Micro Level Priority Setting for Elderly Patients with Acute Cardiovascular Disease and Complex Needs Practice What We Preach or Preach What We Practice?

............................................................................................................................. 1 LIST OF PAPERS .................................................................................................................... 3 ABBREVIATIONS AND ACRONYMS ................................................................................ 5 AIMS OF THE STUDY ........................................................................................................... 7 General aim ............................................................................................................................ 7 Specific aims .......................................................................................................................... 7 BACKGROUND ....................................................................................................................... 9 Legal, demographic, and economic considerations ............................................................... 9 The Swedish priority setting case ......................................................................................... 10 Parliamentary decisions ................................................................................................... 11 Implementation of the parliamentary decisions ............................................................... 13 Obstacles for priority setting ................................................................................................ 14 THE STUDY OBJECT .......................................................................................................... 17 Why study this object? ......................................................................................................... 17 Elderly patients with complex needs in a cardiovascular context ........................................ 18 Acute cardiovascular disease including NSTEMI ............................................................... 18 CONCEPTUAL FRAMEWORK ......................................................................................... 23 Priority setting ...................................................................................................................... 23 Priority setting principles and criteria .................................................................................. 25 Evidence based medicine ..................................................................................................... 25 Needs .................................................................................................................................... 27 Complex needs with particular attention to comorbidity and frailty ................................... 28 Biological age ....................................................................................................................... 31 MATERIALS AND METHODS ........................................................................................... 33 Paper I .................................................................................................................................. 33 Paper II ................................................................................................................................. 34 Paper III ................................................................................................................................ 36 Paper IV ................................................................................................................................ 37 RESULTS ................................................................................................................................ 39 Paper I .................................................................................................................................. 39 Paper II ................................................................................................................................. 40 Paper III ................................................................................................................................ 43 Paper IV ................................................................................................................................ 46 DISCUSSION ......................................................................................................................... 49 CONCLUSIONS ..................................................................................................................... 61 THE FUTURE CHALLENGE OF ELDERLY WITH COMPLEX NEEDS .................. 63 Using evidence-based guidelines or ”mindlines” in priority setting .................................... 63 Choosing pathways .............................................................................................................. 66 SAMMANFATTNING PÅ SVENSKA ................................................................................ 69 APPENDICES ........................................................................................................................ 73 Appendix A .......................................................................................................................... 74 Appendix B .......................................................................................................................... 80 Appendix C .......................................................................................................................... 81 Appendix D .......................................................................................................................... 82 Appendix E ........................................................................................................................... 83 Appendix F ........................................................................................................................... 84 Appendix G .......................................................................................................................... 86 REFERENCES ....................................................................................................................... 95 PAPERS ................................................................................................................................ 107