Primary Care Clinicians' Experiences With Treatment Decision Making for Older Persons With Multiple Conditions
Open accessAbstract
BACKGROUND: Clinicians are caring for an increasing number of older patients with multiple diseases in the face of uncertainty concerning the benefits and harms associated with guideline-directed interventions. Understanding how primary care clinicians approach treatment decision making for these patients is critical to the design of interventions to improve the decision-making process. METHODS: Focus groups were conducted with 40 primary care clinicians (physicians, nurse practitioners, and physician assistants) in academic, community, and Veterans Affairs-affiliated primary care practices. Participants were given open-ended questions about their approach to treatment decision making for older persons with multiple medical conditions. Responses were organized into themes using qualitative content analysis. RESULTS: The participants were concerned about their patients' ability to adhere to complex regimens derived from guideline-directed care. There was variability in beliefs regarding, and approaches to balancing, the benefits and harms of guideline-directed care. There was also variability regarding how the participants involved patients in the process of decision making, with clinicians describing conflicts between their own and their patients' goals. The participants listed a number of barriers to making good treatment decisions, including the lack of outcome data, the role of specialists, patient and family expectations, and insufficient time and reimbursement. CONCLUSIONS: The experiences of practicing clinicians suggest that they struggle with the uncertainties of applying disease-specific guidelines to their older patients with multiple conditions. To improve decision making, they need more data, alternative guidelines, approaches to reconciling their own and their patients' priorities, the support of their subspecialist colleagues, and an altered reimbursement system.
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Clinicians struggle with the uncertainties of applying disease-specific guidelines to patients with multiple conditions and would benefit from tools to assist decision making for this population.
“Fried et al. showed that clinicians struggle with the uncertainties of applying disease-specific guidelines to their patients with multiple conditions, and would therefore benefit from a number of tools to assist them in decision making for this population [12].”
From ESPEN guideline on nutritional support for polymorbid medical inpatients (2023) · cites this paper as [12]
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BackgroundEindhoven, D., Hilt, A., Zwaan, T. C., Schalij, M., & Borleffs, C. J. (2018) · European Journal of Preventive Cardiology · doi:10.1177/2047487317744363 · Cited by 93 · see citing works
“In addition, discontinuation of medication or well-considered conservative treatment in elderly patients could be considered the treatment of choice by physician or patient.(30,31) Finally, the physician’s perception of lack of benefit from medical treatment could play a role.”
BackgroundVetrano, D., Tosato, M., Colloca, G., Topinková, E., Fialová, D., Gindin, J., der Roest, H. G. V., Landi, F., Liperoti, R., Bernabei, R., et al. (2012) · Alzheimer's & Dementia · doi:10.1016/j.jalz.2012.09.009 · Cited by 92 · see citing works
“This finding suggests that, for prescribing physicians, preserving quality of life rather than treating the specific disease is perceived as a priority in complex patients [10].”
BackgroundInfluentialAnderson, K., Foster, M. M., Freeman, C. R., Luetsch, K., & Scott, I. A. (2017) · Qualitative Health Research · doi:10.1177/1049732316687732 · Cited by 106 · see citing works
A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development
Zullig, L., Whitson, H. E., Hastings, S., Beadles, C., Kravchenko, J., Akushevich, I., & Maciejewski, M. (2016) · Journal of general internal medicine · doi:10.1007/s11606-015-3512-2 · Cited by 83 · see citing works
Drug utilization and polypharmacy in an Italian elderly population: the EPIFARM‐elderly project
Nobili, A., Franchi, C., Pasina, L., Tettamanti, M., Baviera, M., Monesi, L., Roncaglioni, C., Riva, E., Lucca, U., Bortolotti, A., et al. (2011) · Pharmacoepidemiology and Drug Safety · doi:10.1002/pds.2108 · Cited by 82 · see citing works
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“In older patients, the importance of traditional outcomes, such as discrete clinical events or mortality, may be secondary to maintaining physical or cognitive function or relief of symptoms.(30) Because of this, optimal care requires clinical decision support tools that consider issues such as patient preferences, fr…”
BackgroundDeprescribing medications for older adults in the primary care context: A mixed studies review
Gillespie, R. J., Harrison, L., & Mullan, J. (2018) · Health Science Reports · doi:10.1002/hsr2.45 · Cited by 89 · see citing works
“2 | Older adult and GP characteristics General practitioners' approaches to the management of their older adults' medications varied.(46,50,63) A range of characteristics influenced this.”
