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

Statistics Sweden. Population projection for Sweden 2004-2050

Background - Demography

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

0

50

100

150

200

250

300

Betteradherence to

Nationalguidelines forheart disease

Specificevidence-

basedguidelines for

multiple-diseasedelderly

Localguidelines forthe care for

multiple-diseasedelderly

Moretreatmentstudies

includingmultiple-diseasedelderly

Positive

Negative

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 2B - low cardiovascular risk: rank 6

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

Background – Proposed categorization of the needs of elderly NSTEMI patients with multi-morbidity

Hög/måttlig risk Låg risk

CM+ CM- CM+ CM-

CFS+ CFS- CFS-CFS+ CFS+ CFS- CFS+ CFS-

I II III IV V VI VII VIII

High CVR Low CVR

CM+ CM-

CFS+ CFS+

CM+ CM-

CFS+ CFS+CFS- CFS- CFS- CFS-

CVR = Cardiovascular riskCM = Co-morbidityCFS = Clinical Frailty Scale

Background – Tentative relative ranking of the categories regarding coronary angiography from a theoretical standpoint

High cardiovascular risk

IV High rank

III Low-medium rank

II Low-medium rank

I Low rank

Low cardiovascular risk

VIII Medium-high rank

VII Low rank

VI 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

0%

20%

40%

60%

80%

100%

Were the cases realistic?

Do you consider the cases to be realistic?

No

Yes,partly

Yes

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Intensive cardiac care Non-intensive cardiac care

Do you find the cases representative?

No

Yes,partly

Yes

“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

III 2 7.7

II 2 8.2

I 2 10

Category Guidelines´ rankings

Experts´rankings (mean)

VIII 6 3.6

VII 6 8.1

VI 6 9.5

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: 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.