1
|
Bade B, Gwin M, Triplette M, Wiener RS, Crothers K. Comorbidity and life expectancy in shared decision making for lung cancer screening. Semin Oncol 2022; 49:S0093-7754(22)00057-4. [PMID: 35940959 DOI: 10.1053/j.seminoncol.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/02/2022] [Accepted: 07/03/2022] [Indexed: 11/11/2022]
Abstract
Shared decision making (SDM) is an important part of lung cancer screening (LCS) that includes discussing the risks and benefits of screening, potential outcomes, patient eligibility and willingness to participate, tobacco cessation, and tailoring a strategy to an individual patient. More than other cancer screening tests, eligibility for LCS is nuanced, incorporating the patient's age as well as tobacco use history and overall health status. Since comorbidities and multimorbidity (ie, 2 or more comorbidities) impact the risks and benefits of LCS, these topics are a fundamental part of decision-making. However, there is currently little evidence available to guide clinicians in addressing comorbidities and an individual's "appropriateness" for LCS during SDM visits. Therefore, this literature review investigates the impact of comorbidities and multimorbidity among patients undergoing LCS. Based on available evidence and guideline recommendations, we identify comorbidities that should be considered during SDM conversations and review best practices for navigating SDM conversations in the context of LCS. Three conditions are highlighted since they concomitantly portend higher risk of developing lung cancer, potentially increase risk of screening-related evaluation and treatment complications and can be associated with limited life expectancy: chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, and human immunodeficiency virus infection.
Collapse
Affiliation(s)
- Brett Bade
- Veterans Affairs (VA) Connecticut Healthcare System, Section of Pulmonary, Critical Care, and Sleep Medicine, West Haven, CT, United States of America (USA); Yale University School of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT, USA.
| | - Mary Gwin
- University of Washington School of Medicine, Seattle, WA, USA
| | - Matthew Triplette
- University of Washington School of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA, USA; Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research and Medical Service, VA Boston Healthcare System, Boston, MA, USA; The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Kristina Crothers
- University of Washington School of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA, USA; VA Puget Sound Health Care System, Section of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA, USA
| |
Collapse
|
2
|
Van der Linden L, Hias J, Spriet I, Walgraeve K, Flamaing J, Tournoy J. Medication review in older adults: Importance of time to benefit. Am J Health Syst Pharm 2019; 76:247-250. [DOI: 10.1093/ajhp/zxy038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| |
Collapse
|
3
|
Thompson A, Guthrie B, Payne K. Using the Payoff Time in Decision-Analytic Models: A Case Study for Using Statins in Primary Prevention. Med Decis Making 2017; 37:759-769. [PMID: 28441087 PMCID: PMC5580784 DOI: 10.1177/0272989x17700846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 02/06/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The payoff time represents an estimate of when the benefits of an intervention outweigh the costs. It is particularly useful for benefit-harm decision making for interventions that have deferred benefits but upfront harms. The aim of this study was to expand the application of the payoff time and provide an example of its use within a decision-analytic model. METHODS Three clinically relevant patient vignettes based on varying levels of estimated 10-year cardiovascular risk (10%, 15%, 20%) were developed. An existing state-transition Markov model taking a health service perspective and a life-time horizon was adapted to include 3 levels of direct treatment disutility (DTD) associated with ongoing statin use: 0.005, 0.01, and 0.015. For each vignette and DTD we calculated a range of outputs including the payoff time inclusive and exclusive of healthcare costs. RESULTS For a 10% 10-year cardiovascular risk (vignette 1) with low-levels of DTD (0.005), the payoff time was 8.5 years when costs were excluded and 16 years when costs were included. As the baseline risk of cardiovascular increased, the payoff time shortened. For a 15% cardiovascular risk (vignette 2) and for a low-level of DTD, the payoff time was 5.5 years and 9.5 years, respectively. For a 20% cardiovascular risk (vignette 3), the payoff time was 4.2 and 7.2 years, respectively. For higher levels of DTDs for each vignette, the payoff time lengthened, and in some instances the intervention never paid off, leading to an expected net harm for patients. CONCLUSIONS This study has shown how the payoff time can be readily applied to an existing decision-analytic model and be used to complement existing measures to guide healthcare decision making.
Collapse
Affiliation(s)
- Alexander Thompson
- Alexander Thompson, MSc, Manchester Centre for Health Economics, 4th floor, Jean McFarlane Building, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK; telephone: +44 161-306-7685; fax: +44 161-275-5205; e-mail:
| | - Bruce Guthrie
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK (AT, KP)
- Population Health Sciences Division, The University of Dundee, UK (BG)
| | - Katherine Payne
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK (AT, KP)
- Population Health Sciences Division, The University of Dundee, UK (BG)
| |
Collapse
|
4
|
Espaulella-Panicot J, Molist-Brunet N, Sevilla-Sánchez D, González-Bueno J, Amblàs-Novellas J, Solà-Bonada N, Codina-Jané C. [Patient-centred prescription model to improve adequate prescription and therapeutic adherence in patients with multiple disorders]. Rev Esp Geriatr Gerontol 2017; 52:278-281. [PMID: 28476211 DOI: 10.1016/j.regg.2017.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/16/2017] [Accepted: 03/20/2017] [Indexed: 06/07/2023]
Abstract
Patients with multiple disorders and on multiple medication are often associated with clinical complexity, defined as a situation of uncertainty conditioned by difficulties in establishing a situational diagnosis and decision-making. The patient-centred care approach in this population group seems to be one of the best therapeutic options. In this context, the preparation of an individualised therapeutic plan is the most relevant practical element, where the pharmacological plan maintains an important role. There has recently been a significant increase in knowledge in the area of adequacy of prescription and adherence. In this context, we must find a model must be found that incorporates this knowledge into clinical practice by the professionals. Person-centred prescription is a medication review model that includes different strategies in a single intervention. It is performed by a multidisciplinary team, and allows them to adapt the pharmacological plan of patients with clinical complexity.
