Treatment Decision Making for Elderly Patients with Multimorbidities

Primary care clinicians are caring for an increasing number of older patients who have multiple diseases and conditions. Providing optimal care for these patients is a complex task, made more difficult by seemingly contradictory evidence of the harms and benefits of following disease-specific guidelines. New approaches to guide the care of this growing population are needed. According to researchers, gaining an understanding of the ways primary care clinicians approach treatment decision making for elderly patients with multimorbidities is critical in helping design interventions to improve the decision-making process. To that end, the researchers designed a study to identify physicians’ perspectives of and experiences with therapeutic decision making for their older patients. The study used qualitative methods to provide an opportunity for participants to articulate the reasoning and strategies they use. Study results were reported in Archives of Internal Medicine [2011;171(1):75-80]. Study participants were clinicians who had completed training and who belonged to general internal medicine primary care practices. Practices sampled included academic, community, and Veterans Affairs (VA) settings in the New Haven, Connecticut, area. The researchers conducted 5 focus groups with 40 clinicians (physicians, nurse practitioners, and physician assistants). Two focus groups were conducted with community primary care practices, 2 with the primary care practices and the VA Connecticut Healthcare System, and 1 with the full-time general medicine faculty members at Yale School of Medicine, New Haven. Focus group participants were asked open-ended questions about their approach to making decisions about treatment for their older patients who had multiple medical conditions. The responses were organized into themes using qualitative content analysis. Five themes that described approaches to treatment decision making for older patients with multiple conditions emerged: (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, and (5) barriers to clinicians’ preferred approaches to decision making. Participants in each group provided examples of the way they tailored their approach to the care of older persons with multiple conditions because of concerns about the ability of their patients to adhere to complex regimens, including the need to consider factors such as patients’ cognition and the presence of a support system in the patient’s life. There was substantial variability in beliefs about the likelihood of the benefits versus the harms of using guideline-directed care: some clinicians were concerned about the possibility that the harms outweighed the benefits, whereas others were proponents of using guideline-directed care. Those participants who were concerned about the trade-offs between the benefits and harms of guideline-directed care suggested a variety of ways to balance those trade-offs, including prioritizing the patient’s issues, stratifying the risk for individual diseases, and modifying guidelines in anticipation of certain adverse effects. The clinicians described varying ways they involved patients in the decision-making process, including methods to resolve conflicts between what the patient thinks is the best course of action and what the clinician believes is best. Barriers cited by the clinicians to determine what they described as being the highest-quality decisions for or with their patients included unrealistic patient and family expectations, questionable application of measures of quality, involvement of specialists, and lack of both time and reimbursement. In summing up the focus group responses, the researchers said, “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.”