| Goal |
Implementation Strategies & Resources |
| Consider certain key principles in evaluating clinical evidence. |
Consider:
- Applicability and quality of evidence;
- Outcomes;
- Harms and burdens;
- Absolute risk reduction;
- Time horizon to benefit.
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| Ascertain whether the evidence applies to older adults with multimorbidity and whether it has been rigorously evaluated. |
Key questions:
- Does the individual being considered resemble the research population?
- Does multimorbidity modify the effect of the intervention?
- Were older adults with or without multimorbidity included in the study?
- Are the design and analysis of the study of high quality?
- If the evidence comes from a randomized clinical trial, are the results applicable to older adults with multimorbidity? (Observational studies often can provide additional information, but have challenges related to confounding.)
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| Focus on outcomes. |
Key considerations:
- clear identification of expected treatment outcomes;
- importance of outcomes to the patient;
- variations in baseline risk (in order to validate expectations for treatment);
- risks and side effects of interventions in older patients with multimorbidity (to avoid exacerbation of co-morbidities);
- comparator treatments or strategies;
- time to benefits;
- precision and confidence limits of analyses.
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| Weigh anticipated benefits against potential harms and burdens. |
Key considerations:
- Studies may be too short-term to give adequate assessment of harms;
- Treatment burdens experienced by patients are rarely included in study reports;
- Exacerbation of co-existing conditions may be caused by following treatment guidelines for another condition;
- Adherence may be impacted by financial costs and difficulties of regimens;
- Treatment interactions in older adults with multimorbidity may occur.
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| Clarify risk reduction. |
Key considerations:
- Results expressed as relative risk reduction (RRR) are not the same as those expressed by absolute risk reduction (ARR).
- ARR is based on the risk of an outcome without treatment minus outcome with treatment, or on the difference of two comparative treatments.
- RRR usually appears much more impressive than ARR.
- If baseline risk is not reported, RRR is uninterpretable since the baseline risk may be different for older multimorbid adults compared to the general population, and there may be greater variability.
- Baseline risks may be reported in single-disease guidelines, observational studies, prognostic indices, or control groups of single disease trials.
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| Identify time horizon to benefit. |
Key considerations:
- What is the sample size of the study?
- What is the duration of follow-up?
- If evidence is expressed in number needed to treat (NNT) or number needed to harm (NNH), is a time period to outcome reported?
- Is the older adult with multimorbidity at risk of dying from a comorbidity before benefitting from a treatment (e.g., tight glucose control in diabetes).
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