Development of a Tool for Eliciting Patient Priority from Among Competing Cardiovascular Disease, Medication‐Symptoms, and Fall Injury Outcomes

Abstract

OBJECTIVES-To develop a choice task for eliciting priorities in the face of competing cardiovascular disease (CVD) outcomes, medication-related symptoms, and fall injuries. DESIGN-Conjoint analysis. SETTING-Senior housing site.PARTICIPANTS-Convenience sample of 15 senior housing residents for the pretest, 13 residents for the pilot test. MEASUREMENTS-The final task included 11 sets of choices. In each, one option optimized the risk of one or two of the three outcomes at the expense of the other(s); the second option did the reverse. Relative importance scores for CVD, fall injury, and medication-symptom outcomes were calculated. Reliability was assessed for two administrations using intraclass correlations (ICCs). Wilcoxon rank sum tests were used to evaluate order effects. RESULTS-The Conflict of Interest:The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that none of the authors have any financial or any other kind of personal conflicts with this manuscript. This study was supported by Grant R21 AG027078 and Grant P30AG21342 from the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine, both from the National Institute on Aging. Dr. Foody was supported by National Institutes of Health, NIA Career Development Award K08-AG20623-01 and an NIA/Hartford Foundation Fellowship in Geriatrics. Dr. Fraenkel was supported by K23 AR048826 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Fried was supported by K02 AG20113 from the NIA. 0.84, 0.72, and 0.84, respectively. Whether CVD or fall injuries appeared first had no effect on scores. NIH Public AccessCONCLUSION-Preliminary evidence of comprehensibility and reliability supports using the choice task to determine whether individuals' priorities differ in the face of competing outcomes.Keywords patient priorities; competing health outcomes; clinical decision-makingIn patients with multiple health conditions, the treatment of one condition may worsen another one. Clinical decision-making should incorporate patients' priorities when faced with these potentially competing health outcomes. 1 The older adult with coexisting hypertension and fall risk represents a common clinical situation for which a method for eliciting patient priorities would be useful.Falls and hypertension are both major causes of disability. The 3-year incidence of all nonfatal cardiovascular events in older adults with hypertension is 16.2%, 2 similar to the incidence of serious fall injury in elderly persons with fall risk. The co-occurrence of hypertension and fall risk, therefore, can serve as a model for studying health priorities in the face of potentially competing health conditions, although eliciting priorities raises concerns about well-known challenges, including reluctance to articulate feelings about outcomes not yet experienced, the tendency to select all outcomes as equally important, and change in priorities with time and changing health status. 12,13 Limited...

Health Outcome Priorities Among Competing Cardiovascular, Fall Injury, and Medication‐Related Symptom Outcomes

“…Of the 233 screened individuals who otherwise met criteria, 43 residents (18.4%) were excluded during the home interview because they could not select an option when presented with a simplified choice, suggesting that they did not comprehend the choice task. 35 Two other individuals failed to complete the choice task and were thus excluded. Of the remaining 188 residents, 123 (65%) agreed to participate and were enrolled.…”

“…40,41 The development and administration of this choice task has been previously described and briefly summarized. 35 The choice task in-cluded 11 sets of choices to enhance reliability without overburdening participants. Each set consisted of a pair of options that displayed risk for each health outcome under conditions corresponding to use or nonuse of antihypertensive medications.…”

“…The choice task was shown to be reliable and free from order or framing effects. 35,40,41 An example of a choice is shown in Figure 1. The complete choice task with explanatory scripts and all choice sets can be found at http://pepper.med.yale.edu/fall_hypertension_choicetask.…”

General Practitioners’ Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

“…In addition, the older population is heterogeneous. Older people vary widely in their health and function, and in their treatment and health outcome preferences [5–7]. General practitioners (GPs) are at the frontline of providing care for older people, and not surprisingly studies have identified numerous challenges [8, 9].…”

Benefit‐Based Approach to Blood Pressure Control in Older Adults

“…emphasized in support of their view that the appropriate SBP goal for this group should be less than 140 mmHg. Balancing the competing risks between the SBP‐related risk of stroke, heart failure, and other cardiovascular events and the treatment‐related risks, including adverse medication symptoms, falls, and fall‐related injuries, in an individual‐centered approach remains a challenge that merits further research . Results from 2,300 subjects aged 75 and older who are enrolled in the Systolic Pressure Intervention Trial (SPRINT) that is comparing usual (<140 mmHg) with intensive (<120 mmHg) SBP targets (ClinicalTrials.gov, NCT01206062) will help to address important remaining questions, including what should be considered as the optimal, benefit‐based, customized SBP treatment target for the heterogeneous subgroups of the very elderly population.…”