Collapse
Affiliation(s)
- Joan Espaulella-Panicot
- Hospital Universitari de la Santa Creu, Vic, Barcelona, España; Hospital Universitari de Vic, Vic, Barcelona, España.
| | - Núria Molist-Brunet
- Hospital Universitari de la Santa Creu, Vic, Barcelona, España; Hospital Universitari de Vic, Vic, Barcelona, España
| | - Daniel Sevilla-Sánchez
- Hospital Universitari de la Santa Creu, Vic, Barcelona, España; Hospital Universitari de Vic, Vic, Barcelona, España
| | | | - Jordi Amblàs-Novellas
- Hospital Universitari de la Santa Creu, Vic, Barcelona, España; Hospital Universitari de Vic, Vic, Barcelona, España
| | | | - Carles Codina-Jané
- Hospital Universitari de Vic, Vic, Barcelona, España; Hospital Clínic de Barcelona, Barcelona, España
| |
Collapse
|
5
|
Guthrie B, Thompson A, Dumbreck S, Flynn A, Alderson P, Nairn M, Treweek S, Payne K. Better guidelines for better care: accounting for multimorbidity in clinical guidelines – structured examination of exemplar guidelines and health economic modelling. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05160] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BackgroundMultimorbidity is common but most clinical guidelines focus on single diseases.AimTo test the feasibility of new approaches to developing single-disease guidelines to better account for multimorbidity.DesignLiterature-based and economic modelling project focused on areas where multimorbidity makes guideline application problematic.Methods(1) Examination of accounting for multimorbidity in three exemplar National Institute for Health and Care Excellence guidelines (type 2 diabetes, depression, heart failure); (2) examination of the applicability of evidence in multimorbidity for the exemplar conditions; (3) exploration of methods for comparing absolute benefit of treatment; (4) incorporation of treatment pay-off time and competing risk of death in an exemplar economic model for long-term preventative treatments with slowly accruing benefit; and (5) development of a discrete event simulation model-based cost-effectiveness analysis for people with both depression and coronary heart disease.Results(1) Comorbidity was rarely accounted for in the clinical research questions that framed the development of the exemplar guidelines, and was rarely accounted for in treatment recommendations. Drug–disease interactions were common only for comorbid chronic kidney disease, but potentially serious drug–drug interactions between recommended drugs were common and rarely accounted for in guidelines. (2) For all three conditions, the trials underpinning treatment recommendations largely excluded older, more comorbid and more coprescribed patients. The implications of low applicability varied by condition, with type 2 diabetes having large differences in comorbidity, whereas potentially serious drug–drug interactions were more important for depression. (3) Comparing absolute benefit of treatments for different conditions was shown to be technically feasible, but only if guideline developers are willing to make a number of significant assumptions. (4) The lifetime absolute benefit of statins for primary prevention is highly sensitive to the presence of both the direct treatment disutility of taking a daily tablet and competing risk of death. (5) It was feasible to use a discrete event simulation-based model to represent the relevant care pathways to estimate the relative cost-effectiveness of pharmacological treatments of major depressive disorder in primary care for patients who are also likely to go on and receive treatment for coronary heart disease but the analysis was reliant on eliciting some parameter values from experts, which increases the inherent uncertainty in the results. The key limitation was that real-life use in guideline development was not examined.ConclusionsGuideline developers could feasibly (1) use epidemiological data characterising the guideline population to inform consideration of applicability and interactions; (2) systematically compare the absolute benefit of long-term preventative treatments to inform decision-making in people with multimorbidity and high treatment burden; and (3) modify the output from economic models used in guideline development to examine time to benefit in terms of the pay-off time and varying competing risk of death from other conditions.Future workFurther research is needed to optimise presentation of comparative absolute benefit information to clinicians and patients, to evaluate the use of epidemiological and time-to-benefit data in guideline development, to better quantify direct treatment disutility and to better quantify benefit and harm in people with multimorbidity.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Bruce Guthrie
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Alexander Thompson
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Siobhan Dumbreck
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Angela Flynn
- Population Health Sciences Division, University of Dundee, Dundee, UK
| | - Phil Alderson
- Centre for Clinical Practice, National Institute for Health and Care Excellence, Manchester, UK
| | - Moray Nairn
- Scottish Intercollegiate Guidelines Network, Edinburgh, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| |
Collapse
|
6
|
Amblàs-Novellas J, Espaulella-Panicot J, Inzitari M, Rexach L, Fontecha B, Romero-Ortuno R. [The challenge of clinical complexity in the 21st century: Could frailty indexes be the answer?]. Rev Esp Geriatr Gerontol 2016; 52:159-166. [PMID: 27544014 DOI: 10.1016/j.regg.2016.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 07/07/2016] [Accepted: 07/13/2016] [Indexed: 12/14/2022]
Abstract
The number of older people with complex clinical conditions and complex care needs continues to increase in the population. This is presenting many challenges to healthcare professionals and healthcare systems. In the face of these challenges, approaches are required that are practical and feasible. The frailty paradigm may be an excellent opportunity to review and establish some of the principles of comprehensive Geriatric Assessment in specialties outside Geriatric Medicine. The assessment of frailty using Frailty Indexes provides an aid to the 'situational diagnosis' of complex clinical situations, and may help in tackling uncertainty in a person-centred approach.
