Tackling cardiovascular disease and morbidity
Cynthia Boyd, M.D.
For anyone whose career focuses on the long-term care of older adults, the place to be last month was National Harbor, MD, attending the information-rich American Geriatrics Society 2015 Annual Scientific Meeting.
More than 700 research presentations and more than 100 educational sessions informed and enlightened the 2,600 attendees, who included geriatric nurses, geriatricians, social workers, family practitioners, physician assistants, pharmacists, internists, administrators, trainees, and many others from across the country and around the world. The meeting rooms buzzed as colleagues connected, networked, and explored new science and insights that will form and inform future clinical standards — especially where long-term care is concerned.
During the meeting, we were honored to co-moderate a particularly meaningful session, “Multi-morbidity in Cardiovascular Disease: Proceedings of an ACC/AGS/NIA Workshop,” which summarized a two-day workshop orchestrated by the American College of Cardiology, the AGS, and the National Institute on Aging on closing existing knowledge gaps tackling multiple chronic conditions in patients with cardiovascular disease.
As we outlined in our synthesis of workshop proceedings, addressing multimorbidity in patients with CVD is a complex charge, especially as the prevalence of both multiple chronic conditions and heart disease continues to rise. According to research published in JAMA, multimorbidity is the most common chronic condition experienced by older adults. And for those over the age of 45 diagnosed with coronary heart disease, issues with arthritis, urinary incontinence, and polypharmacy can affect half — if not more — of the entire patient population.
To best care for people living with multimorbidity, healthcare professionals need to maximize the use of beneficial therapies, minimize the use of nonbeneficial or harmful treatments, and incorporate patient preferences and values regarding burdens, risks, and benefits into the health and care paradigm. In many respects, bringing these aspects of quality care into greater concert is what our joint workshop was all about.
With colleagues from our workshop planning committee—David B. Reuben, M.D., and Marcel E. Salive, M.D., MPH, specifically—we presented to AGS15 attendees a synthesis of our workshop objectives and opportunities for moving forward in light of the workshop. Based on our discussions, for example, we now know more about how:
- Research gaps exist largely because older adults, especially those over 80, are underrepresented in clinical studies. Those with complex co-morbidities are frequently excluded. While barriers to increasing enrollment of older adults exist, they can be overcome with strategies that specifically target this population, such as conveying the value of participation in research, minimizing environmental barriers to participation through home-based or virtual follow up, and aligning incentives such that all parties are motivated to gain valid information about the effectiveness of interventions in heterogeneous older adults.
- Virtually all cardiovascular studies are disease-centric, not patient-centric. This, in turn, can impede our ability to understand the context in which we care for patients with CVD, particularly when so many of these patients may present with other chronic conditions.
- There are serious gaps in our understanding of what it means to be an older adult with multiple chronic conditions and what it means to take care of this group of older people. Our true challenge is to develop strategies that overcome barriers to study enrollment and address unmet needs in ways that will provide new insights and improve patient care and outcomes.
- Support more clinical trial work that broadly represents this patient population
- Increase the number of geriatrics specialists on FDA and other policy committees; 3 3 Focus on practical training for all healthcare providers that accounts for the complexity of care when confronting multimorbidity in patients with CVD.
From our perspective, the opportunity to examine intersections between CVD and the management of multiple chronic conditions — and to explore an optimal future research agenda — represents the nexus between research and practice that can yield a more responsive healthcare system.
Just days after the AGS15 meeting came to a close, for example, the AGS released a new mobile app and educational toolkit for supporting older adults who live with three or more chronic conditions. Developed with support from the Agency for Healthcare Research and Quality (AHRQ), Multiple Chronic Conditions: Geriatrics Evaluation and Management Strategies (MCC GEMs) Mobile Application is an interactive rendering of AGS guiding principles that help healthcare professionals effectively coordinate care for older adults, like those living with CVD while managing multiple health problems.
The app—and the toolkit it accompanies—offer a roadmap for negotiating guidance on individual diseases or conditions against the backdrop of a more responsive approach to the patient as a person and not the sum total of his or her conditions or concerns. Tools like these reflect the future of responsive, high-quality, person-centered care—a future we hope our joint workshop has helped to advance. Meetings like AGS15 are invaluable for their ability to highlight clinical areas, like multimorbidity in CVD, that require additional research to address the complex health challenges that we will all face as we age.
Cynthia M. Boyd, M.D., MPH, is an associate professor in the Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University.
Michael W. Rich, M.D., AGSF, FACC, is a professor of medicine at the Washington University School of Medicine.