Multiple Chronic Conditions in Research for Emerging Investigators
Multiple Chronic Conditions in Research for Emerging Investigators
MCCs Care and Medical Specialties
Join Dr. Jerry Gurwitz, from UMass Chan Medical School and UMass Memorial Medical Center, and Drs. Namrata Singh from University of Washington, Melissa Loh from the University of Rochester, and Rasheeda Hall from Duke University, as they highlight opportunities for rheumatology, oncology, and nephrology specialists to implement MCC Care.
Welcome, my name is Jerry Gerwitz and I am a geriatrician at UMass Chan Medical School in Worcester, Massachusetts. And I am extremely pleased to be moderating this podcast as part of our AGS Aging Learning Collaborative Curriculum. The AGS Aging Learning Collaborative Curriculum is a comprehensive curriculum specifically designed for early stage investigators interested in incorporating the science of multiple chronic conditions or MCCs into their research. The curriculum is a joint endeavor of the American Geriatric Society and the Aging Initiative and is funded by the National Institute on Aging. And as an aside, if you are applying for an NIH career award, this curriculum is a must to incorporate into the training section of your application. I am truly excited to be speaking with three authors of new topic additions to our Basics of MCCs module. The three topics are multiple chronic conditions in geriatric nephrology, multiple chronic conditions in rheumatic diseases, and multiple chronic conditions in geriatric oncology. So welcome, Dr. Rashida Hall, Dr. Nimrata Singh, and Dr. Melissa Lowe. Thank you, thank you very much for speaking with me today. I'd like to begin by asking each of you to say a few words about yourself, a bit about how you chose your specialty, and also about your personal epiphany, if there was one, that led you to recognize the importance of multiple chronic conditions in caring for your patients, in your research, and in your teaching. So let me begin by asking Rashida.
SPEAKER_00:Thank you, Jerry, for inviting us to be a part of the series. So myself, my name is Rashida Hall, and I am an associate professor in the Division of Nephrology at Duke University School of Medicine. And my clinical research niche has been in geriatric nephrology since my fellowship training. And I point it out because I believe that's when the epiphany actually started when I was a nephrology fellow. There are definitely several occurrences of patients who I encountered where their kidney function recovery was really poor. And often it was related to the other chronic conditions they were experiencing or their failure of those conditions, like if they were in an intensive care unit. So it's really clear to me that for many patients with kidney disease, having other chronic conditions actually played a huge role in what would happen with their kidneys. And in fact, as part of an initial training is remembering and being cognizant that diabetes and hypertension, as common as they are, are chronic conditions that do contribute to the onset and the worsening of kidney disease. And now as an attending at the Durham VA, I lead a geriatric nephrology clinic. Now I get to embrace the complexity. When patients have multiple chronic conditions, I consider that part of thinking through the care plan. So like when it's a conversation about their kidney failure options, dialysis, transplant, or conservative kidney management, the other conditions are relevant to the conversation. because perhaps someone's life expectancy or their preferences would differ based on the presence of those conditions. And not only that, when it comes to having chronic kidney disease and maintaining stable kidney function, it's important that patients are able to manage their condition on their own. Sometimes having other chronic conditions can make it harder to do the self-management, whether it's like dementia. So maybe now we have to engage someone else to help them maintain medication adherence, or maybe there are certain medications for other conditions like heart failure or arthritis that then make managing their kidney disease a little bit harder. So those are my thoughts around the importance of chronic conditions clinically, As a researcher, I spend my research focus on doing research that will lead to better outcomes for older adults with kidney disease. It's hard to disentangle multiple chronic conditions from end-stage kidney disease when it comes to whatever events that may occur and how likely it is from these conditions or kidney disease. But still, I think it's really relevant because we know there's enough data out there that would suggest that having, you know, this accumulation of chronic conditions does make some patients more vulnerable. And so ways that we can identify those patients in a way that might kind of give them a different kind of care pathway from someone else who only has kidney disease does help with improving outcomes for patients.
SPEAKER_01:Thank you, Rashida. Nimrata, can you say a few words about yourself and how you got to where you are?