Collapse
Affiliation(s)
- Jordi Amblàs-Novellas
- Unidad Geriátrica de Agudos, Hospital Universitari de Vic/Consorci Hospitalari de Vic, Vic, Barcelona, España; Unidad Territorial de Geriatría y Cuidados Paliativos, Consorci Hospitalari de Vic/Hospital Universitari de la Santa Creu de Vic, Vic, Barcelona, España; Centro de Estudios Sociales y Sanitarios (CESS)/Cátedra de Cuidados Paliativos, Universitat de Vic-Universitat Central de Catalunya, Vic, Barcelona, España.
| | - Joan Espaulella-Panicot
- Unidad Territorial de Geriatría y Cuidados Paliativos, Consorci Hospitalari de Vic/Hospital Universitari de la Santa Creu de Vic, Vic, Barcelona, España; Centro de Estudios Sociales y Sanitarios (CESS)/Cátedra de Cuidados Paliativos, Universitat de Vic-Universitat Central de Catalunya, Vic, Barcelona, España
| | - Marco Inzitari
- Parc Sanitari Pere Virgili, Barcelona, España; Universitat Autònoma de Barcelona, Barcelona, España
| | - Lourdes Rexach
- Unidad de Cuidados Paliativos, Hospital Ramón y Cajal, Madrid, España
| | - Benito Fontecha
- Servicio de Geriatría y Cuidados Paliativos, Consorci Sanitari Integral, l'Hospitalet de Llobregat, Barcelona, España
| | - Roman Romero-Ortuno
- Department of Medicine for the Elderly, Addenbrooke's Hospital, Cambridge, Reino Unido; Clinical Gerontology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Reino Unido
| |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW The purpose of this review is to consider a patient-centred approach to the care of people living with HIV (PLWH) who have multimorbidity, irrespective of the specific conditions. RECENT FINDINGS Interdisciplinary care to achieve patient-centred care for people with multimorbidity is recognized as important, but the evaluation of models designed to achieve this goal are needed. Key elements of such approaches include patient preferences, interpretation of the evidence, prognosis as a tool to inform patient-centred care, clinical feasibility and optimization of treatment regimens. SUMMARY Developing and evaluating the best models of patient-centred care for PLWH who also have multimorbidity is essential. This challenge represents an opportunity to leverage the lessons learned from the care of people with multimorbidity in general, and vice versa.
Collapse
|
8
|
Holmes HM, Min LC, Yee M, Varadhan R, Basran J, Dale W, Boyd CM. Rationalizing prescribing for older patients with multimorbidity: considering time to benefit. Drugs Aging 2014; 30:655-66. [PMID: 23749475 DOI: 10.1007/s40266-013-0095-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Given the growing number of older adults with multimorbidity who are prescribed multiple medications, clinicians need to prioritize which medications are most likely to benefit and least likely to harm an individual patient. The concept of time to benefit (TTB) is increasingly discussed in addition to other measures of drug effectiveness in order to understand and contextualize the benefits and harms of a therapy to an individual patient. However, how to glean this information from available evidence is not well established. The lack of such information for clinicians highlights a critical need in the design and reporting of clinical trials to provide information most relevant to decision making for older adults with multimorbidity. We define TTB as the time until a statistically significant benefit is observed in trials of people taking a therapy compared to a control group not taking the therapy. Similarly, time to harm (TTH) is the time until a statistically significant adverse effect is seen in a trial for the treatment group compared to the control group. To determine both TTB and TTH, it is critical that we also clearly define the benefit or harm under consideration. Well-defined benefits or harms are clinically meaningful, measurable outcomes that are desired (or shunned) by patients. In this conceptual review, we illustrate concepts of TTB in randomized controlled trials (RCTs) of statins for the primary prevention of cardiovascular disease. Using published results, we estimate probable TTB for statins with the future goal of using such information to improve prescribing decisions for individual patients. Knowing the relative TTBs and TTHs associated with a patient's medications could be immensely useful to a clinician in decision making for their older patients with multimorbidity. We describe the challenges in defining and determining TTB and TTH, and discuss possible ways of analyzing and reporting trial results that would add more information about this aspect of drug effectiveness to the clinician's evidence base.
Collapse
Affiliation(s)
- Holly M Holmes
- Department of General Internal Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA.
| | | | | | | | | | | | | |
Collapse
|
9
|
Development of clinical practice guidelines for patients with comorbidity and multiple diseases. Rev Clin Esp 2014. [DOI: 10.1016/j.rceng.2014.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
10
|
Bernabeu-Wittel M, Alonso-Coello P, Rico-Blázquez M, Rotaeche del Campo R, Sánchez Gómez S, Casariego Vales E. [Development of clinical practice guidelines for patients with comorbidity and multiple diseases]. Aten Primaria 2014; 46:385-92. [PMID: 24968962 PMCID: PMC6985605 DOI: 10.1016/j.aprim.2013.11.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 11/12/2013] [Indexed: 11/19/2022] Open
Abstract
La atención a pacientes con comorbilidad y pluripatología supone un reto para cualquier sistema sanitario. Las guías de práctica clínica (GPC) presentan limitaciones cuando se aplican a esta población. El objetivo de este trabajo es realizar una propuesta terminológica y metodológica sobre el abordaje de la comorbilidad y la pluripatología en las GPC. De acuerdo a la revisión bibliográfica efectuada, se sugieren algunas propuestas para su abordaje en las diferentes fases de elaboración de las GPC, con especial atención a la inclusión de los clusters de comorbilidad en las preguntas clínicas iniciales, la incorporación de la evidencia indirecta, el peso de la carga de gestionar la enfermedad para el paciente y su entorno en la formulación de recomendaciones, así como las estrategias de difusión e implementación. Estas propuestas deben desarrollarse en mayor profundidad con la participación de más agentes para disponer de herramientas válidas y útiles en esta población.
