Development of a Tool for Eliciting Patient Priority from Among Competing Cardiovascular Disease, Medication‐Symptoms, and Fall Injury Outcomes

In patients with multiple health conditions, the treatment of one condition may worsen another one. Clinical decision-making should incorporate patients’ priorities when faced with these potentially competing health outcomes.1 The older adult with coexisting hypertension and fall risk represents a common clinical situation for which a method for eliciting patient priorities would be useful. Falls and hypertension are both major causes of disability. The 3-year incidence of all nonfatal cardiovascular events in older adults with hypertension is 16.2%,2 similar to the incidence of serious fall injury in elderly persons with fall risk.3,4 Treatment of hypertension in elderly patients decreases the risk of cardiovascular disease (CVD) outcomes.2,5–7 Although the relationship between antihypertensive medications and fall risk is complex and as yet inadequately studied, most studies adjusting for appropriate confounders have reported a greater risk of falls, fall injuries, or fall risk factors with antihypertensive medications. Conversely, the risk of falls may be decreased if medications are reduced.8 Cardiovascular medications, including antihypertensives, are the drugs most commonly implicated in medication-related symptoms and adverse effects.9 Furthermore, falling and fall risk factors such as postural unsteadiness, weakness, dizziness, and postural hypotension are among the most common adverse effects of medications, including antihypertensive medications.10,11 The co-occurrence of hypertension and fall risk, therefore, can serve as a model for studying health priorities in the face of potentially competing health conditions, although eliciting priorities raises concerns about well-known challenges, including reluctance to articulate feelings about outcomes not yet experienced, the tendency to select all outcomes as equally important, and change in priorities with time and changing health status.12,13 Limited health literacy, the effects of framing and ordering, and inadequate numeracy and communication skills of patients and clinicians further complicate efforts to elicit patient priorities and preferences reliably.14–16 If, as precepts of patient-centered care espouse, clinical decision-making is to incorporate patients’ priorities and individualize therapy to meet these priorities,1 then an approach must be found that addresses these challenges. Conjoint analysis,17 which elicits priorities by asking respondents to make explicit tradeoffs between competing outcomes, is one possible approach that has been applied in several health-related areas. Conjoint analysis has been used successfully in older individuals with visual deficits, limited education, and lack of computer experience.18–20 The aim of the present study was to describe the development and testing of a choice-based conjoint analysis task designed to elicit older individuals’ priorities in the face of competing CVD outcomes, medication-related symptoms, and fall injuries.