Research ArticleOriginal Research

Multimorbidity and Decision-Making Preferences Among Older Adults

Winnie C. Chi, Jennifer Wolff, Raquel Greer and Sydney Dy
The Annals of Family Medicine November 2017, 15 (6) 546-551; DOI: https://doi.org/10.1370/afm.2106

Abstract

PURPOSE Understanding individuals’ preferences for participating in health care decisions is foundational to delivering person-centered care. We aimed to (1) explore preferences for health care decision making among older adults, and (2) identify multimorbidity profiles associated with preferring less active, ie, passive, participation among older US adults.

METHOD Ours was a cross-sectional, nationally representative study of 2,017 National Health and Aging Trends Study respondents. Passive decision-making preference was defined as preferring to leave decisions to physicians. Multimorbidity profiles, based on 13 prevalent chronic conditions, were examined as (1) presence of 2 or more conditions, (2) a simple conditions count, and (3) a condition clusters count. Multiple logistic regression was used with adjustment for age, sex, education, English proficiency, and mobility limitation.

RESULTS Most older adults preferred to participate actively in making health care decisions. Older adults with 4 or more conditions, however, and those with multiple condition clusters are relatively less likely to prefer active decision making.

CONCLUSIONS Primary care physicians should initiate a shared decision-making process with older adults with 4 or more conditions or multiple condition clusters. Physicians should anticipate variation in decision-making preferences among older adults and adapt a decision-making process that suits individuals’ preferences for participation to ensure person-centered care delivery.

INTRODUCTION

Providing person-centered care, which reflects an individual’s preferences and health outcomes goals, is central to the management of individuals with multimorbidity, given the variation in the patterns of coexisting conditions and the lack of empirical evidence-based guidelines.1–4 Shared decision making is a useful strategy to operationalize person-centeredness, seeking to align physician-patient communication with individuals’ preferences, values, and goals through a process of information exchange, joint consensus building, and agreement on treatment choice.5 Some studies have found that shared decision making is associated with better health outcomes, greater patient satisfaction,6 and reduced health care costs.7,8 Putting shared decision making in practice, however, could be challenging because it is an iterative dynamic process that requires participation from both patient and physician.

Understanding the relationship between multimorbidity and individuals’ decision-making preferences is particularly important, given the inherent complexity of shared decision making and the increasing attention it is receiving from payers, regulatory agencies, and other stakeholders.9,10 Variation in decision-making preferences among older adults with multimorbidity, however, is largely unknown. Previous studies indicate that preference for active participation in health care decisions declines with an increasing number of chronic conditions among older adults.11 This relationship, however, may be more nuanced; certain conditions may exert greater influence and interact with other conditions in shaping decision-making preferences.12–16 Our study therefore aimed to (1) explore preferences for health care decision making among older adults, and (2) identify multimorbidity profiles associated with preferring less active participation among older US adults.

METHODS

Our retrospective cross-sectional study used data collected in 2012 from the National Health and Aging Trends Study (NHATS), a US population-based longitudinal study of older adults. The NHATS study design and procedures have been described previously.17 This study sample included a random sample of 2,017 older adults living in community settings who completed the health care decision-making module. We excluded participants with missing responses to the module (n = 24) and nursing home participants (n = 22). With sample weights, the study sample represented approximately 33.0 million Medicare beneficiaries aged 65 years and older in the United States. This study used public use files, and it was exempted from the Johns Hopkins School of Public Health Institutional Review Board review.

Dependent Variables

Survey respondents were asked their preferences for making health care decisions with doctors using a standardized question derived from existing empirical measures (Supplemental Appendix 1, available at http://www.annfammed.org/content/15/6/546/suppl/DC1/).11,14,16 In the preliminary analyses, we found that older adults who preferred making decisions alone shared similar characteristics with older adults who preferred making decisions with doctors. We therefore categorized preferences into 2 distinct roles: (1) active role, in which individuals make decisions alone or together with their physician; and (2) passive role, in which individuals leave decisions to their physician.5,18

Independent Variables

We examined multimorbidity profiles in 3 ways to reflect various multimorbidity measures.1 We included 13 conditions: heart attack, heart diseases, hypertension, arthritis, osteoporosis, diabetes, lung disease, stroke, cancer, vision and hearing impairment, depression, and dementia (further description in Supplemental Appendix 2, available at http://www.annfammed.org/content/15/6/546/suppl/DC1/).19 First, we used the presence of multimorbidity, defined as having 2 or more chronic conditions.20 Second, we used a simple chronic conditions count, a commonly used approach.21 Third, we used a count of related condition clusters to address the limitation that a simple conditions count is sensitive to the number of conditions included (eg, study participants are likely to receive higher condition counts on average when a study includes more conditions). We included (1) cardiopulmonary, (2) sensory-motor, (3) depression-dementia, (4) arthritis-osteoporosis, and (5) cancer clusters (Supplemental Appendix 2),22 because these sets of clusters exhibited good predictability to future health outcomes.23–25

Analysis

We conducted simple logistic regression models for bivariate analysis and 3 parallel multiple logistic regression models (ie, 1 for each type of multimorbidity profiles) to examine the relationship between multimorbidity profiles and passive role preferences. Using backward elimination process, we included age, sex, educational attainment, English proficiency, and mobility limitation in multiple regression models. We conducted analyses in Stata SE 11 (StataCorp LP) using svy commands with analytical weight adjustment and a significance level of α =.05.

