Characteristics of multiple-diseased elderly in Swedish hospital care and clinical guidelines

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Niklas Ekerstad
Annika Edberg
Per Carlsson

Abstract

In Sweden, an expected growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines and priority setting into focus. There are problems, however, in areas where the evidence base is weak and underlying ethical values are controversial. Based on a specified definition of multiple-diseased elderly patients, the aims of this study are: (i) to describe and quantify inpatient care utilisation and patient characteristics, particularly regarding cardiovascular disease and co-morbidity; and (ii) to question the applicability of evidence-based guidelines for these patients with regard to the reported characteristics (i.e. age and co-morbidity), and to suggest some possible strategies in order to tackle the described problem and the probable presence of ageism. We used data from three sources: (a) a literature review, (b) a register study, based on a unique population-based register of inpatient care in Sweden, and (c) a national cost per patient database. The results show that elderly patients with multiple co-morbidities constitute a large and growing population in Swedish inpatient hospital care. They have multiple and complex needs and a large majority have a cardiovascular disease. There is a relationship between reported characteristics, i.e. age and co-morbidity, and limited applicability of evidence-based guidelines, and this can cause an under-use as well as an over-use of medical interventions. As future clinical studies will be rare due to methodological and financial factors, we consider it necessary to condense existing practical-clinical experiences of individual experts into consensus-based guidelines concerning elderly with multi-morbidity. In such priority setting, it will be important to consider co-morbidity and different degrees of frailty

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References

Akner, G. (2004). Multimorbidity in Elderly. Analysis, Management and Proposal for an Integrated Elderly Care Centre. Stockholm: Liber. (English translation via Professor Gunnar Akner’s homepage.)


Alderson, P., Green, S. & Higgins J. P. T (eds.) (2004). Cochrane Reviewers’ Handbook 4.2.1 (updated December 2003). The Cochrane Library, Issue 1. Chichester: John Wiley & Sons Ltd.


Altman, D. G., Schulz, K. F. & Moher, D. for the Consort Group (2001). The revised CONSORT statement for reporting randomised trials: Explanation and elaboration. Annals of Internal Medicine 134(8): 663–694.


American Heart Association Council (2007). Acute coronary care in the elderly, Part 1. Circulation. 115(19): 2549–2569. [Read this article] PMid:17502590


Bierman, A. S. (2004). Coexisting illness and heart disease among elderly Medicare managed care enrollees. Health Care Financing Review 25(4): 105–117.


Bowling, A. (1999). Ageism in cardiology. British Medical Journal 319(7221): 1353–1355.


Bowling, A., Harries, C., Forrest, D. & Harvey, N. (2006). Variations in cardiac interventions: Doctors practices and views. Family Practice 23(4): 427–436. [Read this article] PMid:16611650


Bowling, A. & Iliffe, S. (2006). Which model of successful ageing should be used? Baseline findings from a British longitudinal survey of ageing. Age and Ageing 35(6): 607–614. [Read this article] PMid:16951427


Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, C. & Wu, A. W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. The Journal of the American Medical Association 294(6): 716–724. [Read this article] PMid:16091574


Boyd, C., Weiss, C., Halter, J., Han, K., Ershler, W. & Fried, L. (2007). Framework for evaluating disease severity measures in older adults with comorbidity. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 62(3): 286–295.


Braithwaite, R. S., Concato, J., Chang, C. C., Roberts, M. S. & Justice, A. C. (2007). A framework for tailoring clinical guidelines at the point of care. Archives of Internal Medicine 167(21): 2361–2365. [Read this article] PMid:18039996


Butler, R. N. (1969). Ageism: Another form of bigotry. The Gerontologist 9(4): 243–246.


