Personalized preventive care and life expectancy among older multimorbid adults
Description: BACKGROUND AND RATIONALEProviding high value care and avoiding care overuse is a challenge among older multimorbid adults. There is evidence on benefits and harms of cancer screening and cardiovascular diseases (CVD) preventive treatment up to the age of 75. However, this evidence is not directly applicable to older multimorbid patients. Because each cancer and CVD preventive care has a specific lagtime to benefit, many guidelines recommend tailoring preventive care according to the estimated life expectancy (LE). If the lagtime to benefit of a given preventive care is longer than the expected LE, the patient has not the time to benefit from this care. Because multimorbid patients have a relatively short LE, they are at higher risk of not having the time to benefit. Key is that estimating LE is a serious challenge in older patients with chronic diseases due to the lack of accurate, validated, and simple LE estimator. Further, both physicians and patients overestimate benefit of preventive care. As a result, questionable use of cancer and CVD preventive care is probably frequent. However, almost no data are available among older multimorbid patients. Further, developing an accurate LE estimator to provide personalized preventive care, to help prevent under- and overuse of such care, is urgently needed.OBJECTIVESOur objectives are therefore (1) to assess the practice of cancer screening and use of CVD preventive treatments in older multimorbid patients; (2) to assess the association of preventive care with estimated LE and identify questionable use; (3) to develop new 1-year and 3-year mortality risk prognostic indices; and (4) to derive a new LE estimator. METHODFor the objectives 1 to 4, we will conduct a prospective cohort study by extending the follow-up of patients included in the OPERAM study, a 1 year randomized controlled trial (Horizon 2020 EU-funded). Extensive data are collected about general health status, including vital status, co-morbidities, and treatment. For the current research proposal, the follow-up and data collection of the 822 patients included in Bern, Switzerland, will be extended over 3 years. Detailed information about cancer screening and CVD preventive treatment will be collected. A questionable use of screening will be defined (1) for breast cancer in women with LE<7 years, (2) for colorectal cancer in men/women>85 years old or with LE<10 years; (3) for prostate cancer in men aged >70 years old or with LE<10 years; (4) for lung cancer in men/women with LE<10 years or >80 years old whatever the LE; (5) for cervical cancer in women =65 years old with prior screening or who have had hysterectomy, or with LE<10 years. A questionable use of CVD preventive treatment will be defined as use of lipid lowering drugs among men/women without previous CVD events with LE<3 years or aged>75 years old and as antihypertensive use among men/women without previous CVD events with LE <2 years. Cancer and CVD preventive care will be also considered as questionable among patients with dementia or metastatic cancer. For the objective 2, LE will be estimated using the calibrated Lee’s LE estimator. For the objective 3, we will identify variables independently associated with mortality and weighted the variables to create new 1 year and 3 year mortality prognostic indices. For the objective 4, we will transform the 3 year mortality risk index into a LE estimator. This new LE estimator will be compared to the (calibrated) Lee’s LE estimator. Finally, a panel of clinicians will evaluate the validity and usability of these estimators.RELEVANCE AND IMPACTOur hypotheses are that cancer and CVD preventive care are frequently performed among older multimorbid patients and that there is no association with LE. We expect therefore that questionable use is frequent. Major strengths of our proposal are (1) the follow-up of 822 multimorbid older patients already included insuring the high feasibility of our project and (2) the development for the first time of a LE estimator specifically for older patients with multiple chronic conditions. This will have a major impact on preventive care practice because it will help physicians applying a personalized/precision risk-based harm-benefit approach by tailoring cancer and CVD prevention care in older patients according to their LE; it will eventually help preventing under- and overuse of such care.
Amount: CHF 494,900
Funding type: research
Funder scheme: Project funding
Start date: 2020-01-01
End date: 2023-06-30
Investigator: Chiolero, Arnaud
Institution: University of Berne – BE
Funded outputs count: 23
Funder award ID: 188549
OpenAlex ID: G1697094490