Transcript Consensus-based priority setting for frail elderly NSTEMI

Consensus-based priority setting
for elderly NSTEMI patients with
multi-morbidity
Niklas Ekerstad, MD
Rurik Löfmark, MD
Per Carlsson, Professor
National Centre for Priority Setting in Health Care, Sweden
Background - Demography
Statistics Sweden. Population projection for Sweden 2004-2050
Background – Key components regarding
medical priority setting in Sweden
• The ethical platform (parliamentary decision)
• The Swedish national model for priority
setting
• Evidence-based guidelines for priority setting
Background - Problems regarding
evidence-based priority setting for elderly
patients with multi-morbidity
• Lack of a relevant description of needs
(severity;potential effect of treatment) in terms
of subgrouping (heterogenous population).
• Lack of evidence/limited applicability of
evidence
”Our base of scientific expertise is weakest for the age groups
(75+) that most often receive various types of treatments.”
(The Swedish Council on Technology Assessment in Health
Care)
Background – a critical case
Setting priorities within health care
when the evidence base is weak
- A critical case: Decision-making for
frail elderly with acute cardiovascular
disease and co-morbid conditions
Background – Cardiologists´attitudes to suggested ways
of improving clinical priority setting for elderly
NSTEMI patients with multi-morbidity
300
250
200
Positive
150
Negative
100
50
0
Better
Specific
Local
adherence to
evidenceguidelines for
National
based
the care for
guidelines for guidelines for
multipleheart disease
multiplediseased
diseased
elderly
elderly
More
treatment
studies
including
multiplediseased
elderly
Ekerstad, N., Löfmark, R., Carlsson, P. Elderly with Multimorbidity and Acute Cardiac Disease: Doctors´
Views on Decision-Making. Accepted 091015. Scand J Public Health
Background – Description of the needs of
NSTEMI patients in the national guidelines
AAA
A
B
National guidelines regarding the measure coronary
angiography for NSTEMI patients:
Two categories based on disease-specific risk
(cardiovascular risk)
A - high or medium cardiovascular risk: rank 2
B - low cardiovascular risk: rank 6
Background – Proposed description of the needs
of elderly patients with multi-morbidity
Diseasespecific risk
Comorbidity
Frailty
Background – Proposed categorization of the needs of
elderly NSTEMI patients with multi-morbidity
risk
High Hög/måttlig
CVR
CM+
CM-
CM+
CFS+
Low Låg
CVR
risk
CM+CM+
CM-
CFS-
CFS+
CFS-
I
II
CFS+
CFS+
III
CFS-
CFS+
CFS+
CFSCFS-
IV
V
VI
CFS-
CVR = Cardiovascular risk
CM = Co-morbidity
CFS = Clinical Frailty Scale
CM-CM-
CFS+
CFS+
VII
CFSCFS-
VIII
Background – Tentative relative ranking of the categories
regarding coronary angiography from a theoretical standpoint
High cardiovascular risk
IV High rank
Low cardiovascular risk
VIII
Medium-high rank
III
Low-medium rank
VII
Low rank
II
Low-medium rank
VI
Low rank
I
Low rank
V
Very low rank
Background – a pilot study regarding
experts´priority setting for elderly NSTEMI
patients with multi-morbidity
• 6 experts validated 15 authentic NSTEMI
cases, each case belonging to one of the eight
model categories, and the model´s components
• For each case the measure coronary
angiography was individually ranked; the
convergence between the experts´rankings was
evidently good.
Objectives
• To re-validate the clinical cases and the model´s
components regarding their relevance
• To evaluate the interrater reliability concerning the
experts´rankings regarding each category
• To compare the rankings of the experts and the
guidelines
• To compare the rankings of the experts with the
model´s suggested relative rankings
Methods
• Selection process of experts
• A questionnaire study
• Intra class correlation test
Results of the interimistic analysis (n=28) –
Validation of the selected cases
Do you consider the cases to
be realistic?
100%
Do you find the cases representative?
100%
90%
80%
70%
80%
60%
60%
40%
20%
No
Yes,partly
Yes
No
50%
Yes,partly
40%
Yes
30%
20%
10%
0%
Were the cases realistic?
0%
Intensive cardiac care
Non-intensive cardiac care
“Very realistic cases! Daily problems!” (A male cardiologist at a small hospital)
“A few of the cases are typically found in non-cardiac care departments. “(A
male cardiologist at a university hospital)
Results of the interimistic analysis – Convergence
among the experts´rankings
Intra-class correlation test, two-way random, absolute:
Single: 0,530 (0,359 – 0,751)
Average: 0,964 (0,931 – 0,986)
The inter-rater reliability was good. The experts´rankings
converge well.
Results of the interimistic analysis – Comparisons between
different sources of rankings: guidelines and experts
Category
Guidelines´
rankings
Experts´
rankings (mean)
IV
2
3.6
Category
Guidelines´
rankings
Experts´
rankings (mean)
VIII
6
3.6
VII
6
8.1
III
2
7.7
II
2
8.2
VI
6
9.5
I
2
10
V
6
10.5
High cardiovascular risk
Low cardiovascular risk
Results of the interimistic analysis (n=28) –
Estimated relevance of the model´s components
Conclusions
• Evidence-based guidelines should be adapted to be applicable
for elderly patients with multi-morbidity.
• Consensus-based experts´ priority setting for elderly patients
with multi-morbidity could be one way to achieve this.
• The tentative model contains three components: diseasespecific risk, comorbidity and frailty
• The interimistic analysis indicates that the model´s
components are considered relevant and that the inter-rater
reliability of the experts´ rankings is good.