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A Tentative Consensus-Based Model for Priority Setting : An Example from Elderly Patients with Myocardial Infarction and Multi-morbidity
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
Stockholm Centre for Healthcare Ethics, LIME, Karolinska Institutet, Stockholm.
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
2011 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 39, no 4, 345-353 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, such guidelines are difficult to use when the evidence base is weak. Priority setting for frail elderly patients with heart disease illustrates this problem. We have outlined a tentative model for priority setting regarding frail elderly heart patients. The model takes cardiovascular risk, frailty, and comorbidity into account. Objective: Our aim is to validate the model’s components. We want to evaluate the inter-rater reliability of the study experts’ rankings regarding each of the model’s categories. Methods: A confidential questionnaire study consisting of 15 authentic and validated cases was conducted to assess the views of purposefully selected cardiology experts (n = 58). They were asked to rank the cases regarding the need for coronary angiography using their individual clinical experience. The response rate was 71%. Responses were analysed with frequencies and descriptive statistics. The inter-rater reliability regarding the experts’ rankings of the cases was estimated via an intra-class correlation test (ICC). Results: The cardiologists considered the clinical cases to be realistic. The intra-class correlation (two-way random, consistency, average measure) was 0.978 (95% CI 0.958–0.991), which denotes a very good inter-rater reliability on the group level. The model’s components were considered relevant regarding complex cases of non-ST elevation myocardial infarction. Comorbidity was considered to be the most relevant component, frailty the second most relevant, followed by cardiovascular risk.

Conclusions: A framework taking comorbidity, frailty, and cardiovascular risk into account could constitute a foundation for consensus-based guidelines for frail elderly heart patients. From a priority setting perspective, it is reasonable to believe that the framework is applicable to other groups of elderly patients with acute disease and complex needs.

Place, publisher, year, edition, pages
Sage , 2011. Vol. 39, no 4, 345-353 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-67637DOI: 10.1177/1403494811405092ISI: 000290757500002OAI: oai:DiVA.org:liu-67637DiVA: diva2:412157
Available from: 2011-04-20 Created: 2011-04-20 Last updated: 2017-12-11Bibliographically 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, NiklasAndersson, DavidCarlsson, Per

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