【文献Abstract】多併存疾患患者へのアプローチ（フレームワーク）

〈要点〉

多併存疾患へのアプローチ：PACE
①優先順位づけ（PRIORITIZE）
　その日の診療と次回までの懸念事項を特定。今後数日または数週間で起こりうる可能性のある問題に焦点を当てる。

②効果的なコミュニケーション（COMMUNICATE EFFECTIVELY）
　アクティブリスニングを行う。患者に最も差し迫った懸念を尋ねることから始めるとよい。「引き出す－与える－引き出す」　専門用語を避け、抽象的ではなく具体的な言葉で伝える。その他、通訳や視覚を使ったコミュニケーションを行う。

③エビデンスに基づく医療の提供（APPLY EVIDENCE-BASED MEDICINE）
　患者固有のエビデンスに基づくアプローチを行うことは、診断的または治療的介入の利益と害のバランスをとるのに役立つ。多くの慢性疾患のある患者の予後は、患者の平均余命に基づいて決定を優先するとよい。

④コラボレーション（COLLABORATE）
　多職種、家族・介護者を巻き込み支援を行う。特に気になる患者対しては、診察前・診察後を管理するとよい。例えば、予約の全日に電話をしたり、診察の終了時にフォローアップスケジュールを立てる等。

〈雑感〉

高齢者、訪問患者などは特に多併存疾患患者が多い。今回の文献で個人的には新しい知見があったわけではないが、多併存疾患患者に対するアプローチの「フレームワーク」として、初学者に提供するのもいいのかと感じた。

〈文献〉

Complex Care: Treating an Older Patient with Multiple Comorbidities
RAVISHANKAR RAMASWAMY, MD, Icahn School of Medicine at Mount Sinai, New York, New York

Am Fam Physician. 2014 Mar 1;89(5):392-394.

Case Scenario
A 74-year-old Latino patient with a history of hypertension, diabetes mellitus, dyslipidemia, multivessel coronary and peripheral arterial diseases, and chronic osteomyelitis was recently discharged from our hospital after undergoing several toe amputations. His hospital course was complicated by contrast-induced nephropathy that required hemodialysis; heparin-induced thrombocytopenia; lower extremity cellulitis; and significant functional decline.

One week after discharge, he presented to the geriatrics clinic for follow-up about his pain and mobility. He wanted to know if he could obtain a motorized wheelchair. He appeared to have moderate leg pain, apparently because he never filled his discharge prescription for oxycodone (Roxicodone). He did not remember his medications or their dosages, and had not brought his pill bottles with him. He was unsure about when and where to follow up with his multiple subspecialists. How can I best treat this patient with multiple chronic conditions? How should I address his limited health literacy?

Commentary
Although there are guidelines for management of single chronic illnesses, the evidence base for management of multiple comorbidities is lacking. The American Geriatrics Society described a clinical approach to managing patients with multiple comorbidities in 2012.1 A summary of the American Geriatrics Society expert opinion is available at http://www.americangeriatrics.org/files/documents/MultimorbidityPocketCardPrintable.pdf.

The challenge of managing multiple comorbidities can be compounded by limited health literacy, which is more common in older persons, poor persons, and certain minorities, such as Latinos.2 For a typical older patient, medical care has become more complex, comprising multiple steps with crucial exchanges of information.3 Most physicians have between 15 and 30 minutes for a follow-up visit, which is often insufficient to address many or all comorbidities effectively. The following management strategy attempts to address clinical and system-based challenges. Additionally, applying an approach based on the acronym PACE can help physicians to pace themselves during visits with these patients .

PRIORITIZE

Prioritizing involves identifying concerns that need attention during this visit and those that can wait until the next visit. Focus on problems that may lead to the greatest morbidity, and possibly mortality, in the next days or weeks. A discussion of the patient's agenda, as well as your own, at the beginning of the visit will help to create a realistic framework of the items that will be addressed in the time available. The patient in this case scenario is mainly concerned about the toe amputation, the pain in the leg, and getting a motorized wheelchair for ambulation. At the beginning of the visit, create a pain management plan, discuss wound care, and follow up on his kidney function and cell counts. At the end of the visit, it would be beneficial to alert a social worker to assist the patient with procuring durable medical equipment.

COMMUNICATE EFFECTIVELY
Good communication is key when interacting with older patients who have comorbidities. There are several components to facilitating effective communication with this population.

Active Listening. Start by asking the patient for his or her most pressing concerns. It is appropriate to probe for general and specific goals and values, as well as any preference for a particular plan of action. The ask-tell-ask and teach-back methods can elicit the patient's understanding of key medical concepts or recommendations.4 Avoid medical jargon, and use concrete and direct words rather than abstract terminology.

Interpreter Services. Nonverbal communication is best gauged by someone who is well versed in the patient's culture. Check whether your institution provides language interpreters, and schedule them for visits as needed. Another option is a phone interpreter service. Family members should not be used as proxy history providers or interpreters.

Reinforcement. Visual aids can clarify and reinforce comprehension of key medical issues. For example, decision aids for diabetes management are available for teaching patients about their medications' benefits, adverse effects, and dosages.5 Electronic medical records can create individualized visit summaries that include instructions and educational materials.

APPLY EVIDENCE-BASED MEDICINE
Employing a patient-specific, evidence-based approach helps balance the benefits and harms of diagnostic or therapeutic interventions. Reviewing current practice recommendations and calculating the absolute risk reduction and the number needed to treat will guide management decisions. Prognostication in patients with many chronic conditions, although imperfect, may help prioritize decisions based on the patient's life expectancy. This patient has a five-year mortality risk of roughly 69% and a 10-year mortality risk of roughly 93% based on Schonberg and Lee indices, respectively.6

COLLABORATE
An interdisciplinary care team can help manage a complicated case. A social worker, nurse practitioner, or registered nurse, if available, is often able to meet with the patient or family at more frequent intervals to assist with health education, chronic care management, and psychosocial counseling.

In my practice, the social worker assists with determining insurance coverage and payment sources, and the medical assistant orders supplies from our durable medical equipment vendor. In the absence of a social worker, another member of your practice can visit the Medicare website (http://www.medicare.gov) to find a list of covered medical equipment vendors in your area.

INVOLVE THE CAREGIVER OR FAMILY
With the patient's permission, reach out to a caregiver or responsible family member and give him or her a few tasks to complete and report back to you at a specified date. This person could be asked to obtain immunization or procedure records from other physicians or clinics or to report on the patient's response to a new medication in a week's time.

MANAGE PRE- AND POSTVISIT FACTORS
Alert your front-desk staff and administrative assistant to any special needs of particularly worrisome patients. Such patients may benefit from a personal phone call the day before the appointment (rather than an automated call) reminding them to bring their medication bottles to the visit and clarifying the date, time, and location. At the end of the visit, the patient should have an easy-to-understand follow-up schedule to take home. Some physicians may feel comfortable sharing their cell phone number so the patient can bypass the delay and frustration that may be associated with an answering service.

Author disclosure: No relevant financial affiliations.

Address correspondence to Ravishankar Ramaswamy, MD, at ravishankar.ramaswamy@mssm.edu. Reprints are not available from the author.