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Consensus-based priority setting for elderly NSTEMI patients with multi-morbidity

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.

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Consensus-based priority setting for elderly NSTEMI patients with multi-morbidity

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  1. Consensus-based priority setting for elderly NSTEMI patients with multi-morbidity NiklasEkerstad, MD Rurik Löfmark, MD Per Carlsson, Professor National Centre for Priority Setting in Health Care, Sweden

  2. Background - Demography Statistics Sweden. Population projection for Sweden 2004-2050

  3. 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

  4. 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)

  5. 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

  6. Background – Cardiologists´attitudes to suggested ways of improving clinical priority setting for elderly NSTEMI patients with multi-morbidity Ekerstad, N., Löfmark, R., Carlsson, P. Elderly with Multimorbidity and Acute Cardiac Disease: Doctors´ Views on Decision-Making. Accepted 091015. Scand J Public Health

  7. 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

  8. Background – Proposed description of the needs of elderly patients with multi-morbidity

  9. Background – Proposed categorization of the needs of elderly NSTEMI patients with multi-morbidity High CVR Low CVR CM+ CM- CM+ CM- CFS+ CFS- CFS+ CFS- CFS+ CFS- CFS+ CFS- I II III IV V VI VII VIII CVR = Cardiovascular risk CM = Co-morbidity CFS = Clinical Frailty Scale

  10. Background – Tentative relative ranking of the categories regarding coronary angiography from a theoretical standpoint High cardiovascular risk Low cardiovascular risk VIII Medium-high rank VII Low rank VI Low rank V Very low rank IV High rank III Low-medium rank II Low-medium rank I Low rank

  11. 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.

  12. 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

  13. Methods • Selection process of experts • A questionnaire study • Intra class correlation test

  14. Results of the interimistic analysis (n=28) – Validation of the selected cases “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)

  15. 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.

  16. Results of the interimistic analysis – Comparisons between different sources of rankings: guidelines and experts High cardiovascular risk Low cardiovascular risk

  17. Results of the interimistic analysis (n=28) – Estimated relevance of the model´s components

  18. 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: disease-specific 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.

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