Decision Making for Older Adults With Multiple Chronic Conditions: Executive Summary for the American Geriatrics Society Guiding Principles on the Care of Older Adults With Multimorbidity

Journal of the American Geriatrics Society

Volumn 67, Issue 4, 2019, Pages 665-673

  Boyd, Cynthia ^a   Smith, Cynthia Daisy ^b   Masoudi, Frederick A ^c   Blaum, Caroline S ^d   Dodson, John A ^d   Green, Ariel R ^a   Kelley, Amy ^e   Matlock, Daniel ^f   Ouellet, Jennifer ^g   Rich, Michael W ^h   Schoenborn, Nancy L ^a   Tinetti, Mary E ^g  

^a JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b AMERICAN COLLEGE OF PHYSICIANS   (United States)

^c UNIVERSITY OF COLORADO   (United States)

^d NEW YORK UNIVERSITY SCHOOL OF MEDICINE   (United States)

^e MOUNT SINAI SCHOOL OF MEDICINE   (United States)

^f UNIVERSITY OF COLORADO SCHOOL OF MEDICINE   (United States)

^g YALE UNIVERSITY SCHOOL OF MEDICINE   (United States)

^h WASHINGTON UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

AGS guiding principles; multimorbidity; multiple chronic conditions

Indexed keywords

ARTICLE; CARDIOLOGIST; CAREGIVER; CLINICIAN; DECISION MAKING; DOCTOR PATIENT RELATIONSHIP; GENERAL PRACTITIONER; GERIATRICIAN; GERIATRICS; HEALTH CARE PLANNING; HEALTH STATUS; HUMAN; INTERPERSONAL COMMUNICATION; LIFE EXPECTANCY; MULTIPLE CHRONIC CONDITIONS; PRACTICE GUIDELINE; QUALITY OF LIFE; AGED; CLINICAL DECISION MAKING;

AGED; CLINICAL DECISION-MAKING; HUMANS; MULTIPLE CHRONIC CONDITIONS;

EID: 85062795179     PISSN: 00028614     EISSN: 15325415     Source Type: Journal    
DOI: 10.1111/jgs.15809     Document Type: Article

References (87)

1. Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition--multimorbidity. JAMA. 2012;307(23):2493-2494.
2. Sorace J, Wong HH, Worrall C, Kelman J, Saneinejad S, MaCurdy T. The complexity of disease combinations in the Medicare population. Popul Health Manag. 2011;14(4):161-166.
3. Quiñones AR, Markwardt S, Botoseneanu A. Multimorbidity combinations and disability in older adults. J Gerontol A Biol Sci Med Sci. 2016;71(6):823-830.
4. American Geriatrics Society Expert Panel on the Care of Older Adults With Multimorbidity. Guiding principles for the care of older adults with multimorbidity: an approach for clinicians. J Am Geriatr Soc. 2012;60(10):E1-E25.
5. Tran VT, Harrington M, Montori VM, Barnes C, Wicks P, Ravaud P. Adaptation and validation of the Treatment Burden Questionnaire (TBQ) in English using an internet platform. BMC Med. 2014;12:109.
6. Fried TR, McGraw S, Agostini JV, Tinetti ME. Views of older persons with multiple morbidities on competing outcomes and clinical decision-making. J Am Geriatr Soc. 2008;56(10):1839-1844.
7. Case SM, O'Leary J, Kim N, Tinetti ME, Fried TR. Older adults' recognition of trade-offs in healthcare decision-making. J Am Geriatr Soc. 2015;63(8):1658-1662.
8. Jowsey T, Yen L, Mathews P. Time spent on health related activities associated with chronic illness: a scoping literature review. BMC Public Health. 2012;12(1):1044.
9. Tran VT, Barnes C, Montori VM, Falissard B, Ravaud P. Taxonomy of the burden of treatment: a multi-country web-based qualitative study of patients with chronic conditions. BMC Med. 2015;13:115.
10. Boyd CM, Wolff JL, Giovannetti E, et al. Healthcare task difficulty among older adults with multimorbidity. Med Care. 2014;52(suppl 3)):S118-S125.
11. Weiss JW, Boyd CM. Managing complexity in older patients with CKD. Clin J Am Soc Nephrol. 2017;12(4):559-561.
12. Bowling CB, Vandenberg AE, Phillips LS, McClellan WM, Johnson TM, Echt KV. Older patients' perspectives on managing complexity in CKD self-management. Clin J Am Soc Nephrol. 2017;12(4):635-643.
13. 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(6):716-724.
14. Tinetti ME, Esterson J, Ferris R, Posner P, Blaum CS. Patient priority-directed decision making and care for older adults with multiple chronic conditions. Clin Geriatr Med. 2016;32(2):261-275.
15. American Geriatrics Society Expert Panel on the Care of Older Adults With Multimorbidity. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society. J Am Geriatr Soc. 2012;60(10):1957-1968.
16. Fried TR, Tinetti ME, Towle V, O'Leary JR, Iannone L. Effects of benefits and harms on older persons' willingness to take medication for primary cardiovascular prevention. Arch Intern Med. 2011;171(10):923-928.
17. Wolff JL, Boyd CM. A look at person- and family-centered care among older adults: results from a national survey [corrected]. J Gen Intern Med. 2015;30(10):1497-1504.
18. Naik AD, Dyer CB, Kunik ME, McCullough LB. Patient autonomy for the management of chronic conditions: a two-component re-conceptualization. Am J Bioeth. 2009;9(2):23-30.
19. Boyd CM, Kent DM. Evidence-based medicine and the hard problem of multimorbidity. J Gen Intern Med. 2014;29(4):552-553.
20. Uhlig K, Leff B, Kent D, et al. A framework for crafting clinical practice guidelines that are relevant to the care and management of people with multimorbidity. J Gen Intern Med. 2014;29(4):670-679.
21. Weiss CO, Varadhan R, Puhan MA, et al. Multimorbidity and evidence generation. J Gen Intern Med. 2014;29(4):653-660.
22. Boyd CM, Vollenweider D, Puhan MA. Informing evidence-based decision-making for patients with comorbidity: availability of necessary information in clinical trials for chronic diseases. PLoS One. 2012;7(8):e41601.
23. Navar AM, Pencina MJ, Peterson ED. Assessing cardiovascular risk to guide hypertension diagnosis and treatment. JAMA Cardiol. 2016;1(8):864-871.
24. O'Hare AM, Hotchkiss JR, Kurella Tamura M, et al. Interpreting treatment effects from clinical trials in the context of real-world risk information: end-stage renal disease prevention in older adults. JAMA Intern Med. 2014;174(3):391-397.
25. Tinetti ME, McAvay GJ, Fried TR, et al. Health outcome priorities among competing cardiovascular, fall injury, and medication-related symptom outcomes. J Am Geriatr Soc. 2008;56(8):1409-1416.
26. Fortin M, Contant E, Savard C, Hudon C, Poitras ME, Almirall J. Canadian guidelines for clinical practice: an analysis of their quality and relevance to the care of adults with comorbidity. BMC Fam Pract. 2011;12:74.
27. Lugtenberg M, Burgers JS, Clancy C, Westert GP, Schneider EC. Current guidelines have limited applicability to patients with comorbid conditions: a systematic analysis of evidence-based guidelines. PLoS One. 2011;6(10):e25987.
