title: Views of older persons with multiple morbidities on competing outcomes and clinical decision-making.
abstract: OBJECTIVE
  To examine the ways in which older persons with multiple conditions think about potentially competing outcomes in order to gain insight into how processes to elicit values regarding these outcomes can be grounded in the patient's perspective.
  
  
  METHODS
  Qualitative study consisting of purposefully sampled focus groups.
  
  
  METHODS
  Community.
  
  
  METHODS
  Persons aged 65 and older taking five or more medications.
  
  
  METHODS
  Participants were asked their perceptions about whether their illnesses or treatment interacted with each other, goals of their treatment, and decisions to change or stop treatment.
  
  
  RESULTS
  Although participants were largely unaware that treatment of one condition could worsen another, many had experience with adverse medication effects as a competing outcome. Participants initially discussed their conditions in terms of disease-specific outcomes, such as achieving a target blood pressure or lipid level. In the context of decision-making, participants shifted their discussion from disease-specific to global, cross-disease health outcomes, such as survival, preservation of physical function, and relief of symptoms. Despite having some misconceptions regarding the likelihood of these outcomes, they weighed the outcomes against one another to consider what was most important to them. Their preference was for the treatment that would achieve the most desired outcome.
  
  
  CONCLUSIONS
  Because of their experience with adverse medication effects, older persons with multiple morbidities can understand the concept of competing outcomes. The task of prioritizing global, cross-disease outcomes can help to clarify what is most important to seniors who are faced with complex healthcare decisions.
authors.affiliation: Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA. terri.fried@yale.edu
authors.forename: Terri R
authors.initials: TR
authors.lastname: Fried
authors.forename: Sarah
authors.initials: S
authors.lastname: McGraw
authors.forename: Joseph V
authors.initials: JV
authors.lastname: Agostini
authors.forename: Mary E
authors.initials: ME
authors.lastname: Tinetti
mesh_terms: D000368:Aged / Q000523:psychology*; D002755:Choice Behavior; D015897:Comorbidity; D003657:Decision Making; D004358:Drug Therapy; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D017144:Focus Groups; D006801:Humans; D008297:Male; D017060:Patient Satisfaction; D016896:Treatment Outcome; D016312:Treatment Refusal
references.citation: N Engl J Med. 2004 Dec 30;351(27):2870-4
references.pmid: 15625341
references.citation: J Rheumatol. 2004 Mar;31(3):591-3
references.pmid: 14994409
references.citation: J Gerontol A Biol Sci Med Sci. 2002 Feb;57(2):M100-5
references.pmid: 11818428
references.citation: Am J Geriatr Psychiatry. 2006 May;14(5):391-400
references.pmid: 16670243
references.citation: J Clin Epidemiol. 2003 Mar;56(3):221-9
references.pmid: 12725876
references.citation: N Engl J Med. 1981 Dec 10;305(24):1467-9
references.pmid: 7300866
references.citation: J Gen Intern Med. 2006 Apr;21(4):298-303
references.pmid: 16686804
references.citation: J Am Geriatr Soc. 2004 Oct;52(10):1719-23
references.pmid: 15450051
references.citation: J Adv Nurs. 1998 Aug;28(2):345-52
references.pmid: 9725732
references.citation: Arch Intern Med. 2008 Apr 28;168(8):826-31
references.pmid: 18443257
references.citation: Health Psychol. 2005 Jul;24(4S):S57-62
references.pmid: 16045420
references.citation: J Chronic Dis. 1970 Dec;23(7):455-68
references.pmid: 26309916
references.citation: Med Decis Making. 2002 Jul-Aug;22(4):326-39
references.pmid: 12150598
references.citation: JAMA. 2004 Nov 24;292(20):2516-8
references.pmid: 15562133
references.citation: BMJ. 1995 Jul 29;311(7000):299-302
references.pmid: 7633241
references.citation: N Engl J Med. 1988 Dec 29;319(26):1701-7
references.pmid: 3205267
references.citation: JAMA. 2005 Aug 10;294(6):716-24
references.pmid: 16091574
references.citation: Soc Sci Med. 2005 Jul;61(1):133-55
references.pmid: 15847968
references.citation: Med Decis Making. 2005 Jan-Feb;25(1):96-105
references.pmid: 15673587
references.citation: Cochrane Database Syst Rev. 2001;(3):CD001431
references.pmid: 11686990
references.citation: J Am Geriatr Soc. 1999 Feb;47(2):227-30
references.pmid: 9988295
references.citation: Ann Intern Med. 2005 Aug 16;143(4):293-300
references.pmid: 16103473
references.citation: Ann Fam Med. 2003 May-Jun;1(1):15-21
references.pmid: 15043175
references.citation: J Am Geriatr Soc. 1995 Nov;43(11):1214-21
references.pmid: 7594154
references.citation: Arch Intern Med. 2008 Apr 28;168(8):820-5
references.pmid: 18443256
references.citation: J Gen Intern Med. 2005 Jun;20(6):531-5
references.pmid: 15987329