title: A tentative consensus-based model for priority setting: an example from elderly patients with myocardial infarction and multi-morbidity.
abstract: BACKGROUND
  In most Western countries the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines into focus. However, such guidelines are difficult to use when the evidence base is weak. Priority setting for frail elderly patients with heart disease illustrates this problem. We have outlined a tentative model for priority setting regarding frail elderly heart patients. The model takes cardiovascular risk, frailty, and comorbidity into account.
  
  
  OBJECTIVE
  Our aim is to validate the model's components. We want to evaluate the inter-rater reliability of the study experts' rankings regarding each of the model's categories.
  
  
  METHODS
  A confidential questionnaire study consisting of 15 authentic and validated cases was conducted to assess the views of purposefully selected cardiology experts (n = 58). They were asked to rank the cases regarding the need for coronary angiography using their individual clinical experience. The response rate was 71%. Responses were analysed with frequencies and descriptive statistics. The inter-rater reliability regarding the experts' rankings of the cases was estimated via an intra-class correlation test (ICC).
  
  
  RESULTS
  The cardiologists considered the clinical cases to be realistic. The intra-class correlation (two-way random, consistency, average measure) was 0.978 (95% CI 0.958-0.991), which denotes a very good inter-rater reliability on the group level. The model's components were considered relevant regarding complex cases of non-ST elevation myocardial infarction. Comorbidity was considered to be the most relevant component, frailty the second most relevant, followed by cardiovascular risk.
  
  
  CONCLUSIONS
  A framework taking comorbidity, frailty, and cardiovascular risk into account could constitute a foundation for consensus-based guidelines for frail elderly heart patients. From a priority setting perspective, it is reasonable to believe that the framework is applicable to other groups of elderly patients with acute disease and complex needs.
authors.affiliation: The Center for Medical Technology Assessment/IMH, Linköping University, Sandbäcksgatan 7, 58183 Linköping, Sweden. niklas.ekerstad@ihs.liu.se
authors.forename: Niklas
authors.initials: N
authors.lastname: Ekerstad
authors.forename: Rurik
authors.initials: R
authors.lastname: Löfmark
authors.forename: David
authors.initials: D
authors.lastname: Andersson
authors.forename: Per
authors.initials: P
authors.lastname: Carlsson
mesh_terms: D000368:Aged; D002318:Cardiovascular Diseases / Q000209:etiology* / Q000517:prevention & control; D015897:Comorbidity; D032921:Consensus; D017023:Coronary Angiography; D003657:Decision Making; D019317:Evidence-Based Medicine; D005260:Female; D016330:Frail Elderly; D006292:Health Priorities; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009203:Myocardial Infarction / Q000150:complications* / Q000175:diagnosis; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D012307:Risk Factors; D011795:Surveys and Questionnaires