BackgroundResultInfluentialThe Impact of Comorbidity Type on Measures of Quality for Diabetes Care
Woodard, L., Urech, T., Landrum, C. R., Wang, D.-G., & Petersen, L. (2011) · Medical Care · doi:10.1097/mlr.0b013e31820f0ed0 · Cited by 76 · see citing works
“Although our results show high levels of guideline-recommended care among the most complex diabetic patients, studies indicate that such care may not be equally beneficial across all chronically ill patients.(17,18) For example, elderly patients with multiple comorbidities receiving care in accordance with multiple gu…”
ResultVetrano, D., Landi, F., Buyser, S. D. D., Carfì, A., Zuccalà, G., Petrovic, M., Volpato, S., Cherubini, A., Corsonello, A., Bernabei, R., et al. (2014) · European journal of internal medicine · doi:10.1016/j.ejim.2013.08.709 · Cited by 76 · see citing works
“The incidence of complications expected during the hospital stay is higher than that of the middleaged population, and multimorbidity, geriatric syndromes, and social and economic conditions may represent relevant factors influencing LOS [6–8].”
BackgroundA three‐goal model for patients with multimorbidity: A qualitative approach
Vermunt, N., Harmsen, M., Elwyn, G., Westert, G., Burgers, J., Rikkert, M. O. O., & Faber, M. (2017) · Health Expectations · doi:10.1111/hex.12647 · Cited by 72 · see citing works
Telemedicine interventions for older adults: A systematic review
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Developing dementia-capable health care systems: a 12-step program.
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“However, the principles of measuring disease complexity are important for future development of guidelines for managing complexity in practice.(73,74) Patient-centered care aims to extend care beyond diseasemanagement to incorporate its lived reality and the goals, values, and priorities of patients and families.”
BackgroundArcher, N., Keshavjee, K., Demers, C., & Lee, R. Y. (2014) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2014.01.005 · Cited by 59 · see citing works
Interpreting Treatment Effects From Clinical Trials in the Context of Real-World Risk Information
O’Hare, A. M., Hotchkiss, J. R., Tamura, M. K., Larson, E. B., Hemmelgarn, B. R., Batten, A., Do, T. P., & Covinsky, K. E. (2014) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2013.13328 · Cited by 67 · see citing works
Franchi, C., Tettamanti, M., Pasina, L., Djignefa, C. D., Fortino, I., Bortolotti, A., Merlino, L., & Nobili, A. (2014) · European Journal of Clinical Pharmacology · doi:10.1007/s00228-013-1621-6 · Cited by 61 · see citing works
Cohen, J., Blustein, J., Weinstein, B., Dischinger, H., Sherman, S. E., Grudzen, C., & Chodosh, J. (2017) · Journal of The American Geriatrics Society · doi:10.1111/jgs.14860 · Cited by 60 · see citing works
Kuluski, K., Peckham, A., Gill, A., Gagnon, D., Wong-Cornall, C., McKillop, A., Parsons, J. G. M., & Sheridan, N. (2019) · International Journal of Integrated Care · doi:10.5334/ijic.4655 · Cited by 66 · see citing works
Lundby, C., Graabæk, T., Ryg, J., Søndergaard, J., Pottegård, A., & Nielsen, D. S. (2019) · British Journal of Clinical Pharmacology · doi:10.1111/bcp.13861 · Cited by 63 · see citing works
“Like previous literature [17,18], this review found that HCPs may deviate from engaging in deprescribing activities due to low self-assurance [25–32].”
BackgroundMethodBurden of Multiple Chronic Conditions among Patients with Urological Cancer
Garg, T., Young, A., Kost, K. A., Danella, J., Larson, S. L., Nielsen, M., & Kirchner, L. (2018) · Journal of Urology · doi:10.1016/j.juro.2017.08.005 · Cited by 57 · see citing works
“Corroborating this fact, data from interviews with primary care physicians suggest that 1 potential barrier to appropriate care in complex patients may include specialist focus on a single disease and failure to incorporate other chronic conditions in treatment decisions.(17) Our findings add to and expand the limited…”
Grant, R. W., Adams, A. S., Bayliss, E. A., & Heisler, M. (2013) · Healthcare · doi:10.1016/j.hjdsi.2013.07.008 · Cited by 57 · see citing works
Geriatric management of older patients with multimorbidity
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van de Pol, M. V. D., Fluit, C., Lagro, J., Slaats, Y. H. P., Rikkert, M. O., & Lagro-Janssen, A. (2017) · Gerontology & Geriatrics Education · doi:10.1080/02701960.2016.1276014 · Cited by 53 · see citing works
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“They are too disease-speci fi c. 38 4.”