Collapse
Affiliation(s)
- M Bernabeu-Wittel
- Unidad de Gestión Clínica de Medicina Interna, Hospital Universitario Virgen del Rocío, SEMI, Sevilla, España.
| | - P Alonso-Coello
- Centro Cochrane Iberoamericano, Instituto de Investigación Biomédica (IIB Sant Pau), Grupo MBE semFYC, Barcelona, España
| | - M Rico-Blázquez
- Unidad de Apoyo a la Investigación, Gerencia de Atención Primaria, Servicio Madrileño de Salud, Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Madrid, España; Facultad de Enfermería, Universidad de Alcalá, FAECAP, Alcalá de Henares, España
| | | | - S Sánchez Gómez
- Comarca de Araba, Osakidetza, Escuela Universitaria de Enfermería de Vitoria-Gasteiz, Grupo de Crónicos, FAECAP, Vitoria, España
| | - E Casariego Vales
- Servicio de Medicina Interna, Hospital Lucus Augusti, SEMI, Lugo, España
| |
Collapse
|
11
|
Development of clinical practice guidelines for patients with comorbidity and multiple diseases. Rev Clin Esp 2014; 214:328-35. [PMID: 24856043 DOI: 10.1016/j.rce.2014.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 03/25/2014] [Accepted: 04/07/2014] [Indexed: 11/21/2022]
Abstract
The management of patients with comorbidity and polypathology represents a challenge for all healthcare systems. Clinical practice guidelines (CPGs) have limitations when applied to this population. The aim of this study is to propose the terminology and methodology for optimally approach comorbidity and polypathology in the CPGs. Based on a literature review, we suggest a number of proposals for the approach in different phases of CPG preparation, with special attention to the inclusion of clusters of comorbidity in the initial questions the implementation of indirect evidence, the burden of disease management for patients and their environment, when establishing recommendations, as well as the strategies of dissemination and implementation. These proposals should be developed in greater depth with the implication of more agents in order to have valid and useful tools for this population.
Collapse
|
12
|
A framework for crafting clinical practice guidelines that are relevant to the care and management of people with multimorbidity. J Gen Intern Med 2014; 29:670-9. [PMID: 24442332 PMCID: PMC3965742 DOI: 10.1007/s11606-013-2659-y] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 06/19/2013] [Accepted: 09/04/2013] [Indexed: 12/19/2022]
Abstract
Many patients of all ages have multiple conditions, yet clinicians often lack explicit guidance on how to approach clinical decision-making for such people. Most recommendations from clinical practice guidelines (CPGs) focus on the management of single diseases, and may be harmful or impractical for patients with multimorbidity. A major barrier to the development of guidance for people with multimorbidity stems from the fact that the evidence underlying CPGs derives from studies predominantly focused on the management of a single disease. In this paper, the investigators from the Improving Guidelines for Multimorbid Patients Study Group present consensus-based recommendations for guideline developers to make guidelines more useful for the care of people with multimorbidity. In an iterative process informed by review of key literature and experience, we drafted a list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes. The recommended approaches address consideration of coexisting conditions at all major steps in CPG development, from nominating and scoping the topic, commissioning the work group, refining key questions, ranking importance of outcomes, conducting systematic reviews, assessing quality of evidence and applicability, summarizing benefits and harms, to formulating recommendations and grading their strength. The list of issues and recommendations was reviewed and refined iteratively by stakeholders. This framework acknowledges the challenges faced by CPG developers who must make complex judgments in the absence of high-quality or direct evidence. These recommendations require validation through implementation, evaluation and refinement.
Collapse
|
13
|
Zulman DM, Asch SM, Martins SB, Kerr EA, Hoffman BB, Goldstein MK. Quality of care for patients with multiple chronic conditions: the role of comorbidity interrelatedness. J Gen Intern Med 2014; 29:529-37. [PMID: 24081443 PMCID: PMC3930789 DOI: 10.1007/s11606-013-2616-9] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/30/2013] [Accepted: 08/26/2013] [Indexed: 12/21/2022]
Abstract
Multimorbidity--the presence of multiple chronic conditions in a patient--has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient's number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relationship between multimorbidity and quality of care, and discuss how this relationship may be mediated by the degree to which conditions interact with one another to generate clinical complexity (comorbidity interrelatedness). Drawing on established theoretical frameworks from cognitive engineering and biomedical informatics, we describe how interactions among conditions result in clinical complexity and may affect quality of care. We discuss how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics, and describe opportunities to quantify this construct using data widely available through electronic health records. Incorporating comorbidity interrelatedness into conceptualizations of multimorbidity has the potential to enhance clinical and research efforts that aim to improve care for patients with multiple chronic conditions.
Collapse
Affiliation(s)
- Donna M Zulman
- Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, CA, USA,
| | | | | | | | | | | |
Collapse
|
14
|
Taksler GB, Keshner M, Fagerlin A, Hajizadeh N, Braithwaite RS. Personalized estimates of benefit from preventive care guidelines: a proof of concept. Ann Intern Med 2013; 159:161-8. [PMID: 23922061 DOI: 10.7326/0003-4819-159-3-201308060-00005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The U.S. Preventive Services Task Force (USPSTF) makes recommendations for 60 distinct clinical services, but clinicians rarely have time to fully evaluate and implement the recommendations. OBJECTIVE To complete a proof of concept for prioritization and personalization of USPSTF recommendations, using patient-specific clinical characteristics. DESIGN Mathematical model. DATA SOURCES USPSTF recommendations and supporting evidence and National Vital Statistics Reports. TARGET POPULATION Nonpregnant adults. TIME HORIZON Lifetime. PERSPECTIVE Individual. INTERVENTION USPSTF grade A and B recommendations. OUTCOME MEASURES Personalized gain in life expectancy associated each recommendation. RESULTS OF BASE-CASE ANALYSIS Increases in life expectancy varied more than 100-fold across USPSTF recommendations, and the rank order of benefits varied considerably among patients. For an obese man aged 62 years who smoked and had hypercholesterolemia, hypertension, and a family history of colorectal cancer, the model’s top 3 recommendations (from most to least gain in life expectancy) were tobacco cessation (adding 2.8 life-years), weight loss (adding 1.6 life-years), and blood pressure control (adding 0.8 life-year). Lower-ranked recommendations were a healthier diet, aspirin use, cholesterol reduction, colonoscopy, screening for abdominal aortic aneurysm, and HIV testing (each adding 0.1 to 0.3 life-years). For a person with the same characteristics plus uncontrolled type 2 diabetes mellitus, the model’s top 3 recommendations were diabetes control, tobacco cessation, and weight loss (each adding 1.4 to 1.8 life-years). RESULTS OF SENSITIVITY ANALYSIS Robust to variation of model inputs and satisfied face validity criteria. LIMITATION Expected adherence rates and quality of life were not considered. CONCLUSION Models of personalized preventive care may illustrate how magnitude and rank order of benefit associated with preventive guidelines vary across recommendations and patients. These predictions may help clinicians to prioritize USPSTF recommendations at the patient level.
