Cynthia M. Boyd

Future of multimorbidity research: how should understanding of multimorbidity inform health system design?

Many people living with chronic conditions have multiple chronic conditions. Multimorbidity is defined here as the co-existence of two or more chronic conditions, where one is not necessarily more central than the others. Multimorbidity affects quality of life, ability to work and employability, disability and mortality. Currently, clinicians have limited guidance or evidence as to how to approach care decisions for such patients. Understanding how to best care and design the health system for patients with multimorbidity may lead to improvements in quality of life, utilization of healthcare, safety, morbidity and mortality. The objective of this paper is to review the implications of multimorbidity for the design of health system and to understand the research needs for this population. The consideration of people with multimorbidity is essential in the design and evaluation of health systems. Fundamentally, people with multimorbidity should receive a patient — and family-centered approach to care throughout the health system, and understanding how to deliver this type of care in effective and efficient ways is an enormous challenge, and opportunity, for clinicians, researchers, and policy makers today.

From Bedside to Bench: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Comorbidity and Multiple Morbidity in Older Adults

Most aging patients have multiple concurrent health problems. However, most current medical practice and research are largely based on a single disease model, failing to account for the simultaneous presence of multiple conditions. Clinical trials, practice guidelines, and pay-for-performance schemes may thus have limited applicability in older patients. We report on the 2005 American Geriatrics Society/National Institute on Aging conference on Comorbid Disease and Multiple Morbidity in an Aging Society. The two-day conference was designed to clarify concepts of multiple concurrent health conditions; explore implications for causation, health, function and systems of care; identify important gaps in knowledge; and propose useful next steps. While the conference did not attempt to standardize terminology, we here develop the concepts of comorbidity, multiple morbidity, condition clusters, physiological health, and overall health as they were used. The present report also summarizes sessions addressing the societal burden of comorbidity, and clinical research on particular diseases within the framework of comorbidity concepts. Next steps recommended include continuing clarification of terms and conceptual approaches, consideration of developing and improving measures, as well as developing new research directions.

Five comorbidities reflected the health status in patients with chronic obstructive pulmonary disease: the newly developed COMCOLD index

OBJECTIVEnThis study aimed to identify those comorbidities with greatest impact on patient-reported health status in patients with chronic obstructive pulmonary disease (COPD) and to develop a comorbidity index that reflects their combined impact.nnnSTUDY DESIGN AND SETTINGnWe included 408 Swiss and Dutch primary care patients with COPD from the International Collaborative Effort on Chronic Obstructive Lung Disease: Exacerbation Risk Index Cohorts (ICE COLD ERIC) in this cross-sectional analysis. Primary outcome was the Feeling Thermometer, a patient-reported health status instrument. We assessed the impact of comorbidities at five cohort assessment times using multiple linear regression adjusted for FEV1, retaining comorbidities with associations Pxa0≤xa00.1. We developed an index that reflects strength of association of comorbidities with health status.nnnRESULTSnDepression (prevalence: 13.0%; regression coefficient: -9.00; 95% CI: -13.52, -4.48), anxiety (prevalence: 11.8%; regression coefficient: -5.53; 95% CI -10.25, -0.81), peripheral artery disease (prevalence: 6.4%; regression coefficient: -5.02; 95% CI-10.64, 0.60), cerebrovascular disease (prevalence: 8.8%; regression coefficient: -4.57; 95% CI -9.43, 0.29), and symptomatic heart disease (prevalence: 20.3%; regression coefficient: -3.81; 95% CI -7.23, -0.39) were most strongly associated with the Feeling Thermometer. These five comorbidities, weighted, compose the COMorbidities in Chronic Obstructive Lung Disease (COMCOLD) index.nnnCONCLUSIONnThe COMCOLD index reflects the combined impact of five important comorbidities from patients perspective and complements existing comorbidity indices that predict death. It may help clinicians focus on comorbidities affecting patients health status the most.

A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients

ABSTRACTBACKGROUNDPatients at risk for generating high health care expenditures often receive fragmented, low-quality, inefficient health care. Guided Care is designed to provide proactive, coordinated, comprehensive care for such patients.OBJECTIVEWe hypothesized that Guided Care, compared to usual care, produces better functional health and quality of care, while reducing the use of expensive health services.DESIGN32-month, single-blind, matched-pair, cluster-randomized controlled trial of Guided Care, conducted in eight community-based primary care practices.PATIENTSThe “Hierarchical Condition Category” (HCC) predictive model was used to identify high-risk older patients who were insured by fee-for-service Medicare, a Medicare Advantage plan or Tricare. Patients with HCC scores in the highest quartile (at risk for generating high health care expenditures during the coming year) were eligible to participate.INTERVENTIONA registered nurse collaborated with two to five primary care physicians in providing eight services to participants: comprehensive assessment, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for self-management, caregiver support, and access to community-based services.MAIN MEASURESFunctional health was measured using the Short Form–36. Quality of care and health services utilization were measured using the Patient Assessment of Chronic Illness Care and health insurance claims, respectively.KEY RESULTSOf the eligible patients, 904 (37.8xa0%) gave written consent to participate; of these, 477 (52.8xa0%) completed the final interview, and 848 (93.8xa0%) provided complete claims data. In intention-to-treat analyses, Guided Care did not significantly improve participants’ functional health, but it was associated with significantly higher participant ratings of the quality of care (differenceu2009=u20090.27, 95xa0% CIu2009=u20090.08–0.45) and 29xa0% lower use of home care (95xa0% CIu2009=u20093–48xa0%).CONCLUSIONSGuided Care improves high-risk older patients’ ratings of the quality of their care, and it reduces their use of home care, but it does not appear to improve their functional health.