28. Fabbri LM, Boyd C, Boschetto P, et al. How to integrate multiple comorbidities in guideline development: article 10 in integrating and coordinating efforts in COPD guideline development: an official ATS/ERS workshop report. Proc Am Thorac Soc. 2012;9(5):274-281.
29. Trikalinos TA, Segal JB, Boyd CM. Addressing multimorbidity in evidence integration and synthesis. J Gen Intern Med. 2014;29(4):661-669.
30. Tinetti ME, McAvay GJ, Chang SS, et al. Contribution of multiple chronic conditions to universal health outcomes. J Am Geriatr Soc. 2011;59(9):1686-1691.
31. Lorgunpai SJ, Grammas M, Lee DSH, McAvay G, Charpentier P, Tinetti ME. Potential therapeutic competition in community-living older adults in the U.S.: use of medications that may adversely affect a coexisting condition. PLoS One. 2014;9(2):e89447.
32. Blaum C, Rosen J, Naik AD, et al. Feasibility of implementing patient priorities care for patients with multiple chronic conditions. J Am Geriatr Soc. 2018;66(10):2009-2016.
33. Naik AD, Dindo L, Van Liew J, et al. Development of a clinically-feasible process for identifying patient health priorities. J Am Geriatr Soc. 2018;66(10):1872-1879.
34. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
35. Ledford CJ, Cafferty LA, Seehusen DA. Socializing identity through practice: a mixed methods approach to family medicine resident perspectives on uncertainty. Fam Med. 2015;47(7):549-553.
36. Ledford CJ, Seehusen DA, Chessman AW, Shokar NK. How we teach U.S. medical students to negotiate uncertainty in clinical care: a CERA study. Fam Med. 2015;47(1):31-36.
37. Fried TR. Shared decision making-finding the sweet spot. N Engl J Med. 2016;374:104-106.
38. Chi WC, Wolff J, Greer R, Dy S. Multimorbidity and decision-making preferences among older adults. Ann Fam Med. 2017;15:546-551.
39. Gill TM, Allore HG, Holford TR, Guo Z. Hospitalization, restricted activity, and the development of disability among older persons. JAMA. 2004;292(17):2115-2124.
40. Boyd CM, Landefeld CS, Counsell SR, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc. 2008;56(12):2171-2179.
41. Narayan V, Jiang S, Warlick CA. Early stage cancer in older adults: prostate-avoiding overtreatment and undertreatment. Cancer J. 2017;23(4):238-241.
42. Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database Syst Rev. 2015;3:CD010523.
43. Naik AD, Palmer N, Petersen NJ, et al. Comparative effectiveness of goal setting in diabetes mellitus group clinics: randomized clinical trial. Arch Intern Med. 2011;171(5):453-459.
44. Naik AD, Martin LA, Moye J, Karel MJ. Health values and treatment goals of older, multimorbid adults facing life-threatening illness. J Am Geriatr Soc. 2016;64(3):625-631.
45. Brown VA, Bartholomew LK, Naik AD. Management of chronic hypertension in older men: an exploration of patient goal-setting. Patient Educ Couns. 2007;69(1):93-99.
46. Kelley AS, Back AL, Arnold RM, et al. Geritalk: communication skills training for geriatric and palliative medicine fellows. J Am Geriatr Soc. 2012;60(2):332-337.
47. Patient Priorities Care Specific Ask Conversation Guide (online). https://patientprioritiescare.org. Accessed January 16, 2019.
48. VitalTalk (online). http://vitaltalk.org/. Accessed January 16, 2019.
49. Prepare for your care (online). The Regents of the University of California. c2012-2018. www.prepareforyourcare.org. Accessed January 16, 2019.
50. Kruser JM, Nabozny MJ, Steffens NM, et al. "best case/worst case": qualitative evaluation of a novel communication tool for difficult in-the-moment surgical decisions. J Am Geriatr Soc. 2015;63(9):1805-1811.
51. Pollack CE, Blackford AL, Schoenborn NL, Boyd CM, Peairs KS, DuGoff EH. Comparing prognostic tools for cancer screening: considerations for clinical practice and performance assessment. J Am Geriatr Soc. 2016;64(5):1032-1038.
52. ePrognosis (online). University of California. https://eprognosis.ucsf.edu. Accessed January 16, 2019.
53. Holmes HM, Cox Hayley D, Alexander CB, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166:605-609.
54. Lee SJ, Leipzig RM, Walters L. Incorporating lag time to benefit into prevention decisions for older adults. JAMA. 2013;310(24):2609-2610.
55. Lee SJ, Kim CM. Individualizing prevention for older adults. J Am Geriatr Soc. 2018;66(2):229-234.
56. Reuben DB. Medical care for the final years of life: “when you're 83, it's not going to be 20 years.”. JAMA. 2009;302(24):2686-2694.
57. Lewis CL, Esserman D, DeLeon C, Pignone MP, Pathman DE, Golin C. Physician decision making for colorectal cancer screening in the elderly. J Gen Intern Med. 2013;28(9):1202-1207.
58. Ahalt C, Walter LC, Yourman L, Eng C, Pérez-Stable EJ, Smith AK. “Knowing is better”: preferences of diverse older adults for discussing prognosis. J Gen Intern Med. 2012;27(5):568-575.