Collapse
Affiliation(s)
- Glen B Taksler
- New York University School of Medicine, New York, New York, USA.
| | | | | | | | | |
Collapse
|
15
|
First do no harm: the review frequency of illness depends as much on family dynamics as on material factors. Br J Gen Pract 2013; 63:94. [DOI: 10.3399/bjgp13x663145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
|
16
|
Justice AC, Modur SP, Tate JP, Althoff KN, Jacobson LP, Gebo KA, Kitahata MM, Horberg MA, Brooks JT, Buchacz K, Rourke SB, Rachlis A, Napravnik S, Eron J, Willig JH, Moore R, Kirk GD, Bosch R, Rodriguez B, Hogg RS, Thorne J, Goedert JJ, Klein M, Gill J, Deeks S, Sterling TR, Anastos K, Gange SJ. Predictive accuracy of the Veterans Aging Cohort Study index for mortality with HIV infection: a North American cross cohort analysis. J Acquir Immune Defic Syndr 2013; 62:149-63. [PMID: 23187941 PMCID: PMC3619393 DOI: 10.1097/qai.0b013e31827df36c] [Citation(s) in RCA: 182] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND By supplementing an index composed of HIV biomarkers and age (restricted index) with measures of organ injury, the Veterans Aging Cohort Study (VACS) index more completely reflects risk of mortality. We compare the accuracy of the VACS and restricted indices (1) among subjects outside the Veterans Affairs Healthcare System, (2) more than 1-5 years of prior exposure to antiretroviral therapy (ART), and (3) within important patient subgroups. METHODS We used data from 13 cohorts in the North American AIDS Cohort Collaboration (n = 10, 835) limiting analyses to HIV-infected subjects with at least 12 months exposure to ART. Variables included demographic, laboratory (CD4 count, HIV-1 RNA, hemoglobin, platelets, aspartate and alanine transaminase, creatinine, and hepatitis C status), and survival. We used C-statistics and net reclassification improvement (NRI) to test discrimination varying prior ART exposure from 1 to 5 years. We then combined Veterans Affairs Healthcare System (n = 5066) and North American AIDS Cohort Collaboration data, fit a parametric survival model, and compared predicted to observed mortality by cohort, gender, age, race, and HIV-1 RNA level. RESULTS Mean follow-up was 3.3 years (655 deaths). Compared with the restricted index, the VACS index showed greater discrimination (C-statistics: 0.77 vs. 0.74; NRI: 12%; P < 0.0001). NRI was highest among those with HIV-1 RNA <500 copies per milliliter (25%) and age ≥50 years (20%). Predictions were similar to observed mortality among all subgroups. CONCLUSIONS VACS index scores discriminate risk and translate into accurate mortality estimates over 1-5 years of exposure to ART and for diverse patient subgroups from North American.
Collapse
Affiliation(s)
- Amy C Justice
- Department of Internal Medicine, Yale University and the Veterans Affairs Healthcare System, West Haven, CT 06516, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
A theoretical framework for multimorbidity: from complicated to chaotic. Br J Gen Pract 2012; 62:e659-62. [PMID: 22947588 DOI: 10.3399/bjgp12x654740] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
|
18
|
Fabbri LM, Boyd C, Boschetto P, Rabe KF, Buist AS, Yawn B, Leff B, Kent DM, Schünemann HJ. 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. PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY 2012; 9:274-81. [PMID: 23256171 PMCID: PMC5820992 DOI: 10.1513/pats.201208-063st] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Professional societies, like many other organizations around the world, have recognized the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the 10th of a series of 14 articles that were prepared to advise guideline developers in respiratory and other diseases. This article deals with how multiple comorbidities (co-existing chronic conditions) may be more effectively integrated into guidelines. METHODS In this review we addressed the following topics and questions using chronic obstructive pulmonary disease (COPD) as an example. (1) How important are multiple comorbidities for guidelines? (2) How have other organizations involved in the development of guidelines for single chronic disease approached the problem of multiple comorbidities? (3) What are the implications of multiple comorbidities for pharmacological treatment? (4) What are the potential changes induced by multiple comorbidities in guidelines? (5) What are the implications of considering a population of older patients with multiple comorbidities in designing clinical trials? Our conclusions are based on available evidence from the published literature, experience from guideline developers, and workshop discussions. We did not attempt to examine all Clinical Practice Guidelines (CPGs) and relevant literature. Instead, we selected CPGs generated by prominent professional organizations and relevant literature published in widely read journals, which are likely to have a high impact on clinical practice. RESULTS AND CONCLUSIONS A widening gap exists between the reality of the care of patients with multiple chronic conditions and the practical clinical recommendations driven by CPGs focused on a single disease, such as COPD. Guideline development panels should aim for multidisciplinary representation, especially when contemplating recommendations for individuals aged 65 years or older (who often have multiple comorbidities), and should evaluate the quality of evidence and the strength of recommendations targeted at this population. A priority area for research should be to assess the effect of multiple concomitant medications and assess how their combined effects are altered by genetic, physiological, disease-related, and other factors. One step that should be implemented immediately would be for existing COPD guidelines to add new sections to address the impact of multiple comorbidities on screening, diagnosis, prevention, and management recommendations. Research should focus on the possible interaction of multiple medications. Furthermore, genetic, physiological, disease-related, and other factors that may influence the directness (applicability) of the evidence for the target population in clinical practice guidelines should be examined.
