Rethinking How a Clinician Discusses Management in Older Adults With Multiple Chronic Conditions

ashok-krishnaswamiAs a non-invasive geriatric cardiologist, I am proud of the fact that I spend a large proportion of a clinic visit or hospital consultation speaking with my patients and their families about their medical or procedural management plan(s). I obsess over their understanding of the topic.  I would like patients and families to make the best choice with all the available information. However, I have to honestly state, these discussions thoroughly exhaust me. It is time consuming and often difficult when patients and families do not have the sufficient skillset to comprehend the information. Tools such as pictorial decision aids are now being used to improve comprehension by patients and their families of this shared decision-making process. However, improvements in the implementation of these tools are needed.

Broadly speaking, Cardiology has often focused on single-disease cardiovascular states. However, Geriatric Cardiology welcomes with open arms the complexity of multiple conditions tied to the index cardiac disease. Appropriately, both are tied to value. However, value is defined differently in Geriatric Cardiology. A recent (March 16, 2016) JAMA Cardiology viewpoint addressed the concept of patient value based care. The authors defined value as a simple formula (Value = Health Outcome/ Cost).  From the broader Cardiology perspective, health outcomes are typically mortality, myocardial infarction, stroke; and cost is most often seen as the financial cost. From the Geriatric Cardiology perspective, health outcomes can encompass a myriad of other states. These patient centered outcomes  (“Doc, I want to be able to walk 2-3 blocks everyday, be able to work for another year, to see a favorite football sports team in the super bowl” etc.) are starkly different from the previous ones, in that they prioritize personal patient experience and quality of life. Within this patient centered perspective, cost is considered to include willingness to get labs, diet, exercise, regularly attend clinic, diligently take medication, report adverse reactions, undergo procedures, as well as financial costs.

The wonderful promise of this new formula is its hope for improving the quality of discussions between patients and clinicians. In my opinion, incorporating this formula into a larger, clinical, decision-making framework that includes concepts such as life expectancy assessments, risk scores based on geriatric specific syndromes, lag time to benefit, and competing risks, will further this field greatly by reorganizing our priorities for what is best for the patient on a qualitative and individual level.

By: Ashok Krishnaswami, MD, MAS