Individualising Therapy for Older Adults with Diabetes Mellitus

The goal when treating patients with diabetes mellitus is to achieve the maximum longevity consistent with an optimal quality of life. To achieve this goal, treatment is typically focused on management of hyperglycaemic symptoms and prevention of microvascular and macrovascular complications. While appropriate for most individuals, including many older adults with robust health, this focus is often too limited for older adults facing diminished life expectancy and co-existing medical illness, frailty and disability. Creating a treatment plan that optimises health and function, and reduces the risk for morbidity and mortality, requires individualised therapy that judiciously manages symptoms and multiple competing health risks while remaining consistent with the patient’s or his/her caregiver’s healthcare preferences. Physicians caring for older adults with diabetes must be adept at recognising conditions commonly associated with diabetes, including the interplay with co-morbid illness, and be able to assess the patient’s health status and use this information to recommend a treatment plan that is consistent with the patient’s personal goals for care.The majority of older adults with diabetes will benefit from management of cardiovascular risk, including intensive management of hypertension, lipids, use of aspirin (acetylsalicylic acid) and smoking cessation, and screening for common geriatric syndromes. For a significant minority of older adults with life expectancy of ≥10 years, it is reasonable to consider intensive management of hyperglycaemia (glycosylated haemoglobin [HbA1c] target ≤7%). For frail older adults with life expectancy of ≤5 years, strategies for reducing medical burden, improving function and moderate glucose control (HbA1c ≈8%) is reasonable and sufficient to control hyperglycaemic symptoms.

Chronic care improvement in primary care: evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes.

OBJECTIVEnTo examine the effects of an intervention comprising (1) a practice-based care coordination program, (2) augmented by pay for performance (P4P) for meeting quality targets, and (3) complemented by a third-party disease management on quality of care and resource use for older adults with diabetes.nnnDATA SOURCES/STUDY SETTINGnClaims files of a managed care organization (MCO) for 20,943 adults aged 65 and older with diabetes receiving care in Alabama, Tennessee, or Texas, from January 2004 to March 2007.nnnSTUDY DESIGNnA quasi-experimental, longitudinal study in which pre- and postdata from 1,587 patients in nine intervention primary care practices were evaluated against 19,356 patients in MCO comparison practices (>900). Five incentivized quality measures, two nonincentivized measures, and two resource-use measures were investigated. We examined trends and changes in trends from baseline to follow-up, contrasting intervention and comparison group member results.nnnPRINCIPAL FINDINGSnQuality of care generally improved for both groups during the study period. Only slight differences were seen between the intervention and comparison group trends and changes in trends over time.nnnCONCLUSIONSnThis study did not generate evidence supporting a beneficial effect of an on-site care coordination intervention augmented by P4P and complemented by third-party disease management on diabetes quality or resource use.

A Look at Person-Centered and Family-Centered Care Among Older Adults: Results from a National Survey

ABSTRACTBACKGROUNDPerson-centered and family-centered care represents the pinnacle of health care quality, but delivering it is challenging, as is assessing whether it has occurred. Prior studies portray older adults as passive in health decisions and burdened by care—but emphasize age-based differences or focus on vulnerable subgroups.OBJECTIVESWe aimed to examine domains of person-centered and family-centered care among older adults and whether the social context in which older adults manage their health relates to preferences for participating in health decisions and experiences with care.DESIGN AND PARTICIPANTSThis was an observational study of a nationally representative survey of adults aged 65+ years, conducted in concert with the 2012 National Health and Aging Trends Study (nu2009=u20092040).MAIN MEASURESApproach to managing health (self-manage, co-manage, delegate); preferences for making health care decisions with: (1) doctors, (2) family/close friends; and experiences with care pertaining to treatment burden were measured.KEY RESULTSApproximately two-thirds of older adults self-manage (69.4xa0%) and one-third co-manage (19.6xa0%) or delegate (11.0xa0%) health care activities. The majority prefer an independent or shared role when making health decisions with doctors (84.7xa0%) and family/close friends (95.9xa0%). Nearly four in ten older adults (37.9xa0%) experience treatment burden—that managing health care activities are sometimes or often hard for either them or their family/close friends, that health care activities get delayed or don’t get done, or that they are cumulatively too much to do. Relative to older adults who self-manage, those who delegate health care activities are more likely to prefer to share or leave health decisions to doctors (aORu2009=u20091.79 (95xa0% CI, 1.37–2.33) and family/close friends (aORu2009=u20093.12 (95xa0% CI, 2.23–4.36), and are more likely to experience treatment burden (aORu2009=u20092.37 (95xa0% CI, 1.61–3.47).CONCLUSIONSAttaining person-centered and family-centered care will require strategies that respect diverse decision-making preferences, minimize treatment burden, and support the broader social context in which older adults manage their health.

