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Eidam A, Roth A, Frick E, Metzner M, Lampert A, Seidling HM, Haefeli WE, Bauer JM. Development of an Electronic Tool to Assess Patient Preferences in Geriatric Polypharmacy (PolyPref). Patient Prefer Adherence 2022; 16:1733-1747. [PMID: 35910298 PMCID: PMC9329442 DOI: 10.2147/ppa.s364681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/10/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Medical decision-making in older adults with multiple chronic conditions and polypharmacy should include the individual patient's treatment preferences. We developed and pilot-tested an electronic instrument (PolyPref) to elicit patient preferences in geriatric polypharmacy. PATIENTS AND METHODS PolyPref follows a two-stage direct approach to preference assessment. Stage 1 generates an individual preselection of relevant health outcomes and medication regimen characteristics, followed by stage 2, in which their importance is assessed using the Q-sort methodology. The feasibility of the instrument was tested in adults aged ≥70 years with ≥2 chronic conditions and regular intake of ≥5 medicines. After the assessment with PolyPref, the patients rated the tool with regard to its comprehensibility and usability and assessed the accuracy of the personal result. Evaluators rated the patients' understanding of the task. RESULTS Eighteen short-term health outcomes, 3 long-term health outcomes, and 8 medication regimen characteristics were included in the instrument. The final population for the pilot study comprised 15 inpatients at a clinic for geriatric rehabilitation with a mean age of 80.6 (± 6.0) years, a median score of 28 (range 25-30) points on the Mini-Mental State Examination, and a mean of 11.6 (± 3.6) regularly taken medicines. Feedback by the patients and the evaluators revealed ratings in favor of understanding and comprehensibility of 86.7% to 100%. The majority of the patients stated that their final result summarized the most important aspects of their pharmacotherapy (93.3%) and that its ranking order reflected their personal opinion (100%). Preference assessment took an average of 35 (± 8.5) min, with the instrument being handled by the evaluator in 14 of the 15 participants. CONCLUSION Preference assessment with PolyPref was feasible in older adults with multiple chronic conditions and polypharmacy, offering a new strategy for the standardized evaluation of patient priorities in geriatric pharmacotherapy.
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Affiliation(s)
- Annette Eidam
- Center for Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
- Correspondence: Annette Eidam, Center for Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany, Tel +49 6221-319-1795, Fax +49 6221-319-1505, Email
| | - Anja Roth
- Center for Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Eduard Frick
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany
| | - Michael Metzner
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany
| | - Anette Lampert
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
| | - Jürgen M Bauer
- Center for Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
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Eidam A, Roth A, Lacroix A, Goisser S, Seidling HM, Haefeli WE, Bauer JM. Methods to Assess Patient Preferences in Old Age Pharmacotherapy - A Systematic Review. Patient Prefer Adherence 2020; 14:467-497. [PMID: 32184575 PMCID: PMC7061412 DOI: 10.2147/ppa.s236964] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/14/2020] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The aim of this systematic review was to identify methods used to assess medication preferences in older adults and evaluate their advantages and disadvantages with respect to their applicability to the context of multimorbidity and polypharmacy. MATERIAL AND METHODS Three electronic databases (PubMed, Web of Science, PsycINFO) were searched. Eligible studies elicited individual treatment or outcome preferences in a context that involved long-term pharmacological treatment options. We included studies with a study population aged ≥ 65 years and/or with a mean or median age of ≥ 75 years. Qualitative studies, studies assessing preferences for only two different treatments, and studies targeting preferences for life-sustaining treatments were excluded. The identified preference measurement methods were evaluated based on four criteria (time budget, cognitive demand, variety of pharmacological aspects, and link with treatment strategies) judged to be relevant for the elicitation of patient preferences in polypharmacy. RESULTS Sixty articles met the eligibility criteria and were included in the narrative synthesis. Fifty-five different instruments to assess patient preferences, based on 24 different elicitation methods, were identified. The most commonly applied preference measurement techniques were "medication willingness" (description of a specific medication with inquiry of the participant's willingness to take it), discrete choice experiments, Likert scale-based questionnaires, and rank prioritization. The majority of the instruments were created for disease-specific or context-specific settings. Only three instruments (Outcome Prioritization Tool, a complex intervention, "MediMol" questionnaire) dealt with the broader issue of geriatric multimorbidity. Only seven of the identified tools showed somewhat favorable characteristics for a potential use of the respective method in the context of polypharmacy. CONCLUSION Up to now, few instruments have been specifically designed for the assessment of medication preferences in older patients with multimorbidity. To facilitate valid preference elicitation in the context of geriatric polypharmacy, future research should focus on suitable characteristics of existing techniques to develop new measurement approaches for this increasingly relevant population.