RESULTS

Approximately 1 in every 7 older adults living in community settings responded that they prefer to leave health care decisions to their physicians, ie, a passive role, (14.9%, 4.9 million). Older age, lower education, lower English proficiency, and limited mobility among older adults were associated with a passive role preference in health care decision making (Table 1).

View this table:
Table 1

Characteristics Associated With Active and Passive Decision-Making Preferences

Of the older adults, 18.9% with multimorbidity indicated that they preferred a passive role, which was more than twice the odds of those that did not have multimorbidity (8.9%, OR = 2.35, P <.01) (Table 2, unadjusted odds ratios). The odds of preferring a passive role in decision making varied by multimorbidity measures (Table 2, unadjusted odds ratios). The proportion of older adults who preferred a passive role was higher among those with 3 or more conditions and those with multiple condition clusters. Results from our multiple regression models were generally consistent with findings from simple regression models. Having 4 or more conditions and multiple condition clusters were associated with preferring a passive role (Table 2, adjusted odds ratios).

View this table:
Table 2

Odds of Passive Decision-Making Preferences by Multimorbidity Profiles

DISCUSSION

Using data from a representative survey on older adults in the United States, we found that most older adults preferred to participate actively in making health care decisions, a finding corresponding to the observed greater decision-making participation among older adults in the United States,26–28 and to the findings among older adults with at least 3 conditions in Sweden.29 Our finding is promising for physicians, especially those involved in innovative health care delivery models, because shared decision making is considered an integral component and often tied to financial incentives in many of these models.30 For example, engaging individuals and family to actively participate in shared decision making is identified as 1 of the core functions in the Comprehensive Primary Care Plus model.31

Older adults with 4 or more conditions, however, and those with multiple condition clusters were relatively less likely to prefer active decision making. Despite that a stated preference for less active participation may reflect underlying personal traits for some individuals, it may also reflect prior medical encounters and illness experiences. Potential reasons include patients who are less healthy and who may feel more dependent on their physicians, to whom they delegate decision-making power13,14,16; time constraints to address multiple conditions during a single visit, which creates a less friendly environment for shared decision making5,29,32; and competing demands in managing multiple conditions, which makes it harder for patients to gain expertise and confidence to actively participate in decision making.33–36

We also found that older age, male sex, lower education, lower English proficiency, and limited mobility were associated with a passive role preference in health care decision making regardless of multimorbidity. The findings on age, sex, educational attainment, and language barrier were consistent with those of previous studies in general,12,14,37–39 but the association between functional status and preferences for decision making was largely unknown.40 Older adults with mobility limitations are likely to have informal caregivers to transport them to obtain health care, and they may feel more dependent on trusted caregivers or physicians and thus wish to relinquish control to others.14

This study has several limitations. Because our analysis was based on secondary data, the validity partially depends on the structure of the survey questions and participant interpretation of the questions. Multimorbidity was determined by a limited number of self-reported diagnoses that are prevalent or have a considerable impact causing disability among older adults. The analysis uses a single question for decision-making preference, as it was designed to capture individuals’ preferences for overall care.11 Given the cross-sectional design, this study cannot draw causal inferences and may reflect cohort effect.

Primary care physicians should initiate the shared decision-making process with older adults, especially those with 4 or more conditions or multiple condition clusters by inviting them to participate in decision making. Recognizing the variation in stated decision-making preferences, physicians should anticipate that some older adults may be reluctant to participate initially but will participate eventually, and some of them may still prefer having their physicians make decisions. For older adults who prefer less active participation, it would still be important to elicit their goals and outcome preferences to ensure the care plan is person-centered, even if physicians will be making paternalist decisions.41

Future research is needed to identify potential barriers and facilitators to individuals’ involvement in decision making when confronting multiple conditions, and such information may guide physicians in choosing strategies to encourage individuals’ active participation.

Acknowledgments

Dr Christopher Beadles, MD, PhD, at RTI International, provided helpful insight.

Footnotes

  • Conflicts of interest: authors report none.

  • Funding support: This study was supported by the Agency for Health-care Research and Quality predoctoral institutional research training grant (T32) and the Barbara Starfield Scholarship from Johns Hopkins University to support her doctoral training and this dissertation work at Johns Hopkins University, Bloomberg School of Public Health, Department of Health Policy and Management.

  • Previous presentation: An earlier version of the manuscript was presented as a poster at the AcademyHealth Annual Research Meeting; June 26–28, 2016; Boston, Massachusetts.

  • Supplementary materials: Available at http://www.AnnFamMed.org/content/15/6/546/suppl/DC1/.

  • Received for publication September 22, 2016.
  • Revision received February 15, 2017.
  • Accepted for publication March 27, 2017.

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