Finding out goals and preferences can inform decision-making

What is the best way for clinicians to determine realistic treatment goals for older patients with multiple chronic conditions (MCCs)? According to results from a cross-sectional analysis of the Patient Priorities Care study, simply asking patients what their personal priorities are may do the trick.

When it comes to clinical decision-making, many treatments are designed to address disease-specific outcomes and survival, and most tools available to determine patients’ goals and preferences were developed with advanced illness or specific conditions in mind. However, “Some of these approaches may be less useful to older adults weighing the benefits, burdens, and tradeoffs associated with long-term management of several chronic conditions,” Mary E. Tinetti, MD, of the Department of Internal Medicine at Yale School of Medicine in New Haven, Connecticut, and colleagues wrote in JAMA Network Open. A recent study evaluating Patient Priorities Care (PPC), a framework designed to support the alignment of clinical decision-making with patient priorities among older adults with MCCs, found that PPC was associated with increased care aligned with patient priorities, as well as reduced treatment burden and unwanted health care.

Tinetti and colleagues performed this study to describe the outcome goals and health care preferences identified by older adults participating in the Patient Priorities Care study and found that, for the most part, patients prioritized realistic goals geared towards participating in everyday life.

“Identifying outcome goals that are realistic and actionable appears to be feasible among older adults with MCCs,” Tinetti and colleagues reported. “No participant-selected goals were grandiose or unrealistic, likely because arriving at realistic and actionable goals given each person’s health status was part of the facilitation process. Goals often were linked to multiple values as expected, and reported previously, for meaningful human activities.”

The PPC framework’s ability to determine achievable patients goals — such as dining out with family, exercising, and shopping independently — “may help to overcome the contextual blindness and contribute to making care fit” in order to guide clinician decision-making, Marleen Kunneman, PhD, of Leiden University Medical Center in Leiden, the Netherlands, and Victor Montori, MD, MSc, of the Mayo Clinic in Rochester, Minnesota, wrote in an editorial accompanying the study.

What’s not clear, however, is whether this method will do enough to facilitate collaboration between physicians and patients, they argued. “Rather than a conversation, [the PPC] method may facilitate a staccato collaboration by which the patient provides goals and the clinician decides how to achieve those goals. Also, the method may not contribute to cocreation.

“It is possible that in the spirit of efficiency, for example, the elicitation of priorities for documentation and feedforward networking will be coupled with a library of care plans and an algorithmic approach to determine which plan is a better match to the priorities of each patient,” they explained. “…Paradoxically, the application of algorithmic guidelines in response to ’biological priorities’ has contributed to polypharmacy and poorly fitted care, justifying in part the PPC program. How will patient priorities retain the personal context that gives them sense when documented in the medical record and used at another time and place to shape care without a new conversation? How will responding in this manner prevent us from once again missing the person in the patient? How will we ensure that responding to the documented priorities does not produce care plans that fail to make sense intellectually, practically, and emotionally to the patient?”

Kunneman and Montori concluded that more research will be needed to determine how priority elicitation “can support the conversational dance of the patient and the clinician as they work together to continuously fit possible care plans.”

For their analysis, Tinetti and colleagues recruited participants from the PPC study who underwent health priorities identification from Feb. 1, 2017, through Aug. 31, 2018, in a primary care practice. Participants were age 65 years or older, spoke English, and had at least three chronic conditions — also, participants used at least 10 medications, saw at least two specialists, or had at least two emergency department visits or one hospitalization during the prior year.

Participants were guided by facilitators to identify their core values, up to three actionable and realistic outcome goals, health-related barriers to those goals, up to three health care activities they found helpful, and up to three health care activities they found bothersome.

Of 236 eligible patients, 163 (69%) agreed to participate in the study — most participants were White (158 [96.9%]) and women (109 [66.9%]), and mean [SD] participant age was 77.6 (7.6) years.

“Of 459 goals, the most common encompassed meals and other activities with family and friends (111 [24.2%]), shopping (28 [6.1%]), and exercising (21 [4.6%]),” they found. “Twenty individuals (12.3%) desired to live independently without specifying necessary activities. Of 312 barriers identified, the most common were pain (128 [41.0%]), fatigue (45 [14.4%]), unsteadiness (42 [13.5%]), and dyspnea (19 [6.1%]).” Many health goals addressed more than one value, the study authors noted, and most involved a function supporting a goal related to relationships, enjoying life, or productivity, such as personal mobility, cooking, driving, or traveling.

“Similar proportions of patients identified at least 1 medication that was helpful (130 [79.8%]) or bothersome (128 [78.5%]),” they continued. “Medications most commonly cited as helpful were pain medications, including nonopiods (36 of 55 users [65.5%]) and opioids (15 of 27 users [55.6%]); sleep medications (27 of 51 users [52.9%]); and respiratory inhalants (19 of 45 [42.2%]). Most often mentioned as bothersome were statins (25 of 97 users [25.8%]) and antidepressants (13 of 40 users [32.5%]). Thirty-two participants (19.6%) reported using too many medications. Health care visits were identified as helpful by 43 participants (26.4%); 15 (9.2%) reported too many visits. Procedures were named helpful by 38 participants (23.3%); 24 (14.7%) cited unwanted procedures. Among 48 participants with diabetes, monitoring of glucose levels was doable for 18 (37.5%) and too bothersome for 9 (18.8%).”

Tinetti and colleagues concluded that, though further research is needed, “this study suggests that asking people about their goals and preferences and getting responses that can inform decision-making is feasible. Combining patients’ health conditions, function, and health trajectory with these goals and preferences should focus care for older adults with MCCs…aligning care with patients’ priorities will require input from many health care professionals as well as community and other services. The variability in goals and preferences supports patients’ priorities as the targets toward which to aim all health and support services.”

In their editorial, Kunneman and Montori argued that the PPC program does not make a case for a comprehensive map of patient priorities so much as it “makes a strong case for how personal and contextual patient priorities can be.” To tailor patient care to the complexity of patients’ lives, they added, will require ongoing elicitation of patient preferences as they evolve, both at the point of care and at “the point of life,” to integrate care and daily life.

“The PPC program has shown that eliciting patient priorities and using them to craft care is possible and effective,” they wrote. “We need to shed light on the nature of the work of making care fit to ensure that it can effectively advance patient priorities while minimally disrupting their lives and loves.”

  1. Older patients with multiple chronic conditions (MCCs) who participated in the Patient Priorities Care (PPC) program expressed realistic and actionable goals for their care, suggesting that assessing patient priorities can help guide clinical decision-making.

  2. Further research is needed to determine how the PPC framework can facilitate cocreation of treatment plans between physicians and patients.

John McKenna, Associate Editor, BreakingMED™

This study was supported by grants from the John A. Hartford Foundation (Tinetti and Costello), the Gordon and Betty Moore Foundation (Tinetti), and the Robert Wood Johnson Foundation (Tinetti) and grant P30AG021342 from the National Institute on Aging, National Institutes of Health (Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine).

Tinetti and colleagues reported no disclosures.

Kunneman reported receiving personal grant 016.196.138 from the Dutch Research Council, The Netherlands Organization for Health Research and Development, for her research on how to improve making care fit. No other disclosures were reported.

Cat ID: 494

Topic ID: 398,494,282,494,730,255,463,925