Incorporating recommendations for multimorbidity into clinical-decision making, critical knowledge gaps and research priorities may optimize care of complex older patients with cardiovascular disease, according to a state-of-the-art-review paper published May 7 in the Journal of the American College of Cardiology.

The review, by Daniel E. Forman, MD, FACC, et al., was based on a two-day multidisciplinary workshop convened by the ACC and the National Institutes on Aging, in collaboration with the American Geriatrics Society. The workshop identified challenges and opportunities for advanced precepts of multimorbidity, resources for integrating multimorbidity into research and clinical care, and targets such as practice guidelines and methods to assess and record patients' priorities as part of a shift from disease-focused to patient-centered care.

The authors recommend addressing older patients with cardiovascular disease in the context of multimorbidity to build a model of care based on patient-centered medicine and manage diseases in ways that are oriented to patients and their goals. They explain that "the central patient-directed question shifts from 'what is the matter?' to 'what matters to you?'" This approach would also emphasize communication and collaboration across multiple providers and care settings.

While several studies have evolved on multimorbidity in older patients with cardiovascular disease, the authors point out that the research has focused on improving understanding and care of patients with only two or three chronic conditions. Therefore, they suggest using strategies that address more complex diseases and condition combinations such as studying multimorbidity through clinical data from national registries, cohort studies, administrative databases and clinical studies. The authors note that this clinical data could enhance knowledge of practice patterns and provide insight into benefits and harms associated with specific interventions among key subgroups with various multimorbid combinations.

In addition to evolving research for multimorbidity, the authors explain that "scalable methods" to align goals with measurable outcomes also still need to be developed. Policies, guidelines, appropriate use documents and performance metrics, for example, must be structured in order to integrate multimorbidity into customary care.

"Multimorbidity is endemic in older adults with cardiovascular disease and substantially impacts the clinical features, diagnosis, management and outcome of most older cardiac patients," the authors conclude. "Research to support the transition [from disease-focused to patient-centered care] is already under way, and opportunities abound for novel research designed to test specific interventions and programs aimed at moving the field forward."

Keywords: Geriatrics, Research, Chronic Disease, Patient-Centered Care, Academies and Institutes, Registries, Cohort Studies

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