Collapse
|
19
|
Abstract
In this perspective piece, the authors consider what has been learned and is being studied about aging with HIV in resource-rich settings. The authors argue that although there is much that will be different about aging with HIV in other parts of the globe, there are common themes and approaches to care. These include the observation that most patients have more than one health condition, and the need to assess individual risk, prioritize care, and consider the total burden of disease when considering further testing and treatment.
Collapse
Affiliation(s)
- Amy C Justice
- Veterans Administration Connecticut Healthcare System and Yale University, West Haven, Connecticut 06516, USA.
| | | |
Collapse
|
20
|
Affiliation(s)
- Chris Salisbury
- School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK.
| |
Collapse
|
21
|
|
22
|
Nobili A, Garattini S, Mannucci PM. Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium. JOURNAL OF COMORBIDITY 2011; 1:28-44. [PMID: 29090134 PMCID: PMC5556419 DOI: 10.15256/joc.2011.1.4] [Citation(s) in RCA: 152] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 11/16/2011] [Indexed: 12/13/2022]
Abstract
The pattern of patients admitted to internal medicine wards has dramatically changed in the last 20-30 years. Elderly people are now the most rapidly growing proportion of the patient population in the majority of Western countries, and aging seldom comes alone, often being accompanied by chronic diseases, comorbidity, disability, frailty, and social isolation. Multiple diseases and multimorbidity inevitably lead to the use of multiple drugs, a condition known as polypharmacy. Over the last 20-30 years, problems related to aging, multimorbidity, and polypharmacy have become a prominent issue in global healthcare. This review discusses how internists might tackle these new challenges of the aging population. They are called to play a primary role in promoting a new, integrated, and comprehensive approach to the care of elderly people, which should incorporate age-related issues into routine clinical practice and decisions. The development of new approaches in the frame of undergraduate and postgraduate training and of clinical research is essential to improve and implement suitable strategies meant to evaluate and manage frail elderly patients with chronic diseases, comorbidity, and polypharmacy. Journal of Comorbidity 2011;1:28-44.
Collapse
Affiliation(s)
| | | | - Pier Mannuccio Mannucci
- Scientific Direction, IRCCS Cà Granda Foundation Maggiore Policlinico Hospital, Milan, Italy
| |
Collapse
|
23
|
Braithwaite RS. Can life expectancy and QALYs be improved by a framework for deciding whether to apply clinical guidelines to patients with severe comorbid disease? Med Decis Making 2011; 31:582-95. [PMID: 21310855 DOI: 10.1177/0272989x10386117] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Guidelines with short-term harms and long-term benefits are often applied to chronically ill patients who may not benefit. The payoff time framework has been proposed (i.e., do not apply a guideline if a patient's life expectancy (LE) is shorter than when a guideline's cumulative incremental benefits first exceed its cumulative incremental harms), but its health impact is unclear. OBJECTIVE To investigate whether the payoff time framework improves LE and/or quality-adjusted life-years (QALY) for chronically ill patients. METHODS I evaluate impact of the payoff time framework on LE and QALYs, assuming (1) high and constant background mortality rate from chronic illness (≥ 10% per year), (2) immediate guideline-related harm with probability < 1, and (3) constant guideline-related benefit that occurs over an extended time. I apply the framework to questions of whether to screen chronically ill 50-year-old women for colorectal cancer using colonoscopy, and whether to advocate intensive glucose control for chronically ill diabetics. RESULTS If a guideline's payoff time is greater than a patient's LE, then withholding that guideline will increase LE and QALYs for that patient. For a 50-year-old chronically ill woman with background mortality > 0.15 per year (corresponding to LE < 6.5 years), withholding CR screening will increase LE. For a diabetic with background mortality > 0.11 per year (corresponding to LE < 9.4 years), withholding CR screening will increase QALYs. CONCLUSION The payoff time framework may indicate when withholding a guideline with short-term harms and long-term benefits may increase LE and/or QALY.
Collapse
Affiliation(s)
- R Scott Braithwaite
- Section of Value and Comparative Effectiveness, Division of General Internal Medicine, New York University School of Medicine, New York (RSB)
| |
Collapse
|
24
|
|
25
|
Clarfield AM. Screening in Frail Older People: An Ounce of Prevention or a Pound of Trouble? J Am Geriatr Soc 2010; 58:2016-21. [DOI: 10.1111/j.1532-5415.2010.03070.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
26
|
Kent DM, Rothwell PM, Ioannidis JPA, Altman DG, Hayward RA. Assessing and reporting heterogeneity in treatment effects in clinical trials: a proposal. Trials 2010; 11:85. [PMID: 20704705 PMCID: PMC2928211 DOI: 10.1186/1745-6215-11-85] [Citation(s) in RCA: 348] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 08/12/2010] [Indexed: 02/07/2023] Open
Abstract
Mounting evidence suggests that there is frequently considerable variation in the risk of the outcome of interest in clinical trial populations. These differences in risk will often cause clinically important heterogeneity in treatment effects (HTE) across the trial population, such that the balance between treatment risks and benefits may differ substantially between large identifiable patient subgroups; the "average" benefit observed in the summary result may even be non-representative of the treatment effect for a typical patient in the trial. Conventional subgroup analyses, which examine whether specific patient characteristics modify the effects of treatment, are usually unable to detect even large variations in treatment benefit (and harm) across risk groups because they do not account for the fact that patients have multiple characteristics simultaneously that affect the likelihood of treatment benefit. Based upon recent evidence on optimal statistical approaches to assessing HTE, we propose a framework that prioritizes the analysis and reporting of multivariate risk-based HTE and suggests that other subgroup analyses should be explicitly labeled either as primary subgroup analyses (well-motivated by prior evidence and intended to produce clinically actionable results) or secondary (exploratory) subgroup analyses (performed to inform future research). A standardized and transparent approach to HTE assessment and reporting could substantially improve clinical trial utility and interpretability.