Cieza, A., Geyh, S., Chatterji, S., Kostanjsek, N., U¨ stu¨ n, B. & Stucki, G. (2006). Identification of candidate categories of the International Classification of Functioning Disability and Health (ICF) for a Generic Core Set based on regression modelling. BMC Medical Research Methodology 6(1): 36. [Read this article] PMid:16872536    PMCid:1569864


Flood, K., Rohlfing, A. & Le, C. V. (2007). Geriatric syndromes in elderly patients admitted to an inpatient cardiology ward. Journal of Hospital Medicine 2(6): 394–400. [Read this article] PMid:18081154


Fortin, M., Dionne, J., Pinho, G., Armirall, J. & Lapointe, L. (2006). Randomized clinical trials: Do they have external validity for patients with multiple comorbidities? Annals of Family Medicine 4(2): 104–108. [Read this article]


Fried, T. R., Bradley, E. H., Towle, V. R. & Allore, H. (2002). Understanding the treatment preferences of seriously ill patients. New England Journal of Medicine 346(14): 1061–1066. [Read this article] PMid:11932474


Green, L. W. & Glasgow, R. E. (2006). Evaluating the relevance, generalization, and applicability of research. Issues in external validation and translation methodology. Evaluation and Health Professions 29(1): 126–153. [Read this article]


Gurner, U. & Thorslund, M. (2001). Helhetssyn behövs i vården av multisviktande äldre. Förslag till förändring av vård- och omsorgsstrukturen i Stockholms län [Overall vision is needed in the care for multiple-diseased elderly]. Läkartidningen 98(21): 2596–2602.


Guyatt, G. H., Haynes, R. B. & Jaeschke, R. Z. (2000). Users’ Guides to the Medical Literature: XXV. Evidence-based medicine: Principles for applying the Users’ Guides to patient care. Evidence-Based Medicine Working Group. The Journal of the American Medical Association 284(10): 1290–1296. [Read this article]


Hoenig, M. R., Doust, J. A., Aroney, C. N. & Scott, I. A. (2006). Early invasive versus conservative strategies for unstable angina & non-STelevation myocardial infarction in the stent era. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD004815. DOI: 10.1002/14651858.CD004815.pub2. [Read this article] PMid:AMBIGUOUS   PMCid:1713211


Jönsson, L. & Gurner, U. (2001). Vad kostar vård och omsorg av äldre multisjuka? Stiftelsen Stockholms Läns Äldrecentrum. [How much do health care and nursing for elderly multiple-diseased cost?] Report 2001:7 (In Swedish).


Karlamangla, A., Tinetti, M., Guralnik, J., Studenski, S., Wetle, T. & Reuben, D. (2007). Comorbidity in older adults: Nosology of impairment, diseases and conditions. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 62(3): 296–300.


KPP-databasen. [The KPP database on cost per patient]. Available on http://stat.skl.se/kppprod/index.htm (Accessed: July 4, 2007).


Lichtman, J. H., Spertus, J. A. & Reid, K. J. (2007). Acute noncardiac conditions and in-hospital mortality in patients with acute myocardial infarction. Circulation 116(17): 1925–1930. [Read this article]


Metha, S. R., Cannon, C. P., Fox, K. A., Wallentin, L., Braunwald, E., Yusuf, S., Boden, W. E., Spacek, R., Widimsky, P., McCullogh, P. A. & Hunt, D. (2005). Routine vs selective invasive strategies in patients with acute coronary syndromes. The Journal of the American Medical Association 293(23): 2908–2917. [Read this article] PMid:15956636


Mitnitski, A., Graham, J. J., Mogilner, A. E. & Rockwood, K. (2002). Frailty, fitness and late-life mortality in relation to chronological and biological age. BMC Geriatrics, 2:1. [Read this article] PMid:11897015    PMCid:88955


National Committee for Quality Assurance (2003). The State of Health Care Quality. Washington, DC: National Committee for Quality Assurance.


Rockwood, K., Mitnitski, A., Song, X., Steen, B. & Skoog, I. (2006). Longterm risks of death and institutionalization of elderly people in relation to deficit accumulation at age 70. Journal of the American Geriatrics Society 54(6): 975–979. [Read this article] PMid:16776795


Rockwood, K., Song, X., MacKnight, C., Bergman, H., Hogan, D. B., McDowell, I. & Mitnitski, A. (2005). A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal 173(5): 489–495. [Read this article] PMid:16129869    PMCid:1188185


Rothwell, P. M. (2005). External validity of randomised controlled trials: ‘to whom do the results of this trial apply?’ Lancet 365(9453): 82–93. [Read this article]


Social- og Helsedepartementet (1997). [Ministry of Health and Social Affairs, Oslo, 1997]. Nya prioriteringar. [New priorities.] NOU 1997:18.