Older Adults’ Views and Communication Preferences About Cancer Screening Cessation

Importance Older adults with limited life expectancy are frequently screened for cancer even though it exposes them to risks of screening with minimal benefit. Patient preferences may be an important contributor to continued screening. Objective To examine older adults’ views on the decision to stop cancer screening when life expectancy is limited and to identify older adults’ preferences for how clinicians should communicate recommendations to cease cancer screening. Design, Setting, and Participants In this semistructured interview study, we interviewed 40 community-dwelling older adults (≥ 65 years) recruited at 4 clinical programs affiliated with an urban academic medical center. Main Outcomes and Measure We transcribed the audio recorded discussions and analyzed the transcripts using standard techniques of qualitative content analysis to identify major themes and subthemes. Results The participants’ average age was 75.7 years. Twenty-three participants (57.5%) were female; 25 (62.5%) were white. Estimated life expectancy was less than 10 years for 19 participants (47.5%). We identified 3 key themes. First, participants were amenable to stopping cancer screening, especially in the context of a trusting relationship with their clinician. Second, although many participants supported using age and health status to individualize the screening decision, they did not often understand the role of life expectancy. All except 2 participants objected to a Choosing Wisely statement about not recommending cancer screening in those with limited life expectancy, often believing that clinicians cannot accurately predict life expectancy. Third, participants preferred that clinicians explain a recommendation to stop screening by incorporating individual health status but were divided on whether life expectancy should be mentioned. Specific wording of life expectancy was important; many felt the language of “you may not live long enough to benefit from this test” was unnecessarily harsh compared with the more positive messaging of “this test would not help you live longer.” Conclusions and Relevance Although research and clinical practice guidelines recommend using life expectancy to inform cancer screening, older adults may not consider life expectancy important in screening and may not prefer to hear about life expectancy when discussing screening. The described communication preferences can help inform future screening discussions. Better delineating patient-centered approaches to discuss screening cessation is an important step toward optimizing cancer screening in older adults.

Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective

The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients quality of life is improved will ultimately depend on the actual implementation of care and an individual patients access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patients insurance, geographical location, and socioeconomic status. Furthermore, Medicares complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.

Primary Care Practitioners' Views on Incorporating Long-term Prognosis in the Care of Older Adults.

IMPORTANCEnClinical practice recommendations increasingly advocate that older patients life expectancy be considered to inform a number of clinical decisions. It is not clear how primary care practitioners approach these recommendations in their clinical practice.nnnOBJECTIVEnTo explore the range of perspectives from primary care practitioners on long-term prognosis, defined as prognosis regarding life expectancy in the range of years, in their care of older adults.nnnDESIGN, SETTING, AND PARTICIPANTSnA qualitative, semistructured interview study was conducted in a large group practice with multiple sites in rural, urban, and suburban settings. Twenty-eight primary care practitioners were interviewed; 20 of these participants (71%) reported that at least 25% of their patient panel was older adults. The audiorecorded discussions were transcribed and analyzed, using qualitative content analysis to identify major themes and subthemes. The study was conducted between January 30 and May 13, 2015. Data analysis was performed between June 10 and September 1, 2015.nnnMAIN OUTCOMES AND MEASURESnThe constant comparative approach was used to qualitatively analyze the content of the transcripts.nnnRESULTSnOf the 28 participants, 16 were women and 21 were white; the mean (SD) age was 46.2 (10.3) years. Twenty-six were physicians and 2 were nurse practitioners. Their time since completing clinical training was 16.0 (11.4) years. These primary care practitioners reported considering life expectancy, often in the range of 5 to 10 years, in several clinical scenarios in the care of older adults, but balanced the prognosis consideration against various other factors in decision making. In particular, patient age was found to modulate how prognosis affects the primary care practitioners decision making, with significant reluctance among them to cease preventive care that has a long lag time to achieve benefit in younger patients despite limited life expectancy. The participants assessed life expectancy based on clinical experience rather than using validated tools and varied widely in their prognostication time frame, from 2 years to 30 years. Participants often considered prognosis without explicitly discussing it with patients and disagreed on whether and when long-term prognosis needs to be specifically discussed. The participants identified numerous barriers to incorporating prognosis in the care of older adults including uncertainty in predicting prognosis, difficulty in discussing prognosis, and concern about patient reactions.nnnCONCLUSIONS AND RELEVANCEnDespite clinical recommendations to increasingly incorporate patients long-term prognosis in clinical decisions, primary care practitioners encounter several barriers and ambiguities in the implementation of these recommendations.