BackgroundThe role of comorbidities in patients’ hypertension self-management
Fix, G., Cohn, E., Solomon, J., Cortes, D., Mueller, N. M., Kressin, N., Borzecki, A., Katz, L., & Bokhour, B. G. (2014) · Chronic Illness · doi:10.1177/1742395313496591 · Cited by 52 · see citing works
“Providers recognize the complexity of managing patients with multimorbidities and worry about patients’ abilities to adhere to complicated regimens.(32) Our findings have implications for how to best support hypertension self-management in patients with comorbidities and suggest the need for novel approaches addressin…”
BackgroundMedication Overload: America's Other Drug Problem
Garber, J., & Brownlee, S. (2019) · doi:10.46241/li.wouk3548 · Cited by 50 · see citing works
Polypharmacy in Home Care in Europe: Cross-Sectional Data from the IBenC Study
Giovannini, S., der Roest, H. G. V., Carfì, A., Finne-Soveri, H., Garms-Homolová, V., Declercq, A., Jónsson, P., van Hout, H. V., Vetrano, D., Gravina, E. M., et al. (2018) · Drugs & Aging · doi:10.1007/s40266-018-0521-y · Cited by 50 · see citing works
Patient Self-Defined Goals: Essentials of Person-Centered Care for Serious Illness
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“Goal-oriented care(14) promotes the use of self-defined health goals in decision-making and assists providers in managing multiple often conflicting, disease-specific guidelines and an individual’s ideal state of health.(15) Palliative Care guidelines,(16) preferred practices,(17) and a recent Institute of Medicine re…”
BackgroundHow GPs value guidelines applied to patients with multimorbidity: a qualitative study
Luijks, H., Lucassen, P. L., van Weel, C., Loeffen, M. J., Lagro-Janssen, A. L. M., & Schermer, T. R. (2015) · BMJ Open · doi:10.1136/bmjopen-2015-007905 · Cited by 43 · see citing works
“This suggestion, raised by participants in our study, finds support in the literature.(31) 40 A new proposal from this study is to make more use of post-academic trainings focused on multimorbidity.”
BackgroundResultColloca, G., Tosato, M., Vetrano, D., Topinková, E., Fialová, D., Gindin, J., der Roest, H. G. V., Landi, F., Liperoti, R., Bernabei, R., et al. (2012) · PLoS ONE · doi:10.1371/journal.pone.0046669 · Cited by 46 · see citing works
Patterns of Chronic Conditions and Their Association With Visual Impairment and Health Care Use.
Zheng, D., Christ, S., Lam, B. L., Feaster, D. J., McCollister, K., & Lee, D. J. (2020) · JAMA ophthalmology · doi:10.1001/jamaophthalmol.2020.0052 · Cited by 45 · see citing works
Schuttner, L., Sherlock, S. H., Simons, C. E., Johnson, N. L., Wirtz, E. R., Ralston, J. D., Rosland, A.-M. M., Nelson, K. M., & Sayre, G. G. (2022) · Journal of General Internal Medicine · doi:10.1007/s11606-022-07533-1 · Cited by 57 · see citing works
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Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions
Ouellet, G. M., Ouellet, J. A., & Tinetti, M. E. (2018) · Therapeutic Advances in Drug Safety · doi:10.1177/2042098618791371 · Cited by 53 · see citing works
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“This has been further echoed in qualitative studies reporting GPs’ frustration with fee-for-service reimbursement systems that fail to acknowledge the complexities of care for patients with multiple chronic conditions [58,59].”
BackgroundMultimorbidity research challenges: where to go from here?
Caughey, G., & Roughead, E. (2011) · Journal of Comorbidity · doi:10.15256/joc.2011.1.9 · Cited by 41 · see citing works
Vermunt, N. P. C. A., Elwyn, G. J., Westert, G. P., Harmsen, M., Rikkert, M. G. M. O., & Meinders, M. J. (2019) · BMC Family Practice · doi:10.1186/s12875-019-0966-z · Cited by 37 · see citing works
“Health-related goals arise not only from health but also from other dimensions such as social context or wellbeing [1, 13, 14, 51].”
BackgroundRieckert, A., Sommerauer, C., Krumeich, A. J. S. M., & Sönnichsen, A. C. (2018) · BMC Family Practice · doi:10.1186/s12875-018-0789-3 · Cited by 50 · see citing works
“This challenge results from the many care components that need to be considered in a limited consultation time [4] in addition to the fact that easily accessible information on appropriate treatment in multimorbidity is lacking [3].”
BackgroundInfluentialClemson, L., Mackenzie, L., Roberts, C., Poulos, R., Tan, A. C. W., Lovarini, M., Sherrington, C., Simpson, J., Willis, K., Lam, M., et al. (2017) · Implementation Science · doi:10.1186/s13012-016-0529-9 · Cited by 39 · see citing works
“This leaves a huge gap of missed opportunity [7, 8].”