SPEAKER_02:Yes, definitely. But first of all, I want to say, just like Rashida said, thank you so much for including me in this effort. Really appreciate it. I am Namrata Singh. I'm an adult rheumatologist at the University of Washington. First of all, what led me to becoming a rheumatologist, I would say, is really got drawn to the management of complex patients, diagnostic reasoning it entails, and really the long-term relationship we build with our patients as they navigate chronic illnesses. And then over time, you know, it didn't take too long to realize that it was impossible to ignore that most of my patients are not just managing rheumatoid arthritis or lupus, etc. They are really living with other things like they also are navigating heart disease, perhaps depression. Some of my patients are dealing with cancer at the same time. Turning point, I would say the epiphany really came when I realized that so-called gold standard guidelines of which I've been part of, like for rheumatoid arthritis, for example, they really often overlook the realities of older adults, especially with aging, polypharmacy, and focusing on a single disease isn't just enough is really what led me to be gravitating towards multiple chronic conditions and the whole field around it. And keeping in mind that we need to treat the whole person and not just one individual. of their medical problem list. And then this really also guides how I do my research. So for example, my research focuses on the treatment outcomes specifically related to cancer and cardiovascular disease risk in adults with autoimmune rheumatic diseases. And it further shapes how I mentor in my teaching. So for example, more and more I've found myself telling my mentees that let's maybe ask the patient, not just what is the right medication, but maybe perhaps what matters most to you. And keep in mind, how do all the conditions that they have intersect? And maybe what might be drug A as a right choice for somebody with isolated rheumatoid arthritis, perhaps is our drug number 10 of choice when we are managing somebody with rheumatoid arthritis, cancer, heart disease, et cetera. So I think overall, gravitating towards multiple chronic conditions research has definitely guided my practice and how I teach.
SPEAKER_01:Thanks, Namrata, and that's really fascinating. Melissa?
SPEAKER_03:Well, like Rashida and Namrata, thank you for having me here. I'm Melissa Lo. I am an associate professor and geriatric oncologist at the University of Rochester. I'm trained in both hematology, oncology, and geriatrics, and my research focuses focuses on optimizing care of older adults with blood cancers by doing clinical trials, not therapeutic trials, but clinical trials focusing on behavior and supportive care trials, such as exercise study or programs that help elicit patient preferences. So how that interest came about was I have a longstanding interest in cancer, both clinically and research, since medical school. And talking to patients with cancer always gives me a great sense of satisfaction because I felt that I'm able to actually make a difference in making their life a little less lousy. But the epiphany was that as I took care of these patients, like many others, I realized that most of them are older. What I also realized that many of them have multiple chronic conditions and their care are often more complex and really not straightforward. And honestly, emotionally, it was very difficult for me to take care of them, probably because I was not comfortable. And because I know I was not comfortable, I really felt the need to learn geriatrics so I have a better understanding of how best to care for them, cancer and multiple chronic conditions. And then as I got deeper, I was just really interested in geriatric oncology because that made me a better doctor. Again, the more I learned, the more I realized there's no clear answer. And one of the main reasons is that we don't really study this population enough. So in cancer, our treatment decision is often guided by randomized clinical trials. And we love randomized clinical trials. It's all worth a place in cancer. But for many reasons, all older adults are not represented in randomized clinical trials of cancer. So in other words, in clinical practice, it's a little bit of a, it's not a little bit, it's actually a lot of guesswork in terms of recommendations. So whether or not the treatment work, but more importantly, like we actually don't know how much harm we're going to cause. So with that gap, I really feel like the need to research and study older adults with cancer, the gap was really in blood cancer that I found more so than solid tumor. And that sort of led to my interest in geriatric oncology, specifically in hematology.
SPEAKER_01:Really interesting. Let me switch gears a little bit. Are there any key principles that you have found over the course of your careers that you think should be emphasized to trainees or that serve as underpinnings of your research ideas related to multiple chronic conditions in older adults? Let me start with Nimrata.
