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Characteristics of multiple-diseased elderly in Swedish hospital care and clinical guidelines: Do they make evidence-based priority setting a "mission impossible"?
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
Socialstyrelsen.
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
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. Vol. 3, no 2, 71-95 p.
Keyword [en]
priority setting, evidence-based guidelines, elderly, co-morbidity, cardiovascular disease, ageism
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-56241DOI: 10.3384/ijal.1652-8670.083271OAI: oai:DiVA.org:liu-56241DiVA: diva2:317628
Available from: 2010-05-04 Created: 2010-05-04 Last updated: 2011-05-11Bibliographically approved
In thesis
1. Micro Level Priority Setting for Elderly Patients with Acute Cardiovascular Disease and Complex Needs: Practice What We Preach or Preach What We Practice?
Open this publication in new window or tab >>Micro Level Priority Setting for Elderly Patients with Acute Cardiovascular Disease and Complex Needs: Practice What We Preach or Preach What We Practice?
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:nbn:se:liu:diva-67639 (URN)978-91-7393-188-5 (ISBN)
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

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Ekerstad, NiklasCarlsson, Per

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