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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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“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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van de Pol, M. H. J., Fluit, C. R. M. G., Lagró, J., Slaats, Y. H. P., Rikkert, M. G. M. O., & Lagro-Janssen, A. L. M. (2016) · Gerontology & Geriatrics Education · doi:10.1080/02701960.2016.1276014 · Cited by 64
Challenges of deprescribing in the multimorbid patient
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“They are too disease-speci fi c. 38 4.”
BackgroundThe role of comorbidities in patients’ hypertension self-management
Fix, G. M., Cohn, E. S., Solomon, J., Cortés, D. E., Mueller, N., Kressin, N. R., Borzecki, A. M., Katz, L. A., & Bokhour, B. G. (2013) · Chronic Illness · doi:10.1177/1742395313496591 · Cited by 55
“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
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
Patient Self-Defined Goals: Essentials of Person-Centered Care for Serious Illness
Schellinger, S. E., Anderson, E., Frazer, M., & Cain, C. (2017) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/1049909117699600 · Cited by 66
“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 45
“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
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
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 61
Onder, G., Marengoni, A., Russo, P., Esposti, L. D., Fini, M., Monaco, A., Bonassi, S., Palmer, K., Marrocco, W., Pozzi, G., et al. (2016) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2015.08.009 · Cited by 44
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
Self-citationMenear, M., Duhoux, A., Roberge, P., & Fournier, L. (2014) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2014.01.013 · Cited by 43
“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
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
“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
“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
“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
“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
“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 47
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
“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
Quinn, K. G., Sanders, C., & Petroll, A. E. (2017) · AIDS Education and Prevention · doi:10.1521/aeap.2017.29.1.62 · Cited by 39
Herzog, A., Gaertner, B., Scheidt-Nave, C., & Holzhausen, M. (2015) · BMC Family Practice · doi:10.1186/s12875-015-0249-2 · Cited by 36
“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
“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
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
“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
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
"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
“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
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
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
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 47
Martinsson, G., Fagerberg, I., Gustin, L. W., & Lindholm, C. (2012) · BMC Psychiatry · doi:10.1186/1471-244x-12-197 · Cited by 26
“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].”
BackgroundDobbs, D., Emmett, C., Hammarth, A., & Daaleman, T. P. (2012) · Research on Aging · doi:10.1177/0164027511423259 · Cited by 30
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
Blozik, E., van den Bussche, H., Gurtner, F., Schäfer, I., & Scherer, M. (2013) · BMC Health Services Research · doi:10.1186/1472-6963-13-352 · Cited by 26
“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
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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
“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
Metadata
- 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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