59. Schoenborn NL, Lee K, Pollack CE, et al. Older adults' views and communication preferences about cancer screening cessation. JAMA Intern Med. 2017;177(8):1121-1128.
60. Schoenborn NL, Lee K, Pollack CE, et al. Older adults preferences for when and how to discuss life expectancy in primary care. J Am Board Fam Med. 2017;30(6):813-815.
61. Fried TR, Bradley EH, O'Leary J. Prognosis communication in serious illness: perceptions of older patients, caregivers, and clinicians. J Am Geriatr Soc. 2003;51(10):1398-1403.
62. Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: a framework for goals of care conversations. J Oncol Pract. 2017;13(10):e844-e850.
63. The 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. The 2019 American Geriatrics Society Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019; https://doi.org/10.1111/jgs.15767. [Epub ahead of print].
64. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-218.
65. Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet. 2017;389(10081):1778-1780.
66. Kutner JS, Blatchford PJ, Taylor DH Jr, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med. 2015;175(5):691-700.
67. Tjia J, Kutner JS, Ritchie CS, et al. Perceptions of statin discontinuation among patients with life-limiting illness. J Palliat Med. 2017;20(10):1098-1103.
68. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170(18):1648-1654.
69. Haastrup P, Paulsen MS, Begtrup LM, Hansen JM, Jarbøl DE. Strategies for discontinuation of proton pump inhibitors: a systematic review. Fam Pract. 2014;31(6):625-630.
70. Black DM, Rosen CJ. Clinical practice: postmenopausal osteoporosis. N Engl J Med. 2016;374(3):254-262.
71. Graves T, Hanlon JT, Schmader KE, et al. Adverse events after discontinuing medications in elderly outpatients. Arch Intern Med. 1997;157(19):2205-2210.
72. American Geriatrics Society Expert Panel on the Care of Older Adults With Diabetes Mellitus. Guidelines for improving the care of older adults with diabetes mellitus: 2013 update. J Am Geriatr Soc. 2013;61(11):2020-2026.
73. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e133115.
74. Qaseem A, Wilt TJ, Rich R, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017;166(6):430-437.
75. Deprescribing Guidelines and Algorithms (online). Ottawa, ON, Canada: Bruyere Research Institute. 2018. https://deprescribing.org/resources/deprescribing-guidelines-algorithms. Accessed January 16, 2019.
76. Choosing Wisely (online). Philadelphia, PA: ABIM Foundation. 2018. Lists. http://www.choosingwisely.org/patient-resources/. Accessed January 16, 2019.
77. Schoenborn NL, Bowman TL 2nd, Cayea D, Boyd C, Feeser S, Pollack CE. Discussion strategies that primary care clinicians use when stopping cancer screening in older adults. J Am Geriatr Soc. 2016;64(11):e221-e223.
78. Tinetti ME, Han L, Lee DS, et al. Anti-hypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014;174(4):588-595.
79. Scholle SH, Torda P, Peikes D, Han E, Genevro J. Engaging Patients and Families in the Medical Home. (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2.) AHRQ Publication No. 10-0083-EF. Agency for Healthcare Research and Quality: Rockville, MD; 2010.
80. Wolff JL, Roter DL, Boyd CM, et al. Patient-family agenda setting for primary care patients with cognitive impairment: the SAME page trial. J Gen Intern Med. 2018;33(9):1478-1486.
81. Bayliss EA, Bonds DE, Boyd CM, et al. Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters. Ann Fam Med. 2014;12(3):260-269.
82. Wolff JL, Roter DL, Barron J, et al. A tool to strengthen the older patient-companion partnership in primary care: results from a pilot study. J Am Geriatr Soc. 2014;62(2):312-319.
83. CMS Administrator Verma Announces New Meaningful Measures Initiative and Addresses Regulatory Reform: Promotes Innovation at LAN Summit (online). Baltimore, MD: CMS. 2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-10-30.html. Accessed January 16, 2019.
84. Wechsler LR, Demaerschalk BM, Schwamm LH, et al. Telemedicine quality and outcomes in stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;48(1):e3-e25.
85. State Telehealth Laws and Reimbursement Policies: A Comprehensive Scan of the 50 States and District of Columbia. Center for Connected Health Policy. https://www.cchpca.org/sites/default/files/2018-10/CCHP_50_State_Report_Fall_2018.pdf. Accessed January 16, 2019.
86. Welp A, Manser T. Integrating teamwork, clinician occupational well-being and patient safety: development of a conceptual framework based on a systematic review. BMC Health Serv Res. 2016;16:281.
87. Chronic Care Management Services Changes for 2017 (online). CMS. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagementServicesChanges2017.pdf. Accessed January 16, 2019.