1. Consensus-based priority setting for elderly NSTEMI patients with multi-morbidity Niklas Ekerstad, MD Rurik Löfmark, MD Per Carlsson, Professor National Centre for Priority Setting in Health Care, Sweden

2. Statistics Sweden. Population projection for Sweden 2004-2050 Background - Demography

3. Background – Key components regarding medical priority setting in Sweden The ethical platform (parliamentary decision) The Swedish national model for priority setting Evidence-based guidelines for priority setting

4. Background - Problems regarding evidence-based priority setting for elderly patients with multi-morbidity Lack of a relevant description of needs (severity;potential effect of treatment) in terms of subgrouping (heterogenous population). Lack of evidence/limited applicability of evidence ”Our base of scientific expertise is weakest for the age groups (75+) that most often receive various types of treatments.” (The Swedish Council on Technology Assessment in Health Care)

5. Background – a critical case Setting priorities within health care when the evidence base is weak - A critical case: Decision-making for frail elderly with acute cardiovascular disease and co-morbid conditions

6. Background – Cardiologists´attitudes to suggested ways of improving clinical priority setting for elderly NSTEMI patients with multi-morbidity Ekerstad, N., Löfmark, R., Carlsson, P. Elderly with Multimorbidity and Acute Cardiac Disease: Doctors´ Views on Decision-Making. Accepted 091015. Scand J Public Health

7. Background – Description of the needs of NSTEMI patients in the national guidelines AAA A B National guidelines regarding the measure coronary angiography for NSTEMI patients: Two categories based on disease-specific risk (cardiovascular risk) A - high or medium cardiovascular risk: rank 2 B - low cardiovascular risk: rank 6

8. Background – Proposed description of the needs of elderly patients with multi-morbidity Disease- specific risk Frailty Co- morbidity

9. Background – Proposed categorization of the needs of elderly NSTEMI patients with multi-morbidity I II III IV V VI VII VIII High CVR Low CVR CM+CM- CFS+ CM+CM- CFS+ CFS- CVR = Cardiovascular risk CM = Co-morbidity CFS = Clinical Frailty Scale

10. Background – Tentative relative ranking of the categories regarding coronary angiography from a theoretical standpoint High cardiovascular risk IV High rank III Low-medium rank II Low-medium rank I Low rank Low cardiovascular risk VIII Medium-high rank VII Low rank VI Low rank V Very low rank

11. Background – a pilot study regarding experts´priority setting for elderly NSTEMI patients with multi-morbidity 6 experts validated 15 authentic NSTEMI cases, each case belonging to one of the eight model categories, and the model´s components For each case the measure coronary angiography was individually ranked; the convergence between the experts´rankings was evidently good.

12. Objectives To re-validate the clinical cases and the model´s components regarding their relevance To evaluate the interrater reliability concerning the experts´rankings regarding each category To compare the rankings of the experts and the guidelines To compare the rankings of the experts with the model´s suggested relative rankings

13. Methods Selection process of experts A questionnaire study Intra class correlation test

14. Results of the interimistic analysis (n=28) – Validation of the selected cases “Very realistic cases! Daily problems!” (A male cardiologist at a small hospital) “A few of the cases are typically found in non-cardiac care departments. “(A male cardiologist at a university hospital)

15. Results of the interimistic analysis – Convergence among the experts´rankings Intra-class correlation test, two-way random, absolute: Single: 0,530 (0,359 – 0,751) Average: 0,964 (0,931 – 0,986) The inter-rater reliability was good. The experts´rankings converge well.

16. Results of the interimistic analysis – Comparisons between different sources of rankings: guidelines and experts Category Guidelines´ rankings Experts´ rankings (mean) IV23.6 III27.7 II28.2 I210 Category Guidelines´ rankings Experts´ rankings (mean) VIII63.6 VII68.1 VI69.5 V610.5 High cardiovascular riskLow cardiovascular risk

17. Results of the interimistic analysis (n=28) – Estimated relevance of the model´s components

18. Conclusions Evidence-based guidelines should be adapted to be applicable for elderly patients with multi-morbidity. Consensus-based experts´ priority setting for elderly patients with multi-morbidity could be one way to achieve this. The tentative model contains three components: disease- specific risk, comorbidity and frailty The interimistic analysis indicates that the model´s components are considered relevant and that the inter-rater reliability of the experts´ rankings is good.