Dataset Information

Challenges and strategies in patients' health priorities-aligned decision-making for older adults with multiple chronic conditions.

ABSTRACT:

Objectives

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.

Design

Participant observation qualitative study.

Setting

Primary care and cardiology practices in Connecticut.

Participants

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.

Exposure

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.

Main outcomes

Challenges to, and strategies for, aligning decision-making with patient's health priorities.

Results

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.

Conclusions

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.

SUBMITTER: Tinetti M

PROVIDER: S-EPMC6557523 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Publications

Challenges and strategies in patients' health priorities-aligned decision-making for older adults with multiple chronic conditions.

Tinetti Mary M Dindo Lilian L Smith Cynthia Daisy CD Blaum Caroline C Costello Darce D Ouellet Gregory G Rosen Jonathan J Hernandez-Bigos Kizzy K Geda Mary M Naik Aanand A

PloS one 20190610 6

<h4>Objectives</h4>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.<h4>Design</h4>Participant observation qualitative study.<h4>Setting</h4>Primary care and cardiology practices in Connecticut.<h4>Participants</h4>Ten primary care clinicians, five cardiologists, and the Patient Priorities implementation team (f ...[more]

PMID: 31181117

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Project description:Health care may be burdensome and of uncertain benefit for older adults with multiple chronic conditions (MCCs). Aligning health care with an individual's health priorities may improve outcomes and reduce burden. To evaluate whether patient priorities care (PPC) is associated with a perception of more goal-directed and less burdensome care compared with usual care (UC). Nonrandomized clinical trial with propensity adjustment conducted at 1 PPC and 1 UC site of a Connecticut multisite primary care practice that provides care to almost 15% of the state's residents. Participants included 163 adults aged 65 years or older who had 3 or more chronic conditions cared for by 10 primary care practitioners (PCPs) trained in PPC and 203 similar patients who received UC from 7 PCPs not trained in PPC. Participant enrollment occurred between February 1, 2017, and March 31, 2018; follow-up extended for up to 9 months (ended September 30, 2018). Patient priorities care, an approach to decision-making that includes patients' identifying their health priorities (ie, specific health outcome goals and health care preferences) and clinicians aligning their decision-making to achieve these health priorities. Primary outcomes included change in patients' Older Patient Assessment of Chronic Illness Care (O-PACIC), CollaboRATE, and Treatment Burden Questionnaire (TBQ) scores; electronic health record documentation of decision-making based on patients' health priorities; medications and self-management tasks added or stopped; and diagnostic tests, referrals, and procedures ordered or avoided. Of the 366 patients, 235 (64.2%) were female and 350 (95.6%) were white. Compared with the UC group, the PPC group was older (mean [SD] age, 74.7 [6.6] vs 77.6 [7.6] years) and had lower physical and mental health scores. At follow-up, PPC participants reported a 5-point greater decrease in TBQ score than those who received UC (ß [SE], -5.0 [2.04]; P = .01) using a weighted regression model with inverse probability of PCP assignment weights; no differences were seen in O-PACIC or CollaboRATE scores. Health priorities-based decisions were mentioned in clinical visit notes for 108 of 163 (66.3%) PPC vs 0 of 203 (0%) UC participants. Compared with UC patients, PPC patients were more likely to have medications stopped (weighted comparison, 52.0% vs 33.8%; adjusted odds ratio [AOR], 2.05; 95% CI, 1.43-2.95) and less likely to have self-management tasks (57.5% vs 62.1%; AOR, 0.59; 95% CI, 0.41-0.84) and diagnostic tests (80.8% vs 86.4%; AOR, 0.22; 95% CI, 0.12-0.40) ordered. This study's findings suggest that patient priorities care may be associated with reduced treatment burden and unwanted health care. Care aligned with patients' priorities may be feasible and effective for older adults with MCCs. ClinicalTrials.gov identifier: NCT03600389.

Project description:To evaluate the effects of a shared decision making (SDM) intervention for older adults with multiple chronic conditions (MCCs). A pragmatic trial evaluated the effects of the SDMMCC intervention, existing of SDM training for nine geriatricians in two hospitals and a preparatory tool for patients. A prospective pre-intervention post-intervention multi-center clinical study was conducted in which an usual care group of older patients with MCC and their informal caregivers was included before the implementation of the intervention and a new cohort of patients and informal caregivers after the implementation of the intervention. SDM was observed using the OPTIONMCC during video-recorded consultations. Patient- and caregivers reported outcomes regarding their role in SDM, involvement, perceived SDM and decisional conflict were measured. The differences between groups regarding the level of observed SDM (OPTIONMCC) were analyzed with a mixed model analysis. Dichotomous patient-reported outcomes were analyzed with a logistic mixed model. From two outpatient geriatric clinics 216 patients with MCCs participated. The mean age was 77.3 years, and 56.3% of patients were female. No significant difference was found in the overall level of SDM as measured with the OPTIONMCC or in patient-reported outcomes. However, at item level the items discussing 'goals', 'options', and 'decision making' significantly improved after the intervention. The items discussing 'partnership' and 'evaluating the decision-making process' showed a significant decrease. Fifty-two percent of the patients completed the preparatory tool, but the results were only discussed in 12% of the consultations. This study provides scope for improvement of SDM in geriatrics. Engaging older adults with MCCs and informal caregivers in the decision making process should be an essential part of SDM training for geriatricians, beyond the SDM steps of explaining options, benefits and harms. More attention should be paid to the integration of preparatory work in the consultation.

Dataset Information

Challenges and strategies in patients' health priorities-aligned decision-making for older adults with multiple chronic conditions.

Objectives

Design

Setting

Participants

Exposure

Main outcomes

Results

Conclusions

Publications

Challenges and strategies in patients' health priorities-aligned decision-making for older adults with multiple chronic conditions.

Similar Datasets

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