The patient with multiple chronic conditions: balancing guidelines and patient preference

Transcription

1 The patient with multiple chronic conditions: balancing guidelines and patient preference Sid Feldman MD CCFP FCFP Associate Professor, Department of Family and Community Medicine, University of Toronto Geriatrics Update, Mount Sinai Hospital November 1 st, 2013

2 Disclosure Relationship with commercial interests: None Disclosure of Commercial Support This program has received no financial support. This program has received no in-kind support. Potential for conflict(s) of interest: None Mitigating Potential Bias: No potential bias to mitigate

3 Onil Bhattacharyya Ross Upshur Jamie Meuser

4 Objectives Understand some of the key limitations of applying single disease guidelines to patients with multiple chronic conditions (MCC) Accept the critical role for patient preference in implementing clinical practice guidelines with our older patients List critical factors in assisting the patient with MCC to make optimal health care decisions

5 So what is a chronic disease anyway? Affects a diverse group of patients Results in multiple and varied patient needs Progressive: patients needs will alter over time Long duration (many years)

6 So what is a chronic disease anyway? Affects a diverse group of patients Results in multiple and varied patient needs Progressive: patients needs will alter over time Long duration (many years) We are well situated for dealing with complex chronic disease management with our elderly patients!

7 Demographics of aging: Population aged 80 and over Source: Statistics Canada

8 Many seniors have multiple complex chronic diseases

9 80 % of people s health issues are chronic WHO 2008

10 % % have no CHCs! Number of chronic health conditions (age 80+) Number of chronic conditions Multiple Chronic Conditions is the norm! % of seniors have 3 or more chronic health conditions 9.9 Denton and Spencer 2010

11 Burden of chronic disease Chronic diseases account for 55% of health care costs in Ontario By 2020 chronic diseases will account for 73% of all deaths and 60% of the global burden of disease (WHO) Chaplain: Congregation: Chaplain: Congregation: Chaplain: Congregation: Oh, You are so big... Oh, You are so big... So absolutely huge. So absolutely huge. Gosh, we're all really impressed down here, I can tell You. Gosh, we're all really impressed down here, I can tell You.

12 Medication management is becoming more complex

13 Frequency distribution of number of unique medication classes for older adults aged 65+ in Ontario, Canada, % 20% Proportion of patients 15% 10% 5% Proportion of older people on 4 or more classes has substantially increased 0% >10 Number of unique medication classes

14 The treatments for complex conditions may compete

15 Case: Therapeutic competition A 75 year old man with dementia, osteoporosis, and GERD. He has been prescribed a cholinesterase inhibitor, bisphosphonate and PPI. Any concerns? Condition Suggested therapy Concerns? Dementia Osteoporosis GERD Cholinesterase inhibitor Bisphosponate PPI

16 Individual guidelines do not address tradeoffs, nor do they account for patient-centred decision making

17 Treating an Illness Is One Thing. What About a Patient With Many? Dr. Cynthia Boyd, March 30 th, 2009

18 Impact of attempting to adhere to multiple CPGs 79 year old woman with COPD, DM (type2), osteoporosis, hypertension and osteoarthritis 12 medications; 19 doses; 5 times per day Complicated non-pharmacologic regimen: something to do just about all day long 7 patient tasks with multiple subtasks 18 clinician tasks Boyd CM JAMA 2005

19 Trade-offs and patient preference Pts over age 70 with both hypertension and a risk of falling Asked 123 patients their treatment wishes ½ opted for reducing stroke risk and ½ opted for fall reduction Treatment of HTN reduces 5 year risk of stroke by ~ 8% (from 26 to 18%) but increases the risk of falls by about 6% (from 18-24%) Tinetti JAGS 2008.

20 Patient preferences change over time 189 community dwelling seniors with serious illness (HF, COPD, cancer)followed for 2 years 35% had a variable trajectory in whether they would accept high-burden therapy for a chance to avoid death and risk an impaired health state Increased to ~ ½ with variable trajectory when decision included potential for physical or cognitive disability as a result of treatment Fried, TR JAGS 2007

21 Patient preference influenced by adverse effects, not just clinical benefit Fried TR Arch Int Med 2011 If 5-yr ARR in MI 6/100: Of those who declined treatment, BUT: Daily fatigue and dizziness 52% 88% of participants would agree to medication 17% changed preference if ARR was 10 instead of 6 82% remained willing if ARR was only 3 And if also effect on function 12% Daily mild to moderate nausea 35% Daily fuzzy or slowed thinking 31% 11% 11%

22 Universal health outcomes Perhaps all people want the same if we look at universal health outcomes rather than disease specific outcomes? Symptoms Function Longevity

23 Nope. Survey: 40% of 1000 pts wanted to be as functional as possible, 30% wanted decreased symptoms (e.g.dyspnea), 30% wanted to live as long as possible. Fried T 2007

24 Collaborative Care Shared expertise: I know stuff. Patient Lived experience Professional Expert about disease I know me.

