Physicians, Patients at Odds on Chronic Care Priorities

Diana Swift

September 09, 2019

Think you're in sync with your patients about their chronic health conditions and what concerns them most? You may need to think again, according to the results of an exploratory study of primary care physicians and their patients.

The study, published online today in Annals of Family Medicine, found low physician-patient agreement on patients' self-reported health priorities, with almost 30% of patients' top concerns not even making their physicians' corresponding lists.

Among the 10 most prevalent conditions reported by patients, concordance was very good for hypothyroidism (κ = .85, 95%); it was good for diabetes (κ = .70) and hypertension (κ = .74).

However, agreement fell to moderate for asthma (κ = .53) and obesity (κ = .45) and was only fair for osteoarthritis (κ = .36), hearing impairment (κ = .32), and eczema (κ = .25).

Agreement was downright poor for chronic sleep disorder (κ = .16) and chronic anxiety disorder (κ = .12).

"Our findings suggest the need for more patient-centered care for patients with various chronic conditions," write Stéphanie Sidorkiewicz, MD, PhD, of the Department of General Medicine at Descartes University in Paris, France. "The pursuit of patient-centered care might require a shift in how our models of care are designed to help physicians and patients build a therapeutic alliance and a better partnership."

Among the 153 physician-patient pairs who responded to the survey, 87.6% had at least one matching priority on their list; 12.4% had no matches.

At the extremes of agreement, one pair had identical priority lists, consisting of obesity, high blood pressure, and sleep apnea. In one totally discordant pair, the patient listed allergic rhinitis, benign prostatic hypertrophy, and recurrent herpes as most important, whereas the physician listed skin cancer, dyslipidemia, and osteoarthrosis.

The findings align with other research suggesting that patients attach more importance to ailments that affect daily life or that entail clear symptoms, such as osteoarthritis, whereas general practitioners (GPs) are more likely to prioritize the prevention of complications from conditions associated with a poor prognosis, such as chronic obstructive pulmonary disease.

Priority Lists

During April and May 2017, 233 patients from 16 Parisian general practices were matched with physicians who had treated them for at least 12 months. The median age of the patients was 59 years (interquartile range, 41.0 – 72.0), and 139 were women (59.7%).

Both patients and physicians were asked the following question in an anonymous survey: "Among your (or your patient's) chronic conditions, can you tell us which are, in your opinion, the most important to manage or care for?"

Participants were asked to write a priority list of up to three chronic conditions and to rank them in order of importance.

On the number of chronic conditions reported by both groups, agreement was moderate (intraclass correlation coefficient, .59; 95% confidence interval, .49 – .68). The three conditions most frequently reported by patients and GPs alike were high blood pressure (34.3% and 38.6%, respectively), osteoarthritis (25.3% and 18.0%), and chronic anxiety disorder (14.2% and 13.7%).

The mean number of chronic conditions reported by patients was 3.8 (SD, 3.1); for GPs, the mean number was 3.4 (SD, 2.5). A total of 182 patients (78.1%) reported having two or more conditions, which was similar to the proportion cited by physicians (n = 184; 79.0%).

Previous research, the authors note, suggests that agreement is likely to be higher for severe conditions requiring daily treatment or regular monitoring than for milder conditions or those with less clear diagnostic criteria.

In addition, they say, primary care physicians may be less aware of diseases that are followed by specialists. In the current study, for example, six patients reported macular degeneration, which seriously affects daily life, but none of their physicians reported this.

The authors acknowledged the need for studies with larger sample sizes in order to confirm their results.

"Future research should explore the consequences of poor patient-GP agreement on health outcomes," Sidorkiewicz and associates write. It should also focus on how to achieve of patient-centered care in the context of limited time for clinical consultations and "efficient personalized communication adjusted to health literacy."

The authors stress that patient preferences should be integral to clinical decision making, with care shifting from a focus on disease to one on patients' goals.

The authors have disclosed no relevant financial relationships.

Ann Fam Med. Published online September 9, 2019. Full text

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