Optimizing Health Care in the Context of Multimorbidity, Polypharmacy, and Decreasing Physiologic Re...
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Optimizing Health Care in the Context of Multimorbidity, Polypharmacy, and Decreasing Physiologic Reserve. Amy C. Justice, MD, PhD Section Chief, General Internal Medicine VA Connecticut Healthcare System Professor of Medicine and Public Health Yale University. Multimorbidity.

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Amy c justice md phd section chief general internal medicine va connecticut healthcare system

Optimizing Health Care in the Context of Multimorbidity, Polypharmacy, and Decreasing Physiologic Reserve

Amy C. Justice, MD, PhD

Section Chief, General Internal Medicine

VA Connecticut Healthcare System

Professor of Medicine and Public Health

Yale University


Multimorbidity

Multimorbidity


Hiv has never occurred in a vacuum

HIV Has Never Occurred in a Vacuum

  • Irrespective of aging, HIV care complicated by:

    • Multi drug regimens susceptible to non adherence, resistance, and toxicity

    • Co infections (HCV, TB, MDR-TB)

    • Socio economic issues: stigma, substance addiction, incarceration, homelessness, under nutrition

  • Aging adds multiple chronic diseases (multimorbidity) to mix


Multimorbidity and age in hiv south africans

Multimorbidity and Age in HIV+ South Africans

% Prevalence

WHO Survey “Study of global AGEing and adult health (SAGE), South African subjects”Data are restricted to those with HIV infection. Negin J. et al. AIDS 2012 26(S1):S55-63


Incident chronic disease swiss cohort 2008 10

Incident Chronic Disease: Swiss Cohort 2008-10

Of 1,189 events in 8,444 patients, only 16% were HIV events, 84% were Non HIV:

Hasse B. et al. Morbidity and Aging in HIV-Infected Persons: The Swiss HIV Cohort Study CID 2011 53:1130-1139


Limit of silos coordination and communication

Limit of Silos: Coordination and Communication


Accelerated or accentuated

Accelerated or Accentuated?

A. Accelerated and Accentuated: cancer occurs earlier among those with HIV than uninfected comparators and there are more cancer events.

B. Accentuated risk: cancer occurs at the same ages but more often than among comparators.

Shiels MS. Ann Intern Med 2010:153:452-460.


Age at onset of cancer aids patients and age matched uninfected individuals

Age at Onset of Cancer AIDS Patients and Age Matched Uninfected Individuals

Looked at 26 different diagnoses, no difference (p>0.05) for 18 cancer.

Differences for remaining cancers were <5 years.

Shiels MS. Ann Intern Med 2010:153:452-460.


Age at diagnosis in vacs

Age at Diagnosis in VACS

See also: IAC 2012 TUPE160 Shiels M. Age at Cancer Diagnosis in HIV+ in North America Compared to General US Population


Polypharmacy

Polypharmacy


Polypharmacy1

Polypharmacy

  • Typically defined as >5 drugs

  • Associated with diminished marginal benefit from additional medication due to:

    • Nonadherence

    • Adverse drug events (confusion, falls, renal failure, etc.)

  • Risk of adverse events increases approximately 10% with each additional medication

Salazar JA. Expert Opin Drug Saf (2007) 6(6):695-704

Gandhi TK. N Engl J Med 2003;348:1556-64


Decreasing physiologic reserve

Decreasing Physiologic Reserve


Disability frailty and functional status

Disability, Frailty, and Functional Status

  • 3 geriatric concepts increasingly applicable to those aging with HIV

  • Each is a consequence of total physiologic injury rather than of any particular diagnosis

  • Of note, these concepts also relate to cognitive dysfunction, especially delirium and dementia


Amy c justice md phd section chief general internal medicine va connecticut healthcare system

VACS Index Thresholds and Weights

Age

HIV Specific

Biomarkers

Biomarkers of General

Organ System Injury

VACS.MED.YALE.EDU


Vacs index

VACS Index

  • Predicts mortality:

    • All Cause, HIV, and non HIV (European Data)

    • Risk of mortality over 5 years (North American Data)

