Primary Care Clinicians' Experiences With Treatment Decision Making for Older Persons With Multiple Conditions

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Abstract
Optimizing the care of older persons with multiple medical conditions is a complex task, with clinicians receiving potentially contradictory recommendations regarding how to tailor care for these patients from the medical literature. On the one hand, there is a growing evidence base that older persons with multiple conditions have poorer outcomes when treated according to disease-specific guidelines compared with other patients.1-6 There are several reasons for these poorer outcomes. First, the presence of comorbid conditions may result in persons receiving less benefit from therapy directed at a particular condition.1,2 Second, the presence of these conditions may also increase the likelihood that the individual will experience adverse effects with any given intervention.3,4 Finally, the polypharmacy that generally accompanies multimorbidity confers an increased risk of adverse drug events, independent of the chronic conditions.5,6 On the other hand, editorials and clinical studies remind readers that the clinical trials providing the evidence base underlying these guidelines demonstrate that patients have improved outcomes with the medications recommended by these guidelines,7,8 and multiple studies have examined medication underuse and the failure to apply clinical guidelines to individual patients as a problem of poor quality care.9-11 Clinicians are therefore charged with caring for an increasing number of older patients with multimorbidity in the face of the seemingly contradictory evidence of the harms and benefits of following disease guidelines.

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