Socialstyrelsen [The National Board of Health and Welfare 2002]. Äldre inom akutmedicin – Inventering av patienter 80 år och äldre på medicinklinik [Emergency Care for Elderly – Survey of Patients 80 years old and older. Report 2002]. Available on www.socialstyrelsen.se (Accessed: June 4, 2006).


Socialstyrelsen. [The National Board of Health and Welfare 2002]. Vård och omsorg om äldre [Care and Nursing for Elderly. Report 2002].


Socialstyrelsen. [The National Board of Health and Welfare 2004]. Vård och omsorg om äldre [Care and Nursing for Elderly. Report 2004].


Socialstyrelsen [The National Board of Health and Welfare 2005]. Patienter i sluten vård 2005 [Patients in Hospital Care. Report 2005].


Socialstyrelsen [National Board of Health and Welfare 2008]. Socialstyrelsens riktlinjer för vård av hjärtsjukdom [The National Board of Health and Welfare’s guidelines for care of heart disease 2008]. Available on www.socialstyrelsen.se (Accessed: June 15, 2008).


Starfield, B. (2006). Threads and yarns: Weavering the tapestry of comorbidity. Annals of Family Medicine 4(2): 101–103. [Read this article]


Statistics Sweden (2004). Population projection for Sweden 2004–2050. Revised population prognosis from Statistics Sweden. Statistical memorandum BE 18 SM 0401. Available on http://www.pubkat.scb.se/statistik/BE/BE0401/2003M00/BE0401_2004A01_SM_BE18SM0401.pdf (Accessed: June 4, 2006).


Swedish Parliament (1997). Regeringsbeslut om prioriteringar i sjukvården (1996/97:SoU14, rskr. 1996/97:186) [Swedish Parliament’s decision on priority setting in the health care 1997].


Taneva, E., Bogdanova, V. & Shtereva, N. (2004). Acute coronary syndrome, comorbidity and mortality in geriatric patients. Annals of the New York Academy of Science 1019(1): 106–110. [Read this article] PMid:15247001


The Swedish Association of Local Authorities and Regions (2005). Statistik om hälso- och sjukvård samt regional utveckling 2005 [Statistics on Health Care and Regional Development]. Report 2005.


The Swedish Council on Technology Assessment in Health Care (2003). Geriatric care and treatment. A systematic compilation of existing scientific literature 2003. Available on http://www.sbu.se (Accessed: June 10, 2006).


Thorslund, M. & Parker, M. G. (2005). Hur mår egentligen de äldre? Läkartidningen 102(43): 3119–3124. (In Swedish, summary in English.)


Tinetti, M. E., Bogardus, S. T. Jr. & Agostini, J. V. (2004). Potential pitfalls of disease-specific guidelines for patients with multiple conditions. New England Journal of Medicine 351(27): 2870–2874. [Read this article]


Tornstam, L. (2006). The complexity of ageism. A proposed topology. International Journal of Ageing and Later Life 1(1): 43–68. [Read this article]


Tornstam, L. (2007). Stereotypes of old people persist. A Swedish ‘‘Facts on Aging Quiz’’ in a 23-year comparative perspective. International Journal of Ageing and Later Life 2(1): 33–59. [Read this article]


Tsevat, J., Dawson, N. V. & Wu, A. W. (1998). Health values of hospitalized patients 80 years or older. The Journal of the American Medical Association 279(5): 371–375. [Read this article]


Wenger, N. K. (2000). The elderly patient with cardiovascular disease. Heart Disease 2(1): 31–61.


WHO. ICF. (2003). A Classification of Functioning, Disability and Health. Short version.