Collapse
Affiliation(s)
- David M Kent
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.
| | | | | | | | | |
Collapse
|
27
|
Justice A, Sullivan L, Fiellin D. HIV/AIDS, comorbidity, and alcohol: can we make a difference? ALCOHOL RESEARCH & HEALTH : THE JOURNAL OF THE NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOLISM 2010; 33:258-66. [PMID: 23584067 PMCID: PMC3711181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Alcohol use is common among people infected with HIV and plays an important role in their health outcomes. Because alcohol use complicates HIV infection and contributes to comorbid diseases, it is important for researchers and practitioners to understand these interactions and to integrate alcohol treatment with medical management of long-term HIV infection and associated comorbidity. The Veterans Aging Cohort Study (VACS) is a large, multisite study of the effects of alcohol use on HIV outcomes in the broader context of aging. A multilevel strategy intervention trial is needed to address the many modifiable implications of alcohol consumption among those receiving treatment for HIV.
Collapse
|
28
|
Salz T, Brewer NT, Sandler RS, Weiner BJ, Martin CF, Weinberger M. Association of health beliefs and colonoscopy use among survivors of colorectal cancer. J Cancer Surviv 2009; 3:193-201. [PMID: 19760152 PMCID: PMC2809816 DOI: 10.1007/s11764-009-0095-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 07/30/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Clinical practice guidelines recommend ongoing testing (surveillance) for colorectal cancer survivors because they remain at risk for both local recurrences and second primary tumors. However, survivors often do not receive colorectal cancer surveillance. We used the Health Belief Model (HBM) to identify health beliefs that predict intentions to obtain routine colonoscopies among colorectal cancer survivors. METHODS We completed telephone interviews with 277 colorectal cancer survivors who were diagnosed 4 years earlier, between 2003 and 2005, in North Carolina. The interview measured health beliefs, past preventive behaviors, and intentions to have a routine colonoscopy in the next 5 years. RESULTS In bivariate analyses, most HBM constructs were associated with intentions. In multivariable analyses, greater perceived likelihood of colorectal cancer (OR = 2.00, 95% CI = 1.16-3.44) was associated with greater intention to have a colonoscopy. Survivors who already had a colonoscopy since diagnosis also had greater intentions of having a colonoscopy in the future (OR = 9.47, 95% CI = 2.08-43.16). CONCLUSIONS Perceived likelihood of colorectal cancer is an important target for further study and intervention to increase colorectal cancer surveillance among survivors. Other health beliefs were unrelated to intentions, suggesting that the health beliefs of colorectal cancer survivors and asymptomatic adults may differ due to the experience of cancer.
Collapse
Affiliation(s)
- Talya Salz
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, 10021, USA.
| | | | | | | | | | | |
Collapse
|
29
|
Bernabeu-Wittel M, Jadad A, Moreno-Gaviño L, Hernández-Quiles C, Toscano F, Cassani M, Ramírez N, Ollero-Baturone M. Peeking through the cracks: an assessment of the prevalence, clinical characteristics and health-related quality of life (HRQoL) of people with polypathology in a hospital setting. Arch Gerontol Geriatr 2009; 51:185-91. [PMID: 19913928 DOI: 10.1016/j.archger.2009.10.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 10/08/2009] [Accepted: 10/12/2009] [Indexed: 12/21/2022]
Abstract
Little is known about the prevalence of the recently defined polypathology notion in hospital populations. Patients admitted to medical wards were assessed using established criteria of polypathology. Prevalence of polypathology, interobserver reliability, clinical features, nutritional status, and HRQoL were assessed using clinical data and interview, mini-nutritional assessment (MNA), and the 12-item short-form health survey (SF-12) scales. Of a total of 812 patients studied, 196 (24%) met polypathology criteria (65% men, of mean age 71.3+/-11.6 years, mean defining chronic diseases 2.4+/-0.046, and other comorbidities 2.6+/-0.094). Interobserver reliability for the detection of cases was good (kappa=0.628). Their mean Charlson index/prescribed drugs were 3.3/6, respectively. Severe dyspnea, delirium, or active neoplasia were present in 44, 15, and 11%. A bad nutritional status/risk of malnutrition was evident in 10.3/52.6%, and correlated with the number of previous hospitalizations (p=0.041), and the presence of active neoplasia (p=0.037). Mean physical/mental summaries of HRQoL were 33.9+/-10, and 42+/-13, and correlated with a better nutritional status (p=0.011, and p=0.001, respectively). Polypathology affects one quarter of inpatients in a hospital setting, and can be easily and reliably identified. The diversity and complexity of patient needs underscore the need for continuity of care between community and hospital, crossing sub-speciality lines and institutional boundaries.