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Affiliation(s)
- Annette Eidam
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
| | - Anja Roth
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
| | - André Lacroix
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
| | - Sabine Goisser
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg69115, Germany
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg69120, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg69120, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg69120, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg69120, Germany
| | - Jürgen M Bauer
- Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg69126, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg69115, Germany
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Muscat DM, Shepherd HL, Hay L, Shivarev A, Patel B, McKinn S, Bonner C, McCaffery K, Jansen J. Discussions about evidence and preferences in real-life general practice consultations with older patients. PATIENT EDUCATION AND COUNSELING 2019; 102:879-887. [PMID: 30578105 DOI: 10.1016/j.pec.2018.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 11/28/2018] [Accepted: 12/02/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To explore how decisions are made in real-life general practice consultations with older patients (65+ years), and examine how general practitioners (GPs) communicate risk and benefit information and evidence, and integrate patient preferences. METHODS Secondary analysis of 20 video-recorded consultations with older patients in Australian primary healthcare settings. Consultations were analysed qualitatively using the Framework method and quantitatively using the Observer OPTION5 scale and the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool. RESULTS Overall, Observer OPTION5 and ACEPP scores were low, with mean total scores of 11.3 (out of 100) and 10.4 (out of 40) respectively. Together with qualitative findings, these results suggest that shared decision-making did not occur, and that healthcare options (including anticipated benefits and risks), evidence and patient preferences were rarely discussed in our sample of consultations with older people. GPs often unilaterally made treatment decisions (usually pharmacotherapy) while patients reverted to a passive decision-making role. CONCLUSION We observed a lack of shared decision-making in our primary care study, with little engagement of older patients in decisions about their health. PRACTICE IMPLICATIONS Training and support tools may be needed to enhance the capacity and self-efficacy of providers and older patients to share healthcare decisions.
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Affiliation(s)
- Danielle Marie Muscat
- University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, Sydney, Australia
| | - Heather L Shepherd
- University of Sydney, Faculty of Science, School of Psychology, Sydney, Australia; University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney, Australia
| | - Louise Hay
- University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney, Australia
| | - Alex Shivarev
- University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney, Australia
| | - Bindu Patel
- University of Sydney, Faculty of Medicine and Health, School of Public Health, Australia; The George Institute for Global Health, University of New South Wales, Australia
| | - Shannon McKinn
- University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, Sydney, Australia
| | - Carissa Bonner
- University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, Sydney, Australia; University of Sydney, Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, Sydney, Australia
| | - Kirsten McCaffery
- University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, Sydney, Australia; University of Sydney, Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, Sydney, Australia
| | - Jesse Jansen
- University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, Sydney, Australia; University of Sydney, Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, Sydney, Australia.
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Jansen J, McKinn S, Bonner C, Irwig L, Doust J, Glasziou P, Bell K, Naganathan V, McCaffery K. General Practitioners' Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study. PLoS One 2017; 12:e0170228. [PMID: 28085944 PMCID: PMC5234831 DOI: 10.1371/journal.pone.0170228] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 12/30/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Primary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs' decision making about primary CVD prevention in patients aged 75 years and older. METHOD 25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used. RESULTS Analysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear. CONCLUSION Older patients receive different care depending on their GP's perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.
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Affiliation(s)
- Jesse Jansen
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
- * E-mail:
| | - Shannon McKinn
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Carissa Bonner
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Les Irwig
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jenny Doust
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Paul Glasziou
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Katy Bell
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Ageing and Alzheimer’s Institute, Concord Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
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Allore H, McAvay G, Vaz Fragoso CA, Murphy TE. Individualized Absolute Risk Calculations for Persons with Multiple Chronic Conditions: Embracing Heterogeneity, Causality, and Competing Events. INTERNATIONAL JOURNAL OF STATISTICS IN MEDICAL RESEARCH 2016; 5:48-55. [PMID: 27076862 PMCID: PMC4827855 DOI: 10.6000/1929-6029.2016.05.01.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Approximately 75% of adults over the age of 65 years are affected by two or more chronic medical conditions. We provide a conceptual justification for individualized absolute risk calculators for competing patient-centered outcomes (PCO) (i.e. outcomes deemed important by patients) and patient reported outcomes (PRO) (i.e. outcomes patients report instead of physiologic test results). The absolute risk of an outcome is the probability that a person receiving a given treatment will experience that outcome within a pre-defined interval of time, during which they are simultaneously at risk for other competing outcomes. This allows for determination of the likelihood of a given outcome with and without a treatment. We posit that there are heterogeneity of treatment effects among patients with multiple chronic conditions (MCC) largely depends on those coexisting conditions. We outline the development of an individualized absolute risk calculator for competing outcomes using propensity score methods that strengthen causal inference for specific treatments. Innovations include the key concept that any given outcome may or may not concur with any other outcome and that these competing outcomes do not necessarily preclude other outcomes. Patient characteristics and MCC will be the primary explanatory factors used in estimating the heterogeneity of treatment effects on PCO and PRO. This innovative method may have wide-spread application for determining individualized absolute risk calculations for competing outcomes. Knowing the probabilities of outcomes in absolute terms may help the burgeoning population of patients with MCC who face complex treatment decisions.
