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Preferences and priorities to manage clinical uncertainty for older people with frailty and multimorbidity: a discrete choice experiment and stakeholder consultations

Research output: Contribution to journalArticlepeer-review

Original languageEnglish
Article number553
JournalBMC Geriatrics
Volume21
Issue number1
Early online date14 Oct 2021
DOIs
E-pub ahead of print14 Oct 2021
Published14 Oct 2021

Bibliographical note

Funding Information: This report is independent research supported by Health Education England and the National Institute for Health Research (HEE/NIHR Senior Clinical Lectureship, Dr. Catherine Evans, ICA-SCL-2015-01-001). Funding also acknowledged for Marsha Dawkins, HEE/NIHR ICA Pre-doctoral Clinical Academic Fellowship (ICA-PCAF-2018-01-006). Professor Irene J Higginson NIHR Senior Investigator (Emeritus) is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. The views expressed in the publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. Funding Information: SPACE (Symptom and Psychosocial Assessment and Communication Evaluation) is a joint project between by King’s College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, UK and Sussex Community NHS Foundation trust, UK. SPACE is supported by Health Education England and the National Institute for Health Research. We would like to acknowledge members of the steering group committee: Sube Banerjee, Wei Gao, Claire Goodman, Christine Norton, Mathew Maddocks and David Seamark; Independent Project Advisory Group of lay members: John Barry, Mike Bocjzuk, Jack Hazelgrove, Lesley Talmey and Colin Vincent (also steering group committee member); and research nurse, Jenifer Newton. Funding Information: SPACE (Symptom and Psychosocial Assessment and Communication Evaluation) is a joint project between by King?s College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, UK and Sussex Community NHS Foundation trust, UK. SPACE is supported by Health Education England and the National Institute for Health Research. We would like to acknowledge members of the steering group committee: Sube Banerjee, Wei Gao, Claire Goodman, Christine Norton, Mathew Maddocks and David Seamark; Independent Project Advisory Group of lay members: John Barry, Mike Bocjzuk, Jack Hazelgrove, Lesley Talmey and Colin Vincent (also steering group committee member); and research nurse, Jenifer Newton. Publisher Copyright: © 2021, The Author(s).

King's Authors

Abstract

BACKGROUND: Clinical uncertainty is inherent for people with frailty and multimorbidity. Depleted physiological reserves increase vulnerability to a decline in health and adverse outcomes from a stressor event. Evidence-based tools can improve care processes and outcomes, but little is known about priorities to deliver care for older people with frailty and multimorbidity. This study aimed to explore the preferences and priorities for patients, family carers and healthcare practitioners to enhance care processes of comprehensive assessment, communication and continuity of care in managing clinical uncertainty using evidence-based tools.

METHODS: A parallel mixed method observational study in four inpatient intermediate care units (community hospitals) for patients in transition between hospital and home. We used a discrete choice experiment (DCE) to examine patient and family preferences and priorities on the attributes of enhanced services; and stakeholder consultations with practitioners to discuss and generate recommendations on using tools to augment care processes. Data analysis used logit modelling in the DCE, and framework analysis for consultation data.

RESULTS: Thirty-three patients participated in the DCE (mean age 84 years, SD 7.76). Patients preferred a service where family were contacted on admission and discharge (β 0.36, 95% CI 0.10 to 0.61), care received closer to home (β - 0.04, 95% CI - 0.06 to - 0.02) and the GP is fully informed about care (β 0.29, 95% CI 0.05-0.52). Four stakeholder consultations (n = 48 participants) generated 20 recommendations centred around three main themes: tailoring care processes to manage multiple care needs for an ageing population with frailty and multimorbidity; the importance of ongoing communication with patient and family; and clear and concise evidence-based tools to enhance communication between clinical teams and continuity of care on discharge.

CONCLUSION: Family engagement is vital to manage clinical uncertainty. Both patients and practitioners prioritise engaging the family to support person-centred care and continuity of care within and across care settings. Patients wished to maximise family involvement by enabling their support with a preference for care close to home. Evidence-based tools used across disciplines and services can provide a shared succinct language to facilitate communication and continuity of care at points of transition in care settings.

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