Caring for Patients With Multiple Chronic Conditions

Multimorbidity, the coexistence of multiple chronic conditions, is common among all adults receiving health care and the norm among older adults. Almost 15 years ago, we raised concerns about the limitations of disease-focused, guideline-based medication prescribing (and the randomized clinical trials that inform it) for older adults with multimorbidity (1, 2). At that time, we noted the following 9 limitations of such care: Results observed in younger study participants without multimorbidity may not apply to older adults with multimorbidity, prescribing based on survival or disease-specific outcomes may be inadequate for patients with competing risks from multiple diseases and whose quality of life and functional status may take priority over other outcomes, it may be difficult to identify harms or benefits of medications that we expect patients to receive over many years on the basis of trials lasting only a few months or years, attention to the potential harms of following individual disease recommendations in the face of multiple coexisting conditions may be lacking, adhering to guidelines for multiple conditions may diminish benefits and increase burdens, the time to treatment benefit in the context of limited life expectancy may not be considered, the tradeoffs between better short-term quality of life without treatment and the long-term benefits of treatment may not be recognized, following multiple guidelines creates risk for drugdrug and diseasedrug interactions, and methods for incorporating patients' preferences and priorities into guidelines are not available. We concluded that The proliferation of multidrug regimens demands that we consider health priorities as well as the marginal benefit and harm associated with all medications when translating disease guidelines into prescribing decisions . Such an evolution from a disease-driven to a patient-driven focus requires an investment in research and changes in the development of guidelines, in the measurement of quality, and in clinical decision making (2). That statement remains as relevant today as it was then, if not more so, because both persons with multimorbidity and the medications to treat them have increased. There has been some progress. Although not limited to patients with multimorbidity, the Choosing Wisely campaign has advocated for avoidance of unnecessary treatments. Trial enrollees continue to be healthier than clinical populations (3), but an increased number of older adults with multiple chronic conditions are participating. The National Institutes of Health encourages the inclusion of participants across the lifespan, including those with multimorbidity. Recent advances in the development of guidelines have increased their relevance for persons with multimorbidity, and several guidelines now directly address this subject (46). Some guidelines acknowledge the uncertainty of benefit and the importance of avoiding harms; for example, a diabetes guideline from the American Geriatrics Society recommends higher target hemoglobin A1c levels and prioritizes avoiding hypoglycemia in older adults (7). Acknowledging the importance of deprescribing unnecessary medications is nearly mainstream (8). Guiding principles for the care of older adults with multimorbidity emphasize the importance of focusing on patient and family preferences; considering the prognosis and complexity of the treatment regimen when interpreting available evidence; and optimizing medications on the basis of the person, not just his or her individual diseases (9). Despite this progress, guidelines continue to exist largely in silos that focus on individual diseases. Tools to help patients identify their goals and preferences are available but not yet routinely integrated into clinical decision making, except perhaps at the end of life. Even when clinicians elicit patients' goals and preferences, they struggle to translate them into clinical decisions. Notwithstanding the uncertain net benefit of many medications for older adults with multimorbidity, clinicians and patients are cajoled to get with the guidelines. Measures that quality- and value-based payments are based on remain largely focused on individual diseases. Although some groups advocate replacing disease-focused metrics with more patient-centered ones, progress is slow. Incentives continue to support aligning medication decision making with disease-focused guidelines rather than patient priorities, but there are things that clinicians can do today. A good starting point for such decision making is understanding, acknowledging, and communicating the uncertain net benefit of many medications in older adults with multimorbidity (9). Uncertainty means that there is no 1 best approach and thus opens the door to filtering treatment options through the lens of each patient's health priorities. Clinicians should become familiar with and use the tools shown in the Table to ascertain these priorities (10). Together, the clinician and patient should consider the probable prognosis and health trajectory, balance of benefit versus harm, and outcomes (which are often functional) that matter most to the patient when deciding whether to start, continue, or stop therapy with any medication (9). Is the potential benefit of the medication worth the potential harm and burden, and is the medication likely to benefit the outcomes that matter to the patient? Table. Clinical Tools to Support Decision Making for Older Adults With Multiple Chronic Conditions Every clinician, whether a generalist or a specialist, should consider the total burden of a patient's medication regimen and not just the subset of medications that he or she has prescribed. Each clinician who prescribes medications is responsible for the effect of all medications on that patient, including those prescribed by other clinicians. We care for patients, not diseases. We must be willing to work collaboratively with patients and other clinicians when perspectives differ, remembering that there is no 1 best answer for patients with multimorbidity. Aligning care with patients' priorities, even if this means not following guideline recommendations, is the core of patient-centered care for persons with multimorbidity. It requires that clinicians be proficient in deprescribing and decision making based on patient priorities, essential skills in caring for the growing population of adults (and particularly older adults) with multiple chronic conditions.