A tentative consensus-based model for priority setting: An example from elderly patients with myocardial infarction and multi-morbidity

Abstract

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.

Keywords

Cardiovascular risk comorbidity decision model elderly frailty NSTEMI priority setting

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References

Fortin M. , Dionne J. , Pinho G. , Gignac J. , Almirall J. , Lapointe L.

Randomized clinical trials: do they have external validity for patients with multiple comorbidities?

Ann Fam Med 2006 ;4:104-8.

Guyatt GH , Haynes RB , Jaeschke RZ , Cook DJ , Green L. , Naylor CD , et al. Users’ guides to the medical literature: XXV. Evidence-based medicine: principles for applying the users’ guides to patient care. Evidence-Based Medicine Working Group. JAMA 2000;284:1290-6.

Rothwell PM

External validity of randomised controlled trials: ‘‘to whom do the results of this trial apply?’’

Lancet 2005;365:82-93.

Altman DG , Schulz KF , Moher D. , Egger M. , Davidoff F. , Elbourne D. , et al., for the Consort Group. The revised CONSORT statement for reporting randomised trials: explanation and elaboration. Ann Intern Med 2001;134:663-94.

Alderson P , Green S , Higgins JPT , editors. Cochrane Reviewer’s Handbook 4.2.1 [updated December 2003]. The Cochrane Library, Issue 1, 2004. Chichester : John Wiley & Sons; 2004.

Green LW , Glasgow RE Evaluating the relevance, generalization, and applicability of research. Issues in external validation and translation methodology. Eval Health Prof 2006;29:126-53.

Boyd CM , Darer J. , Boult C. , Fried LP , Boult L. , Wu AW Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005;294:716-24.

Norges Offentlige Utredninger , Prioritering på ny. Gjennomgang av retningslinjer for prioriteringer innen norsk helsetjeneste, 1997:18, Statens forvaltningstjeneste: Oslo. (in Norwegian).

Swedish Council on Technology Assessment in Health Care. Geriatric care and treatment: a systematic compilation of existing scientific literature 2003. Stockholm : Swedish Council on Technology Assessment in Health Care, 2003. Available at: www.sbu.se (accessed August 2010).

10.

Akner G. Multimorbidity in elderly: analysis, management and proposal for an integrated elderly care centre. Stockholm: Liber, 2004 (English translation available at Professor Gunnar Akner’s homepage www.gunnar-akner.se ).

11.

Ekerstad N. , Edberg A. , Carlsson P. Characteristics of multiple-diseased elderly in Swedish hospital care and clinical guidelines: Do they make evidence-based priority setting a ‘‘mission impossible’’ ? Int J Ageing Later Life 2009;3:71-95.

12.

Statistics Sweden. Population projection for Sweden 2004- 2050. Revised population prognosis from Statistics Sweden. Statistical memorandum BE 18 SM 0401. Stockholm : Statistics Sweden, 2004. Available at: www.scb.se/templates/Publikation___84397.asp (accessed May 2010).

13.

National Board of Health and Welfare. Patienter i sluten vård 2005 (in Swedish). Stockholm : National Board of Health and Welfare, 2005.

14.

Wenger NK The elderly patient with cardiovascular disease . Heart Dis 2000;2:31-61.

15.

National Board of Health and Welfare. Guidelines for the care of heart disease 2008 (in Swedish). Stockholm: National Board of Health and Welfare, 2008. Available at: www.socialstyrelsen.se (accessed May 2010).

16.

Mitnitski A. , Graham JJ , Mogilner AE , Rockwood K. Frailty, fitness and late-life mortality in relation to chronological and biological age. BMC Geriatr 2002;21.

17.

Rockwood K. , Song X. , MacKnight C. , Bergman H. , Hogan DB , McDowell I. , et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489-95.

18.

Fried LP , Tangen CM , Walston J. , Newman AB , Hirsch C. , Gottdiener , et al. Cardiovascular Health Study Collaborative Research Group Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146-56.

19.

Singh M. , Alexander K. , Roger VL , Rihal CS , Whitson HE , Jahangir A. , et al. Frailty and its potential relevance to cardiovascular care. Mayo Clinical Proc 2008;83:1146-53.

20.

American Heart Association Council. Acute coronary care in the elderly, part 1. Circulation 2007;115:2549-69.

21.

Fitchett D. and Rockwood K. Introduction: heart disease in an elderly population. Canadian Cardiovascular Society Consensus Conference, 2002.

22.

Taneva E. , Bogdanova V. , Shtereva N. Acute coronary syndrome, comorbidity and mortality in geriatric patients. Ann NY Acad Sci 2004 ;1019:106-10.

23.

Lichtman JH , Spertus JA , Reid KJ , Radford MJ , Rumsfeld JS , Allen NB , et al. Acute noncardiac conditions and in-hospital mortality in patients with acute myocardial infarction. Circulation 2007;116:1925-30.

24.

The Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA), 2008. Available at: www.ucr.uu.se/rikshia/ (accessed May 2009 ).

25.

Ekerstad N. , Löfmark R. , Carlsson P. Elderly with multimorbidity and acute cardiac disease: doctors’ views on decision-making. Scand J Public Health 2010;3:325-31.

26.

Lagerqvist B. , Diderholm E. , Lindahl B. , Husted S. , Kontny F. , Ståhle E. , et al. FRISC score for selection of patients for an early invasive treatment strategy in unstable coronary artery disease . Heart 2005;91:1047-52.

27.

Lee DH , Buth KJ , Martin B. -J, Yip AM , Hirsch GM Frail patients are at increased risk for mortality and prolonged institutional care after cardiac care. Circulation 2010;121:973-8.

28.

Metha SR , Cannon CP , Fox KA , Wallentin L. , Braunwald E. , Yusuf S. , et al. Routine vs selective invasive strategies in patients with acute coronary syndromes. JAMA 2005;293:2908-17.

29.

Shrout PE , Fleiss JL Intraclass correlations: uses in assessing rater reliability. Psychol Bull 1979;86:420-8.

30.

Graneheim UH , Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measure to achieve trustworthiness . Nurse Education Today 2004;24:105-12.

31.

Gabbay J. , Le May A. Practice-based evidence for healthcare. London : Routledge, clinical mindlines, 2011.

32.

Garåsen H. , Hendriksen C. Health care for the elderly - perspectives in relation to implementation of results from intervention studies in Norway and Denmark. Scand J Public Health 2009;37:223-6.