BackgroundPloeg, J., Yous, M., Fraser, K. D., Dufour, S. P., Baird, L. G., Kaasalainen, S., McAiney, C. A., & Markle‐Reid, M. (2019) · BMC Geriatrics · doi:10.1186/s12877-019-1345-2 · Cited by 51 · see citing works
“difficulty in managing patients with MCC with limited consultation time [21, 23]; (b) included limited consideration of the interactions between conditions [21]; and (c) encountered conflicts between their own and patient goals [23].”
BackgroundBerry, A. B. L., Lim, C. Y., Hartzler, A., Hirsch, T., Ludman, E., Wagner, E., & Ralston, J. (2017) · Conference on Designing Interactive Systems · doi:10.1145/3064663.3064669 · Cited by 37 · see citing works
“First, providers find care guidelines difficult to navigate for patients with MCC because care guidelines for one condition may conflict with guidelines for another condition [10].”
BackgroundSinnige, J., Korevaar, J. C., van Lieshout, J., Westert, G. P., Schellevis, F., & Braspenning, J. C. C. (2016) · British Journal of General Practice · doi:10.3399/bjgp16x685681 · Cited by 42 · see citing works
How to ask: Older adults’ preferred tools in health outcome prioritization
Case, S. M., Fried, T., & O’Leary, J. (2012) · Patient Education and Counseling · doi:10.1016/j.pec.2012.11.010 · Cited by 37 · see citing works
“For finding time to use tools, primary care physicians already feel overburdened and may not realistically be able to include using tools in an already busy schedule [35].”
BackgroundSelf-citationBauler, S., Jacquin-Courtois, S., Haesebaert, J., Luaute, J., Coudeyre, E., Feutrier, C., Allenet, B., Decullier, E., Rode, G., & Janoly-Dumenil, A. (2014) · European Neurology · doi:10.1159/000362718 · Cited by 36 · see citing works
Quinn, K. G., Sanders, C., & Petroll, A. E. (2017) · AIDS Education and Prevention · doi:10.1521/aeap.2017.29.1.62 · Cited by 37 · see citing works
Herzog, A., Gaertner, B., Scheidt-Nave, C., & Holzhausen, M. (2015) · BMC Family Practice · doi:10.1186/s12875-015-0249-2 · Cited by 36 · see citing works
“The need for this has been emphasized especially for aging populations with complex care needs and the need for specialized services such as geriatric or palliative care [30-32].”
BackgroundMultimorbidity, frailty and chronic obstructive pulmonary disease
Holland, A. E., Harrison, S. L., & Brooks, D. (2016) · Chronic Respiratory Disease · doi:10.1177/1479972316670104 · Cited by 35 · see citing works
“Family physicians described poor communication and lack of care coordination across services, concerns regarding the ability of patients to adhere to complex treatment regimens, difficulty quantifying the harms and benefits of guidelinedirected care, concerns regarding adverse events when following multiple guidelines…”
BackgroundLiu, P. L., Cohen, H. J., Fillenbaum, G. G., Burchett, B. M., & Whitson, H. E. (2016) · Gerontology and Geriatric Medicine · doi:10.1177/2333721415623495 · Cited by 33 · see citing works
Hansen, H., Pohontsch, N., van den Bussche, H., Scherer, M., & Schäfer, I. (2015) · BMC Family Practice · doi:10.1186/s12875-015-0286-x · Cited by 35 · see citing works
“One barrier was the interaction with specialists [18].”
BackgroundCare coordination and provider stress in primary care management of high-risk patients
Okunogbe, A., Meredith, L. S., Chang, E. T., Simon, A., Stockdale, S. E., & Rubenstein, L. V. (2017) · Journal of General Internal Medicine · doi:10.1007/s11606-017-4186-8 · Cited by 39 · see citing works
Yu, X., Qian, Y., Zhang, Y.-D., Chen, Y., & Wang, M. (2024) · Geriatric Nursing · doi:10.1016/j.gerinurse.2024.07.005 · Cited by 34 · see citing works
"It's good to know you're not a stranger every time"
Berry, A. B. L., Lim, C. Y., Hartzler, A., Hirsch, T., Ludman, E., Wagner, E., & Ralston, J. (2017) · Proc. ACM Hum. Comput. Interact. · doi:10.1145/3134658 · Cited by 34 · see citing works
“CSCW, Article 23, Publication date: November 2017 toward single chronic conditions, and guidelines for one condition may conflict with guidelines for other conditions [26].”
