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Primary care providers encounter challenges in incorporating long-term prognosis in care of older adults

Despite clinical recommendations regarding the use of life expectancy to inform clinical decisions in older adults, primary care providers experience barriers and ambiguities in implementing long-term prognosis, according to researchers.

Providers need better guidance on using long-term prognosis to dictate care and how to discuss the topic with patients, Nancy L. Schoenborn, MD, of the division of geriatric medicine and gerontology at Johns Hopkins School of Medicine, and colleagues reported in JAMA Internal Medicine.

"Research and clinical practice recommendations increasingly recognize that older adults of similar age can have widely varying life expectancies and suggest that several clinical decisions regarding older patients — including cancer screening and glycemic goal in diabetes mellitus treatment — should incorporate patients' life expectancy over a time frame of up to 10 years," they wrote. "The potential benefit from these clinical interventions may not be achieved for many years, but the potential harms may occur in the short term."

If physicians fail to consider long-term prognosis, it is possible that patients with short life expectancies will be harmed by clinical interventions that may not help them and patients with longer life expectancies may not receive interventions that would benefit them, Schoenborn and colleagues wrote.

The researchers conducted a qualitative interview study of 28 primary care providers in rural, urban and suburban settings. They analyzed the content of recorded discussions with the physicians.

Results showed that primary care providers considered life expectancy, typically in the time frame of 5 to 10 years, in several clinical scenarios, including preventive care such as cancer screening or hypertension control, and surgery or presence of a life-limiting condition or multiple comorbidities. Physicians weighed prognosis with other factors, including patient preference and age.

Schoenborn and colleagues noted that a majority of the physicians used clinical experience instead of validated prognostic tools when assessing life expectancy, which contributed to a widely varied assessment that ranged from 2 years to 30 years.

In addition, many providers considered long-term prognosis and did not share that with their patients. They reported barriers to incorporating prognosis in care, such as uncertainty in their predictions, difficulty in discussing patients' prognosis, time constraints, concern about patient reactions and litigation concerns.

"Older adults have significantly heterogeneous health status and health trajectories; incorporating long-term prognosis in the care of these individuals helps to differentiate patients who have limited prognosis and inform decision making for the whole population," Schoenborn and colleagues wrote. "Despite clinical recommendations to increasingly incorporate patients' long-term prognosis in clinical decisions, primary care practitioners encounter several barriers and ambiguities in the implementation of these recommendations." – by Chelsea Frajerman Pardes

Disclosures: The researchers report no relevant financial disclosures.