Collapse
Affiliation(s)
- M Bernabeu-Wittel
- Department of Internal Medicine, Hospitales Universitarios Virgen del Rocío, Avda. Manuel Siurot, s/n, 41013 Sevilla, Spain.
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Design patterns for clinical guidelines. Artif Intell Med 2009; 47:1-24. [DOI: 10.1016/j.artmed.2009.05.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 04/15/2009] [Accepted: 05/10/2009] [Indexed: 11/20/2022]
|
31
|
Braithwaite RS, Fiellin D, Justice AC. The payoff time: a flexible framework to help clinicians decide when patients with comorbid disease are not likely to benefit from practice guidelines. Med Care 2009; 47:610-7. [PMID: 19433991 PMCID: PMC3077952 DOI: 10.1097/mlr.0b013e31819748d5] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Practice guidelines rarely consider comorbid illness, and resulting overuse of health services may increase costs without conferring benefit. OBJECTIVE To individualize a framework for inferring when patients with comorbid illness are not likely to benefit from colorectal cancer screening guidelines. METHODS We modified the "payoff time" framework (the minimum time until a guideline's cumulative benefits exceed its cumulative harms) to increase its applicability to a wide range of primary care patients. We show how it may inform colorectal (CR) cancer screening decisions for 3 typical patients in general practice for whom CR screening would be recommended by current guidelines: (1) 60-year-old man with diabetes, congestive heart failure, lung disease, stroke, and substantial frailty; (2) 60-year-old woman with diabetes and obesity, without other comorbidity or frailty; and (3) 50-year-old woman with inflammatory bowel disease. RESULTS For patient 1, the payoff time for CR screening (minimum time until benefits exceed harms) is 7.3 years, and for patient 2, the payoff time for CR screening is 5.4 years. Evidence is insufficient to estimate the payoff time for patient 3. Because patient 1's estimated life expectancy is 3.7 years (less than his payoff time), he is unlikely to benefit from CR screening. Because patient 2's estimated life expectancy exceeds 10 years (greater than her payoff time), she may benefit from CR screening. Because evidence is insufficient to estimate the payoff time for patient 3, the payoff time framework does not inform decision making. CONCLUSION The payoff time framework may identify patients for whom particular clinical guidelines are unlikely to confer benefit, and has the potential to decrease unnecessary health care.
Collapse
Affiliation(s)
- R Scott Braithwaite
- Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine and VA Connecticut Healthcare System, New Haven, Connecticut, USA.
| | | | | |
Collapse
|
32
|
Gebo KA. Epidemiology of HIV and response to antiretroviral therapy in the middle aged and elderly. ACTA ACUST UNITED AC 2008; 4:615-627. [PMID: 19915688 DOI: 10.2217/1745509x.4.6.615] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
HIV is increasing in prevalence in the middle aged and older population owing to both increased longevity, and new infections in these populations. Highly active antiretrorival therapy (HAART) therapy may be less effective at restoring immune function in older patients compared with younger patients. There are significant toxicities associated with HAART therapy that, combined with decreased renal and liver function in older patients, may be more problematic in older HIV-infected patients. Comorbid disease is becoming an increasing problem with coadministration of multiple drugs and significant drug-drug interactions. Psychosocial issues in the older patient are often different than those in younger HIV-infected patients and providers should try to address these issues early. Finally, future research should work to identify the ideal timing and type of HAART regimens for older HIV-infected individuals.
Collapse
Affiliation(s)
- Kelly A Gebo
- Johns Hopkins University School of Medicine, 1830 E Monument St, Room 435, Baltimore, MD 21287, USA
| |
Collapse
|
33
|
Kent DM, Alsheikh-Ali A, Hayward RA. Competing risk and heterogeneity of treatment effect in clinical trials. Trials 2008; 9:30. [PMID: 18498644 PMCID: PMC2423182 DOI: 10.1186/1745-6215-9-30] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 05/22/2008] [Indexed: 11/10/2022] Open
Abstract
It has been demonstrated that patients enrolled in clinical trials frequently have a large degree of variation in their baseline risk for the outcome of interest. Thus, some have suggested that clinical trial results should routinely be stratified by outcome risk using risk models, since the summary results may otherwise be misleading. However, variation in competing risk is another dimension of risk heterogeneity that may also underlie treatment effect heterogeneity. Understanding the effects of competing risk heterogeneity may be especially important for pragmatic comparative effectiveness trials, which seek to include traditionally excluded patients, such as the elderly or complex patients with multiple comorbidities. Indeed, the observed effect of an intervention is dependent on the ratio of outcome risk to competing risk, and these risks - which may or may not be correlated - may vary considerably in patients enrolled in a trial. Further, the effects of competing risk on treatment effect heterogeneity can be amplified by even a small degree of treatment related harm. Stratification of trial results along both the competing and the outcome risk dimensions may be necessary if pragmatic comparative effectiveness trials are to provide the clinically useful information their advocates intend.
Collapse
Affiliation(s)
- David M Kent
- Institute for Clinical Research and Health Policy Studies, Department of Medicine, Tufts Medical Center, 750 Washington St, #63, Boston, MA, 02111, USA
| | - Alawi Alsheikh-Ali
- Institute for Clinical Research and Health Policy Studies, Department of Medicine, Tufts Medical Center, 750 Washington St, #63, Boston, MA, 02111, USA
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, 750 Washington Street, NEMC #108, Boston, Massachusetts 02111, USA
| | - Rodney A Hayward
- Veterans Affairs Ann Arbor Health Services Research and Development Service Center of Excellence
- Department of Internal Medicine, Universty of Michigan, 3110 Taubman Health Care Center, Ann Arbor, MI 48109-0368, USA
| |
Collapse
|
34
|
Mayhew M. Comorbidity in Management of COPD. J Nurse Pract 2008. [DOI: 10.1016/j.nurpra.2008.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|