SPEAKER_02:Yes, that's a wonderful question. So for example, you know, managing rheumatoid arthritis in someone with diabetes, coronary disease or depression doesn't just mean that we give them one pill today, they come four months later, we give them another pill and just keep adding pills if they're not feeling better. It's about what matters most to them. And understanding if maybe the fact that they're not responding is, do they have the financial means to take them or, you know, support at home. So really caring about the person per se, rather than just saying, oh, I'm going to take this pill. X amount of joints are swollen today. We need to keep adding drugs is one principle, I would say. And tied towards that is the other one is about minimizing harm through thoughtful prescribing. I've been at the American Geriatric Society meetings, et cetera. I've learned that polypharmacy sometimes is inevitable in our patients, but at least thoughtful prescribing should not be a difficult decision to make in the clinic. So I try to emphasize deprescribing when possible, looking out for drug-drug interactions, and especially shared decision-making when it comes to immunosuppressing some of our complex patients. And at the same time, maybe the third principle you can say is a cumulative risk awareness. So It's not that sometimes we think one and one will make two. Multiple chronic conditions are not just additive. They're multiplicative in some ways. And similarly, that's why this is driving the research I do. And just as Melissa was outlining, the care for patients with multiple chronic conditions, be they be older adults or in general, just multiple chronic conditions, they are just so paucity of data in terms of What trial data can I extrapolate to a patient right in front of me in the clinic? They never fit a mold that the treatment guidelines present to us. And so keeping in mind that patients sometimes with multiple chronic conditions are not the person that a guidelines X recommendation, Y recommendation might fit. And then last but not least, to keep in mind that I think about is dynamic and longitudinal care. Just like, you know, perhaps true also for Rashida and Melissa, my patients usually tend to live, you know, with their disease. It's not like maybe infection or flu-like illness that will get better over time and that'll be the end of it. So managing multiple chronic conditions requires ongoing reassessment. For example, what might work for somebody at 60 may be very burdensome or harmful even by the age of 80 years old. So keeping in mind and valuing being flexible and reassessing a person's Thank you. Melissa, some key principles that you think about that our listeners
SPEAKER_01:should know.
SPEAKER_03:Thank you for that question. I agree with everything that Namrata said. I think the principles in oncology are and should be very similar to geriatrics. And honestly, across the different specialties, I don't see it being different between an older adult with cancer and an older adult with chronic kidney disease and an older adult with rheumatoid arthritis, for example, or without any chronic illnesses or multiple chronic conditions. Having said that, I would just emphasize on three principles, just making it more concrete. So in the world of geriatric oncology, we have been pushing to do what we call a comprehensive geriatric assessment, basically an evaluation of the overall health of an older adult, which gives you a better understanding of one with multiple chronic condition. So in cancer, precision medicine is such a hot topic where we're always pushing to try and understand the cancer more. But we're not so good at trying to understand the health of an older adult, which is ironic. Through geriatric assessment, that is what we think the best way of understanding the health of an older adult and then combining them with the cancer in terms of better understanding of the tumor biology together, I think will help drive care a little bit better. But it's also beyond that. There's also the next principle, which is really understanding what matters to patients and trying to elicit the values and preferences right from the beginning, and then longitudinally, as well as their caregivers, because in older adults with cancer, roughly 70% of them have caregivers present with them. So understanding the dynamics put in patients and caregivers, as well as the social context, and then try to elicit preferences in the context of that really will help drive personalized medicine for an older adult with cancer. And then finally, now, understanding what their health is through geriatric assessment, what their values and preferences are, really try to optimize care through first recommending the right treatment for the cancer, but also the right supportive care and behavior interventions. Again, make life a little less lousier as they go through cancer treatment because oftentimes we're causing a lot of side effects and we know a lot of the non-drug interventions can help improve a lot of this experience, like fatigue or decrease in physical function. Again, just to come back to the three principles, doing a thorough evaluation, do geriatric assessment, try to elicit their values and preferences, and then with that, try to optimize care through supportive care and behavioral program in the context of their cancer care.
SPEAKER_01:That's great, Melissa. Thank you. Rashida, same question, key principles relevant to your specialty, as well as the care of older adults in general.