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Affiliation(s)
- Heather Allore
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Gail McAvay
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Carlos A. Vaz Fragoso
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Veterans Affairs Clinical Epidemiology Research Center, West Haven, CT, USA
| | - Terrence E. Murphy
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Supiano MA. Benefit-based approach to blood pressure control in older adults. J Am Geriatr Soc 2015; 63:730-2. [PMID: 25900485 DOI: 10.1111/jgs.13341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Mark A Supiano
- Division of Geriatrics, School of Medicine, University of Utah, Salt Lake City, Utah; Veterans Affairs Salt Lake City, Geriatric Research, Education and Clinical Center, Salt Lake City, Utah
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Harrison M, Rigby D, Vass C, Flynn T, Louviere J, Payne K. Risk as an Attribute in Discrete Choice Experiments: A Systematic Review of the Literature. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2014; 7:151-70. [DOI: 10.1007/s40271-014-0048-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hansen TS, Jakobsen D. A decision-algorithm defining the rehabilitation approach: 'Facial oral tract therapy'. Disabil Rehabil 2010; 32:1447-60. [PMID: 20624108 DOI: 10.3109/09638280903556482] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM The aim of this study was to describe and define the rehabilitation approach: 'Facial Oral Tract Therapy' (F.O.T.T.). METHOD We defined the content and process of the rehabilitation approach (F.O.T.T.) in a decision-algorithm supported by a manual with supplementary material. The algorithm was developed by a research occupational therapist and an F.O.T.T. senior instructor. We used an inductive approach combining existing knowledge from: F.O.T.T. instructors, therapists trained in using the F.O.T.T. approach, and existing literature. A group of F.O.T.T. instructors and the originator of the treatment approach Mrs. Kay Coombes has given comments to and approved the algorithm. RESULT The algorithm consist of five flowcharts: 'one assessment' chart guiding the therapist in the examination of the patient and four 'treatment charts', one for each of the four areas of F.O.T.T.: swallowing and eating; oral hygiene; breathing, voice, and speech articulation; facial expression, giving guidance on interventions. The algorithm outlines all important components in the treatment that the therapist should decide to use or not to use in the intervention. The algorithm is supported by a manual with criteria of when to use which components. CONCLUSION This algorithm is designed to be a practical guideline to therapists using F.O.T.T. in clinical practice and in educational settings. The use of this algorithm may support standardization of F.O.T.T. and thereby promote and maintain the quality in the treatment. This in turn will facilitate research that addresses F.O.T.T. and outcomes.
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Affiliation(s)
- Trine S Hansen
- Brain Injury Unit, Department of Neurorehabilitation, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.
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Tinetti ME, McAvay GJ, Fried TR, Allore HG, Salmon JC, Foody JM, Bianco L, Ginter S, Fraenkel L. Health outcome priorities among competing cardiovascular, fall injury, and medication-related symptom outcomes. J Am Geriatr Soc 2008; 56:1409-16. [PMID: 18662210 PMCID: PMC3494099 DOI: 10.1111/j.1532-5415.2008.01815.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the priority that older adults with coexisting hypertension and fall risk give to optimizing cardiovascular outcomes versus fall- and medication symptom-related outcomes. DESIGN Interview. SETTING Community. PARTICIPANTS One hundred twenty-three cognitively intact persons aged 70 and older with hypertension and fall risk. MEASUREMENTS Discrete choice task was used to elicit the relative importance placed on reducing the risk of three outcomes: cardiovascular events, serious fall injuries, and medication symptoms. Risk estimates with and without antihypertensive medications were obtained from the literature. Participants chose between 11 pairs of options that displayed lower risks for one or two outcomes and a higher risk for the other outcome(s), versus the reverse. Results were used to calculate relative importance scores for the three outcomes. These scores, which sum to 100, reflect the relative priority participants placed on the difference between the risk estimates of each outcome. RESULTS Sixty-two participants (50.4%) placed greater importance on reducing risk of cardiovascular events than reducing risk of the combination of fall injuries and medication symptoms; 61 participants did the converse. A lower percentage of participants with chronic obstructive pulmonary disease (P=.02), unsteadiness (P=.02), functional dependency (P=.04), lower cognition (P=.02) and depressive symptoms (P=.03) prioritized cardiovascular outcomes over fall injuries and medication symptoms than did participants without these characteristics. CONCLUSION Interindividual variability in the face of competing outcomes supports individualizing decision-making to individual priorities. In the current example, this may mean forgoing antihypertensive medications or compromising on blood pressure reduction for some individuals.
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Affiliation(s)
- Mary E Tinetti
- Department of Internal Medicine and Epidemiology, New Haven, Connecticut 06504, USA.
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