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Elderly people with multi-morbidity and acute coronary syndrome: Doctors' views on decision-making
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
Department of Medical Ethics, Karolinska Institutet.
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
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.

Place, publisher, year, edition, pages
2010. Vol. 38, no 3, 325-331 p.
Keyword [en]
Acute coronary syndrome, co-morbidity, decision-making, elderly, guidelines
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-56309DOI: 10.1177/1403494809354359ISI: 000277168800014OAI: oai:DiVA.org:liu-56309DiVA: diva2:318324
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: 2017-12-12Bibliographically 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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