Clinical Scenario:

A 74 year old Caucasian male with a history of coronary artery disease with 4 vessel CABG 8 years ago, Type II diabetes with an A1C of 8.2 on insulin and metformin, hyperlipidemia with an LDL of 90 on atorvastatin, hypertension with recent clinic BP of 155/85 on lisinopril, chlorthalidone, and metoprolol.

A recent echocardiogram shows an EF of 40% and recent chemistry shows a GFR slightly decreased from before at 45. The patient has not experienced any falls in the past 12 months. How could the MCC GEMS app be used to optimize his care?

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Patients don’t just have one problem. The older the patient, the more medical conditions they are likely to have. For the management of coronary artery disease, hypertension, hyperlipidemia and Type II diabetes, the busy primary care provider is faced with multiple guidelines from different organizations — some of them conflicting. No one makes a guideline for the 70 year old patient with all of these. This is the very definition of multimorbidity; a condition present in well over 50% of adults. The problem is that even if you try to apply these disparate guidelines, patients with multimorbidity still have worse outcomes — death, adverse drug reactions, increased hospitalization, overutilization and out of control medical costs. There is a growing body of medical literature directed at combating the problem of multimorbidity.

Dr Victor Montori at Mayo has been one of many researchers leading the charge against multimorbidity via what he calls minimally disruptive medicine. With a grant from the Agency for Healthcare Quality and Research (AHRQ), the American Geriatrics Society (AGS) has just launched a new app aimed at assisting providers in providing optimal care for patients with multimorbidity. The app uses the AGS’s guideline entitled, “Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians.” We have previously discussed some AGS apps here on iMedicalApps.com.

Evidence based medicine

The app states that it is evidence based as it is derived from the AGS multimorbidity guidelines. The app conveniently allows you to see the entire guideline. However, the guideline is derived from an expert panel so clearly there is a level of “expert opinion” throughout the content of the app. The app does include a number of excellent evidence based tools including the Mini-Cog screen for dementia, the Vulnerable Elders Assessment (VES-13) and the Patient Health Questionnaires 2 and 9 (PHQ-2, PHQ-9) along with several others. This is one of the first apps I have seen to include all of those together.

What providers would benefit from this App?

Students, residents, mid-levels, Family Medicine, Internal Medicine and subspecialties, and Geriatrics providers. The app could really benefit any provider who manages geriatrics patients with multiple medical conditions.

Disclaimer: The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.

  • Price
    • Free
    • App intends to do the “right thing” by patients by taking into account their preferences, realistic goals, and important evidence based statistics instead of blindly following guidelines.
    • Multiple evidence based geriatric assessment calculators built into the app.
    • Access to entire AGS guideline on multimorbidity.
    • Ability to search the AHRQ Guidelines Clearinghouse from within the app with mobile friendly results.
  • Dislikes
    • App is too verbose to make it easy to use at the POC. It reads too much like a book.
    • Directions on the best sequence and use of the app are lacking.
    • Navigation through the app more convoluted than it should be.
    • Many links missing to relevant calculators and even missing ability to link to other AGS Apps such as iGeriatrics.
  • Overall

    A near miss app from the AGS. I think many providers should “read” this app just to familiarize themselves with the principles of multimorbidity and minimally disruptive medicine.  I think many will find it difficult to use on specific patients at the point of care.  Certainly, it allows you to decide if a patient has multimorbidity and it includes several calculators not easily found elsewhere. However, I don’t think that will be enough for many providers to keep them using the app again and again. With a bit more refinement and a less verbose user experience this app could really change the way many of us approach complex medical patients.

  • Overall Score
  • User Interface

    Too verbose. Has several nice built in calculators.

  • Multimedia Usage

    The app allows searching of the AHRQ guideline clearinghouse and ability to see entire AGS guideline on multimorbidity, but could use more refined search results.

  • Price

    Free!

  • Real World Applicability

    A great concept and the “right thing” to do for our patients with multimorbidity, but the ability to use this rapidly at the point of care falls short of ideal.

  • Device Used For Review

    iPhone 6 running iOS 8.3

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