SPEAKER_00:Absolutely. And my goodness, Nirana and Melissa really, really hit everything I was thinking about as well. So I'll co-sign a few things. One of the first things I thought about was how critical it is to have a patient-centered focus to care planning. And then, Radha, you mentioned that. And the key example really comes through in talking to trainees about shared decision-making with respect to kidney failure, treatment options, and leaning in that direction more so than telling someone, hey, it's time to start dialysis. Instead, really, this is like the perfect arena to take stock of the entire patient and have a shared decision-making conversation so that their choice, what happens next, is really aligned with their preferences. Another thing I heard come up was the lack of evidence, but then more so is that because there's no evidence, then there are limited guidelines. And so one of the principles related to multiple chronic conditions is to be able to walk that fine line when the patient in front of you maybe doesn't fit what the guideline is saying. And that happens quite often for older adults with kidney disease, in particular, whether it's around surgical decisions or maybe even chemotherapy. even more preventative services like cancer, breast cancer, or colon cancer screenings, like many of the things that seem very straightforward for an older adult with very few chronic conditions or just one is not as clear cut because now if you have multiple chronic conditions, including kidney disease or dialysis, now we're thinking about life expectancy, patient preferences, and really trying to find ways what works best for this patient. And oftentimes we really should get their opinion on that. And so that's one other area I like to emphasize with trainees. I think from the conversation, listening to Narada and Melissa, one thought that came to mind is thinking about the healthcare system in general and how our patients fit into it, especially when it's an older adult who is receiving hemodialysis. They have a medical record in their hemodialysis clinic, but they also may have a medical record at their primary care clinic and how many other doctors they have, right? And if they're not all connected, the fragmented care is often a real challenge for managing these patients and really puts them at risk for medication mistakes, as well as delays in care. And so I think is very related to multiple chronic conditions because it's not just these patients. And so the awareness around being more vigilant and trying to find different ways to, to, work the system when needed to make sure that the care is propagated appropriately. And I think even an added component would be the person who's discharged to a skilled nursing facility and how the medication reconciliation may change in those settings also. Because especially for individuals with kidney disease and of older age, we really are at risk of many mistakes from medication dosing and medication-related problems that could be avoided.
SPEAKER_01:Thank you. All of you think in a very progressive way about this topic of multiple chronic conditions. I guess I want to ask you now, what are the opportunities for getting your colleagues to have the same sort of mindset that all of you have? What are the opportunities and also what are the challenges? And I guess I'd like to ask all three of you to respond and say something about that. So nobody in particular. Any of you have thoughts about that?
SPEAKER_03:I think there are many, many challenges. Some of them are easier. Some of them are very difficult. So I'll start. I think the initial challenge was that there was not a lot of evidence that doing geriatric assessment, for example, for older adults with chronic conditions and cancer actually improve outcome. As I say, in the world of cancer, no randomized trial, no evidence, you can't really implement it. That was the big push from the community to create and develop randomized trial to prove that it works. And we finally had that, I think, in the past five years. And since then, the major cancer organizations have put out guidelines. So the evidence is there. Now, does it help? Maybe, maybe not, because really the time and the reimbursement are still the biggest problem. And oncologists only have 10, 15 minutes per patient. How is it possible for them to do it? Having said that, there are many people who have proven that you can do it outside of the clinic visit. It's part of lacking awareness. And also there are just some people who don't believe in it and just wouldn't do it. So it's just continual efforts at multiple levels, including patient advocates and patients themselves to push for this to happen. So partnering with patients is what I think the community is trying to do more as well as influencing reimbursement and also policy levels. I think ultimately to change behavior, you have to reimburse people for their time. Otherwise, people just wouldn't do it. So recently there is reimbursement for eliciting, for example, patient preferences, right? Is there a way to try and do that through geriatric assessment? That I think will probably change practice to a larger extent. because now you get the pressure from the healthcare systems, which is often what's needed to move things forward in the larger extent. So that's my two cents.