  • Predicts morbidity: hospitalization, MICU admission, and fragility fractures

  • Correlated with functional performance and symptom burden

  • Responsive to changes in risk after ART initiation, intensification, and interruption

For more information and full documentation go to: www.vacohort.org

To use/comment on the VACS Index Calculator go to: HTTP://vacs.med.yale.edu


We need a map to optimize care

We Need a “Map” to Optimize Care

  • A comprehensive outcome to compare effectiveness of interventions and identify those with the best benefit/harm ratio

  • A means of combining interventions into a strategy for medical patients with multimorbidity

  • A means of motivating and guiding patients and providers to pay attention to that which matters most for patient outcomes


Health risk assessment a means of navigating complexity

Health Risk Assessment: A Means of Navigating Complexity

  • Identify and prioritize modifiable risks among a lengthening list of possibilities

  • Motivate and map progress

  • Quantify harm and benefit from interventions

    • Level of susceptibility to adverse drug events

    • Short term risk of hospitalization

    • Risk of disability, assisted living requirements

  • Identify end of life to signal change in priorities


We have a sense for 50 64 yrs but 65 remains uncharacterized

We Have a Sense for 50-64 yrs,But 65+ Remains Uncharacterized


Relative risk of incident disease at 50 64 and 65 compared with 50 yrs

Relative Risk of Incident Disease at 50-64 and 65+ Compared with <50 Yrs

Relative Risk (HR)

Hasse B. et al. Morbidity and Aging in HIV-Infected Persons: The Swiss HIV Cohort Study CID 2011 53:1130-9


End of life

End of Life

  • With aging inevitably comes end of life

  • Aging patients want to know when they are within 5 years of death to:1

    • Prepare

    • Make the most of remaining life

    • Make medical/health-related decisions

1. Ahatt C. et al. “Knowing is Better”: Preferences of Diverse Older Adults for Discussing Prognosis. J Gen Intern Med 2011, 27(5):568-75


Conclusions

Conclusions

  • Multimorbidity is common for those aging with HIV and requires a new approach to care and research

    • Individual diagnoses less important than cumulative injury

    • We need tools to assess injury and its impact

  • In the context of polypharmacy and physiologic injury, additional medication may cause more harm than good

    • Need to consider what medications are most essential

  • Ongoing risk assessment, evidence based prioritization, and coordination of care must become the new bywords


Research priorities

Research Priorities

  • Study mechanisms in multimorbidity:

    • “Multi-hit” (cancer) and “cumulative frailty” (geriatrics)

    • Develop a standard approach to measuring physiologic injury

    • Compare HIV+/- to determine whether HIV has distinct mechanisms of injury

  • Compare harms and benefits of additional treatment and of decreased treatment

  • Consider alternative ways of organizing and delivering care in the context of multimorbidity

  • Test whether care prioritized based upon risk, benefit, and preferences is more effective than UC


Two studies in general population illustrate the tension in studying aging and hiv

Two Studies in General Population Illustrate the Tension in Studying Aging and HIV

STOPP

Polycap


Amy c justice md phd section chief general internal medicine va connecticut healthcare system

  • METHODS

  • Randomized 400 hospitalized patients aged 65+ yrs. to receive either usual care or screening with STOPP/START criteria with follow up recommendations to providers.

  • RESULTS

  • Unnecessary drugs decreased 36%

  • Underutilization of indicated drugs decreased by 21%

  • Improvements sustained for 6 mos.

  • No significant differences in deaths, falls, readmission, LOS, or f/u outpt visits—all but readmissions less in intervention arm (but not significant)


Amy c justice md phd section chief general internal medicine va connecticut healthcare system

  • 2007-2008

  • 2,053 subjects; 50 centers in India

  • 45-80 yrs; 1 risk factor

  • Not on medication

  • Aspirin, thiazide, ramipril, atenolol, and simvastatin

  • Outcome: BP, LDL, heart rate, urine biomarker for plt. act.

  • ADE: discontinuation

Yusuf S. Lancet 2009; 373:1341-51.


Amy c justice md phd section chief general internal medicine va connecticut healthcare system

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