson Foundation and by the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (#P30AG21342 NIH/NIA). Dr. Fried is supported by grant K24 AG028443.
Dr. Fried had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.