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26 Can guidelines help?

27 GAG Reflex The involuntary nausea caused by the receipt of yet another clinical practice guideline.

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30 JAGS 2012

31 AGS Guiding principles Establish pt s primary concern Review care plan or focus on one dominant element Current interventions: adherence/comfort Any relevant evidence? Consider prognosis Interactions within/among treatments/conditions Weigh benefits/harms Communicate and make shared decisions for/against interventions Reassess at selected intervals JAGS 2012

32 Treatment burden COMPLEXITY = # MEDICATIONS + # CONDITIONS Highly predictive of hospitalization, ER visit and family practice visit Higher the score, higher the risk Ross Upshur

33 Rockwood K, et al CMAJ 2005;173(5):489-95

34 Clinical Frailty Scale 1. Very fit 2. Well 3. Well, with treated co-morbid disease 4. Apparently vulnerable 5. Mildly frail 6. Moderately frail 7. Severely frail 8. Very Severely frail Health maintenance and health promotion Chronic Disease Management Protection Harm Reduction Maintain Function Comfort 9. Terminally Ill

35 Risk factors associated with mortality Risk Factor Points Male 2 Age Dependence in toiletting 1 Dressing Partially dependent 1 Fully dependent 3 Malignant neoplasm 2 Congestive Heart Failure 3 COPD 1 Carey EC et al. JAGS 2008; 56:68-75

36 Probability of survival at 1-5 years points 4-5 points >5 points Carey EC et al. JAGS 2008; 56:68-75

37 Clinical applicability The recommendation is concerned with a relevant aspect of care in daily practice and is concerned with a common clinical issue or an important decision in daily care. Important to whom?

38 Symptomatic/Asymptomatic Symptomatic conditions impair function and well being and management plans are devoted to ameliorating these. Examples: osteoarthritis, angina, depression. Asymptomatic conditions associated with longer term risk reduction. Examples: hypertension, high lipids, mild glucose elevation.

39 Clinically Dominant Condition A co-morbid condition that eclipses the management of other health conditions in the short or long term Examples: End stage disease (cancer, renal failure, dementia) Severe symptoms ( CHF, Depression) New onset diagnosis (Breast Cancer, Rheumatoid Arthritis)

40 Concordant vs. Discordant Co-morbidity Concordant: part of the same pathophysiologic process or risk profile, so similar management plan. DM and CAD, PVD, HTN Discordant: Not directly related to diabetes in pathopysiology and management plan. DM and BPH, low back pain, GERD

41 Provider values Translating evidence into action often involves value judgments. Stating them clearly helps users understand their influence on interpreting evidence

42 Patient and family factors What are the patient s expectations and stated preferential outcomes/goals? No valid tools to aid clinicians esp. with multiple chronic diseases and advanced age (some in development) Lack of clarity regarding outcomes Suggested template: Longevity, symptom control, independence, optimal function (Universal outcomes) Weigh uncertainties between managing future risks and optimizing present well being.

43 8 Step Potential Approach: 1. What are the patient s expectations and stated preferential outcomes/goals? Keep current as wishes change. 2. Determine treatment burden (may use complexity score) 3. Is there a clinically dominant co-morbidity? (yes/no) 4. How much co-morbidity is concordant/discordant? Consider therapeutic competition and trade-offs. 5. How much co-morbidity is symptomatic/asymptomatic? 6. What is the estimated life expectancy? 7. What is the frailty level? 8. Be honest about the uncertainty regarding benefit and harm!

44 Q1 Primary Care of the Elderly is: A. Easy B. Takes up very little time C. Is remarkably remunerative D. Is challenging but deeply meaningful and rewarding

45 Q2 The percentage of older patients with 3 or more chronic conditions is: A. 20% B. 40% C. 60% D. 80%

46 Q3 Examples of universal health outcomes include all of the following except: A. Longevity B. Functional status C. Optimal blood pressure D. Pain control

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