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.