BackgroundInter‐practice variation in polypharmacy prevalence amongst older patients in primary care
Sinnige, J., Braspenning, J., Schellevis, F., Hek, K., Stirbu, I., Westert, G. P., & Korevaar, J. C. (2016) · Pharmacoepidemiology and Drug Safety · doi:10.1002/pds.4016 · Cited by 34 · see citing works
Chronic disease management: Improving care for people with osteoarthritis
Brand, C. A., Ackerman, I. N., & Tropea, J. (2014) · Best Practice & Research Clinical Rheumatology · doi:10.1016/j.berh.2014.01.011 · Cited by 35 · see citing works
Emerging models of care for individuals with multiple chronic conditions
Savitz, L. A., & Bayliss, E. A. (2021) · Health Services Research · doi:10.1111/1475-6773.13774 · Cited by 32 · see citing works
Nicosia, F. M., Spar, M. J., Stebbins, M. R., Sudore, R. L., Ritchie, C. S., Lee, K. P., Rodondi, K., & Steinman, M. A. (2019) · Journal of General Internal Medicine · doi:10.1007/s11606-019-05463-z · Cited by 41 · see citing works
Martinsson, G., Fagerberg, I., Gustin, L. W., & Lindholm, C. (2012) · BMC Psychiatry · doi:10.1186/1471-244x-12-197 · Cited by 26 · see citing works
“Although the particular knowledge that geriatricians acquire is vital in providing older persons with adequate treatment and care, health care personnel tend to prefer interdisciplinary teams comprising different medical specialties when treating and caring for older persons with or without mental disorders [21,22].”
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Therapeutic Conflicts in Emergency Department Patients with Multimorbidity: A Cross-Sectional Study
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“[10–13] When the recommended therapy for treating one disease is contraindicated in the presence of another concurrent medical condition, this further limits the usefulness of clinical practice guidelines.”
MethodLohr, R. H., West, C., Beliveau, M., Daniels, P., Nyman, M. A., Mundell, W. C., Schwenk, N., Mandrekar, J., Naessens, J., & Beckman, T. (2013) · Mayo Clinic proceedings · doi:10.1016/j.mayocp.2013.08.013 · Cited by 29 · see citing works
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“of their recommendations to multimorbid patients [12-14].”
Molino, C. D. G. R. C., Chocano-Bedoya, P. O., Sadlon, A., Theiler, R., Orav, E. J., Vellas, B. J., Rizzoli, R., Kressig, R. W., Kanis, J. А., Guyonnet, S., et al. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-051881 · Cited by 28 · see citing works
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“Number with COPD or asthma, n (%) 382 (51) 388 (49) Number of COPD or asthma reviews, median (IQR), n 1.”
BackgroundCaughey, G., Tait, K., Vitry, A., & Shakib, S. (2017) · Patient Preference and Adherence · doi:10.2147/ppa.s118836 · Cited by 28 · see citing works
“Outcomes data on treatment strategies in this population and alternative guidelines will help to improve decision-making.(9) The US clinicians have also highlighted the importance of assessing a patient’s function, support networks and evidence of”
BackgroundMethodInfluential
- Authors
- Fried, T. R., Tinetti, M. E., & Iannone, L.
- Affiliations
- Yale University (US)
- Venue
- Archives of Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2010-09-13
- Volume
- 171
- Issue
- 1
- Pages
- 75-80
- ISSN
- 0003-9926 (ISSN-L)
- PMC
- PMC3021478
- OpenAlex
- W2012018261
- Cited by
- 236
- References
- 28
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 7 · 2023: 11 · 2022: 12 · 2021: 10 · 2020: 15 · 2019: 24 · 2018: 15 · 2017: 22 · 2016: 22 · 2015: 15 · 2014: 23 · 2013: 18 · 2012: 24
- FWCI
- 12.37
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Archives of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Yale University (P30AG21342)
- National Institutes of Health
- National Institute on Aging (K24AG028443, P30 AG21342, P30AG021342)
- Topics
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
- Keywords
- treatment decision-making, older adults, multimorbidity, primary care providers, guideline-directed care, medication adherence, benefits and harms, shared decision-making, barriers to decision-making, reimbursement, clinician beliefs
- MeSH terms
- Workforce, Adult, Aged, Chronic Disease, Connecticut, Decision Making, Female, Goals, Hospitals, University, Humans, Male, Middle Aged, Nurse Practitioners, Patient Compliance, Practice Patterns, Physicians', Physician Assistants, Primary Health Care, Residence Characteristics, United States, Comorbidity, Focus Groups, Narration, Qualitative Research, Medication Adherence, Physicians, Primary Care
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