Date Published: June 10, 2019
Publisher: Public Library of Science
Author(s): Mary Tinetti, Lilian Dindo, Cynthia Daisy Smith, Caroline Blaum, Darce Costello, Gregory Ouellet, Jonathan Rosen, Kizzy Hernandez-Bigos, Mary Geda, Aanand Naik, Maw Pin Tan.
While patients’ health priorities should inform healthcare, strategies for doing so are lacking for patients with multiple conditions. We describe challenges to, and strategies that support, patients’ priorities-aligned decision-making.
Participant observation qualitative study.
Primary care and cardiology practices in Connecticut.
Ten primary care clinicians, five cardiologists, and the Patient Priorities implementation team (four geriatricians, physician expert in clinician training, behavioral medicine expert). The patients discussed were ≥ 66 years with >3 chronic conditions and ≥10 medications or saw ≥ two specialists.
Following initial training and experience in providing Patient Priorities Care, the clinicians and Patient Priorities implementation team participated in 21 case-based, group discussions (10 face-to-face;11 telephonic). Using emergent learning (i.e. learning which arises from interactions among the participants), participants discussed challenges, posed solutions, and worked together to determine how to align care options with the health priorities of 35 patients participating in the Patient Priorities Care pilot.
Challenges to, and strategies for, aligning decision-making with patient’s health priorities.
Categories of challenges discussed among participants included uncertainty, complexity, and multiplicity of problems and treatments; difficulty switching to patients’ priorities as the focus of decision-making; and differing perspectives between patients and clinicians, and among clinicians. Strategies identified to support patient priorities-aligned decision-making included starting with one thing that matters most to each patient; conducting serial trials of starting, stopping, or continuing interventions; focusing on function (i.e. achieving patient’s desired activities) rather than eliminating symptoms; basing communications, decision-making, and effectiveness on patients’ priorities not solely on diseases; and negotiating shared decisions when there are differences in perspectives.
The discrete set of challenges encountered and the implementable strategies identified suggest that patient priorities-aligned decision-making in the care of patients with multiple chronic conditions is feasible, albeit complicated. Findings require replication in additional settings and determination of their effect on patient outcomes.
Healthcare decision-making for persons with multiple chronic conditions (MCCs) is difficult [1–5]. The focus on managing individual conditions fails to account for interactions among multiple conditions and their treatments, leading to uncertain benefit and potential harm [3–6]. Evidence to guide care is often lacking because individuals with MCCs are excluded from most clinical trials [7–8]. Even trials that include these individuals address disease-specific outcomes or survival, not always the outcomes most valued by older adults with MCCs . The number and complexity of patient-related activities such as medications, testing, health visits, and self-monitoring tasks, are increasingly burdensome [2,9–12]. Older adults with multiple chronic conditions, when faced with tradeoffs that require difficult choices, vary in their health outcome goals and in their preferences for the healthcare they are willing and able to receive [12–15].
The Patient Priorities implementation team and clinicians reviewed and discussed 35 patient scenarios over the 21 sessions. These sessions included 10 face-to-face (five with PCPs; four with cardiologists; and one with both groups) and 11 telephonic (six with PCPs, two with cardiologists; and three with PCPs and cardiologists) case-based group discussions. The patients discussed ranged from 67–98 (median, 78) years old; 75% were female; all were Caucasian. All had at least five chronic conditions. The number of active problems listed in patients’ EHR ranged from 7–66 (median, 19). Patients received from 5–16 (median, 10) prescription medications. Descriptions of the 35 patients discussed are displayed in S1 Table. Sociodemographic and function information, chronic conditions, active problems, and medications were ascertained from their EHRs. Health outcome goals and healthcare preferences were ascertained from their health priorities identification process.
Through discussions among clinicians and the Patient Priorities implementation team, we identified challenges to aligning clinical decisions with patients’ health priorities as well as feasible strategies for translating patients’ health priorities into decisions and care. The challenges can be addressed by several of the strategies and, in turn, each strategy addresses one or more challenge. For example, all five strategies facilitate decision-making in the face of the uncertainty and complexity inherent in the care of older adults with multiple coexisting conditions and variable priorities. Similarly, all the strategies help get patients and their clinicians on the same page when they start with differing perspectives. Clinicians facing difficulty switching from disease guideline—to patients’ health priorities—aligned decision-making can start with one actionable thing that matters most to the patients and conduct serial trials using patient’s health outcome goals and healthcare preferences in communications with patients and other clinicians. Taken together and applied in appropriate situations, the decisional strategies can guide implementation of patient-centered care, particularly for persons with MCCs .