Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions.
BACKGROUND
Clinicians are caring for an increasing number of older patients with multiple diseases in the face of uncertainty concerning the benefits and harms associated with guideline-directed interventions. Understanding how primary care clinicians approach treatment decision making for these patients is critical to the design of interventions to improve the decision-making process.


METHODS
Focus groups were conducted with 40 primary care clinicians (physicians, nurse practitioners, and physician assistants) in academic, community, and Veterans Affairs-affiliated primary care practices. Participants were given open-ended questions about their approach to treatment decision making for older persons with multiple medical conditions. Responses were organized into themes using qualitative content analysis.


RESULTS
The participants were concerned about their patients' ability to adhere to complex regimens derived from guideline-directed care. There was variability in beliefs regarding, and approaches to balancing, the benefits and harms of guideline-directed care. There was also variability regarding how the participants involved patients in the process of decision making, with clinicians describing conflicts between their own and their patients' goals. The participants listed a number of barriers to making good treatment decisions, including the lack of outcome data, the role of specialists, patient and family expectations, and insufficient time and reimbursement.


CONCLUSIONS
The experiences of practicing clinicians suggest that they struggle with the uncertainties of applying disease-specific guidelines to their older patients with multiple conditions. To improve decision making, they need more data, alternative guidelines, approaches to reconciling their own and their patients' priorities, the support of their subspecialist colleagues, and an altered reimbursement system.
Fried
Terri R
TR
Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA. terri.fried@yale.edu
Tinetti
Mary E
ME
Iannone
Lynne
L
D000328:Adult; D000368:Aged; D002908:Chronic Disease / Q000628:therapy; D015897:Comorbidity; D003237:Connecticut; D003657:Decision Making; D005260:Female; D017144:Focus Groups; D006040:Goals; D006785:Hospitals, University; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D033262:Narration; D009722:Nurse Practitioners / Q000706:statistics & numerical data*; D010349:Patient Compliance; D010823:Physician Assistants / Q000706:statistics & numerical data*; D058007:Physicians, Primary Care / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data / Q000639:trends; D011320:Primary Health Care / Q000379:methods* / Q000706:statistics & numerical data*; D036301:Qualitative Research; D012111:Residence Characteristics; D014481:United States; D000078329:Workforce