Caring for Patients with Multiple Chronic Conditions

Multimorbidity, the coexistence of multiple chronic conditions, is common among all adults receiving healthcare and the norm among older adults. Almost 15 years ago, we raised concerns about the limitations of disease-focused, guideline-based medication prescribing (and the randomized clinical trials that inform such prescribing) for older adults with multimorbidity.^1,2 At that time we noted nine limitations of such care: 1) uncertain applicability of results observed in younger study participants without multimorbidity to older adults with multimorbidity; 2) inadequacy of prescribing based on survival or disease-specific outcomes for patients with competing risks from multiple diseases and for whom quality-of-life and functional status may take priority over other outcomes; 3) the difficulty of identifying harms or benefits of medications we expect patients to take over many years from trials lasting only a few months to years; 4) lack of attention to potential harms of following individual disease recommendations in the face of multiple coexisting conditions; 5) diminishing amount of benefit, and increasing burden, resulting from adherence to guidelines for multiple conditions; 6) inattention to time to treatment benefit in the context of limited life expectancy; 7) insufficient recognition of tradeoffs between better short term quality-of-life without treatment vs. long term benefits of treatment; 8) risk of drug-drug and disease-drug interactions when following multiple guidelines; and 9) lack of methods for incorporating patients’ preferences and priorities into guidelines.

Fifteen years ago we concluded that, “The proliferation of multidrug regimens demands that we consider health priorities as well as the marginal benefit and harm associated with all medications when translating disease guidelines into prescribing decisions…Such an evolution from a disease-driven to a patient-driven focus requires an investment in research and changes in the development of guidelines, in the measurement of quality, and in clinical decision making.” ² That statement remains as relevant today, if not more so, as the numbers of both persons with multimorbidity and medications to treat them grow.

There has been some progress. Although not limited to patients with multimorbidity, the Choosing Wisely campaign has advocated for avoidance of unnecessary treatments. While trial enrollees continue to be healthier than clinical populations,³ more older adults with multiple chronic conditions participate in trials. The National Institutes of Health encourages the inclusion of participants across the lifespan, including those with multimorbidity. Recent advances in the development of guidelines have improved their relevance for persons with multimorbidity. Several guidelines now directly address multimorbidity.^4–6 Some guidelines acknowledge uncertainty of benefit and the importance of avoiding harms. One example is the American Geriatrics Society diabetes guideline that recommends higher target hemoglobin A1C levels and prioritizes avoiding hypoglycemia in older adults.⁷ Acknowledgement of the importance of de-prescribing unnecessary medications is approaching mainstream. ⁸ Guiding principles for the care of older adults with multimorbidity emphasize the importance of focusing on patient and family preferences, interpreting available evidence, considering prognosis and treatment regimen complexity, and optimizing medications based on the person, not just their individual diseases.⁹

Despite this progress, guidelines continue to exist largely in silos that focus on individual diseases. While tools for helping people identify their goals and preferences are available, they are not yet routinely integrated into clinical decision-making, except perhaps at the end-of-life. And even when clinicians elicit patients’ goals and preferences, they struggle translating them into clinical decisions. Despite the uncertainty of net benefit of many medications for older adults with multimorbidity, clinicians and patients are cajoled to “get with the guidelines.” Measures on which quality and value-based payments are based remain largely focused on individual diseases. While some groups advocate replacing disease-focused metrics with more patient-centered metrics, progress is slow.

Despite incentives that continue to support medication decision-making aligned with disease-focused guidelines rather than with patient priorities, there are things that clinicians can do today. A good starting point for such decision-making is understanding, acknowledging, and communicating the uncertainty of net benefit of many medications in older adults with multimorbidity.⁹ Uncertainty means there is no one best approach, thus opening the door to filtering treatment options through the lens of each patient’s health priorities. Clinicians should become familiar with and use the tools shown in the Table to ascertain these priorities.¹⁰ Together, the clinician and patient should consider likely prognosis and health trajectory, the balance of benefit versus harm, and the outcomes (often functional) that matter most to the patient when deciding whether to start, continue, or stop any medication.⁹ Is the potential benefit of the medication worth the potential harm and burden and is it likely to result in the outcomes that matter to the patient?

Table.

Clinical Tools to Support Decision-making for Older Adults with Multiple Chronic Conditions

Clinical issue	Tools
Identifying patients’ health priorities and incorporating these priorities into clinical decision-making	For persons with multiple chronic conditions - Guide and Manual for Identifying Patients’ Health Priorities and other tools for patient priorities-aligned decision-making. Available at patientprioritiescare.org. Accessed 11/16/2018. For persons with serious illness - Serious illness conversation guide. Available at: https://www.ariadnelabs.org/areas-of-work/serious-illness-care/resources/#Downloads&%20Tools. Accessed 11/16/2018. - Prepare for your care. Available at www.prepareforyourcare.org. Accessed 11/16/2018.
Determining prognosis and health trajectory	ePrognosis. University of California. Available at https://eprognosis.ucsf.edu. Accessed 11/16/2018.
Deprescribing	Deprescribing guidelines and algorithms. Available at: https://deprescribing.org/resources/deprescribing-guidelines-algorithms. Accessed 11/16/2018.

Every clinician, whether a generalist or a specialist, should consider the total burden of a patient’s medication regimen, not just the subset of medications they prescribed. Each clinician who prescribes medications is responsible for the effect of all medications on that patient, including medications prescribed by other clinicians. We care for patients, not diseases, and must be willing to work collaboratively with patients and other clinicians when perspectives differ, remembering that there is no one best answer for patients with multimorbidity. Aligning care with patients’ priorities, even if this means not following guideline recommendations, is the core of patient-centered care for persons with multimorbidity. This requires that clinicians be proficient in de-prescribing and in patient priorities-based decision-making, essential skills in caring for the growing population of adults, particularly older adults, with multiple chronic conditions.