SPEAKER_02:I would say for the challenges, again, just want to emphasize already what Melissa said, and actually Rashida started covering also, is the fragmentation, right, of the healthcare system is what you were alluding to earlier, Rashida. And we have the subspecialties are siloed, right? So a person with multiple chronic condition, for example, might get ex-opinion from the cardiologist. Pulmonologists will say, this is not related to your, you know, this drug. Let's put you on another drug for your respiratory issue. And then they come to the arthritis doctors and now they are like, oh, my ankles are swollen. I wonder why. And, you know, maybe I need something for my arthritis. So I think really fragmentation of care, the subspecialties not talking to each other. And again, why? Probably because doing all that behind the scene communication is never rewarded and never taken into account. an RVU-based system, right? Like XRVUs is what you need and this is your target. You have to meet this. And some of the care slides down the hill, unfortunately. So again, these are Maybe lofty steps are needed to overcome these challenges, really, because these have been embedded in the healthcare system for a long time. But hopefully, moving the needle one day at a time will make a difference. But first of all, even recognizing that this is what the barriers are might be a good start, I might say. These are all the system level, but then also cognitively, the cognitive challenges, right? Like for me to even get a buy-in from some of my colleagues in rheumatology, let alone the mentees or fellows or trainees is like, why should I care about their frailty status? Why should I care about their functional status? I am going to just focus on how many tender joints they have, how many swollen joints they have and move on because I only have 10 minutes per patient, as you were saying, or 20 minutes per patient. So sometimes just understanding the question to us as rheumatologists is not how to control their RA, but maybe how to support this person living with RA, depression, cancer, and I'm sure the list will keep going on. So those were like cognitive challenges, system-wide challenges. And I do want to say something about maybe also on the brighter side of things of the opportunities in front of us. And I think for me as a rheumatologist, one big opportunity I see is most of my diseases are multisystem So it's, we've always had a dialogue somehow, either via text or via epic chat or some other way to my cardiologist, geriatric colleague, you know, primary care doctors, because our diseases span systems and not just limited to the joints. This is a great opportunity for me as a rheumatologist to maybe spread the MCC principles on a wider level and not just even within rheumatology. So there's some momentum already I see at our American College of Rheumatology meeting, for example. A few of us are trying again and again to increase attention to our aging population and even now value-based cares being offered in terms of attention given to that, I think should help and be great opportunities for for us to continue to avail in the future. I'm
SPEAKER_00:going to chime in. You guys are so brilliant into so many ideas rolling that gets my mind turning too. I'll speak more about opportunities, but briefly, I think the challenges really do resonate for the silver nephrology too. It's like everything you guys mentioned reminded me of the outcomes from a qualitative paper I did around what are the factors that would impact the prescribing medications in a dialysis clinic. And so the clinicians who participated were like, we don't have time to talk about all these medications. We have competing priorities with focusing on just their dialysis. You know, we're not being paid to do all these other things just to do the dialysis prescription, right? But then not only that, like, I don't even know how to be prescribed. How would I titrate down gabapentin, right? All the self-efficacy competing priorities the incentives because oftentimes there's some regulatory issues behind the scenes or different things that need to be accomplished that create higher priority than this. But then that leads to perhaps an opportunity because I think there's room for new quality measures in general. And I have the honor of being on American Society of Nephrology's Quality Committee. We were just talking yesterday, we were reviewing the Medicare Advantage star ratings and looking at different ways that they are evaluating care. Like for example, there's a metric on medication adherence for high blood pressure that there should be a certain proportion of people on Medicare Advantage who receive a RAS antagonist, like an ACE inhibitor or ARB. Interestingly, that metric excludes people on dialysis. And we're digging into, we're not sure why, maybe because they have other chronic conditions, maybe because they're frail. But, you know, it seems to me that there's an opportunity for specific quality measures to be created that fit this The multiple chronic condition patient who, while we may not have guidelines, I do think that what we're talking about here today with these frameworks really could be boiled into specific metrics that could be accessible one day. So that's my new idea, new shiny idea. But otherwise, more low-hanging fruit would be sharing this curriculum because I'm realizing that, you know, while we say it's so great for early stage investigators, that also many senior nephrologists could also benefit from it, as well as our advanced practice providers, anyone who works with patients with kidney disease. I think it would be eye-opening for them, too.
SPEAKER_01:Well, I agree. And I just want to thank all of you for a fantastic discussion. All of you are great, great role models. And I look forward to hearing about your successes over the rest of your careers. And thank you so much for talking with me today.
SPEAKER_02:Thank you for having us. So much. Thank you for this opportunity. Thank you.