Prioritize Goals of Older Patients With Multimorbidities

Will Pass

May 06, 2021

When caring for older adults with multiple chronic conditions, prioritizing patient goals is more effective and efficient than trying to address each condition in isolation, said Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and Public Health and chief of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians annual Internal Medicine meeting, the gerontologist noted that primary care providers face a number of challenges when managing elderly patients with multimorbidity. These challenges include a lack of representative data in clinical trials, conflicting guideline recommendations, patient nonadherence, and decreased benefit from therapies due to competing conditions, she said.

"Trying to follow multiple guidelines can result in unintentional harms to these people with multiple conditions," Tinetti said. She gave examples of the wide-ranging goals patients can have.

"Some [patients] will maximize the focus on function, regardless of how long they are likely to live," Tinetti said. "Others will say symptom burden management is most important to them. And others will say they want to live as long as possible, and survival is most important, even if that means a reduction in their function. These individuals also vary in the care they are willing and able to receive to achieve the outcomes that matter most to them."

For these reasons, Tinetti recommended patient priorities care, which she and her colleagues have been developing and implementing over the past 5-6 years.

"If the benefits and harms of addressing each condition in isolation is of uncertain benefit and potentially burdensome to both clinician and patient, and we know that patients vary in their health priorities ... then what else would you want to focus on in your 20-minute visit ... except each patient's priorities?" Tinetti asked. "This is one solution to the challenge."

What Is Patient Priorities Care?

Patient priorities care is a multidisciplinary, cyclical approach to clinical decision-making composed of three steps, Tinetti explained. First, a clinician identifies the patient's health priorities. Second, this information is transmitted to comanaging providers, who decide which of their respective treatments are consistent with the patient's priorities. And third, those decisions are disseminated to everyone involved in the patient's care, both within and outside of the health care system, allowing all care providers to align with the patient's priorities, she noted.

"Each person does that from their own expertise," Tinetti said. "The social worker will do something different than the cardiologist, the physical therapist, the endocrinologist – but everybody is aiming at the same outcome – the patient's priorities."

In 2019, Tinetti led a nonrandomized clinical trial to test the feasibility of patient priorities care. The study involved 366 older adults with multimorbidity, among whom 203 received usual care, while 163 received this type of care. Patients in the latter group were twice as likely to have medications stopped, and significantly less likely to have self-management tasks added and diagnostic tests ordered.

How Electronic Health Records Can Help

In an interview, Tinetti suggested that comanaging physicians communicate through electronic health records (EHRs), first to ensure that all care providers understand a patient's goals, then to determine if recommended therapies align with those goals.

"It would be a little bit of a culture change to do that," Tinetti said, "but the technology is there and it isn't too terribly time consuming."

She went on to suggest that primary care providers are typically best suited to coordinate this process; however, if a patient receives the majority of their care from a particular specialist, then that clinician may be the most suitable coordinator.

Systemic Obstacles and Solutions

According to Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, clinicians may encounter obstacles when implementing patient priorities care.

"Our health care system doesn't always make it easy to do this," Boyd said. "It's important to acknowledge this because it can be hard to do. There's no question," Boyd said in an interview.

Among the headwinds that clinicians may face are clinical practice guidelines, the structure of electronic health records, and quality metrics focused on specific conditions, she explained.

"There's a lot of things that push us – in primary care and other parts of medicine – away from the approach that's best for people with multiple chronic conditions," Boyd said.

Tinetti said a challenge to providing this care that she expects is for clinicians, regardless of specialty, "to feel uneasy" about transitioning away from a conventional approach.

Among Tinetti's arguments in favor of providing patient priorities care is that "it's going to bring more joy in practice because you're really addressing what matters to that individual while also providing good care."

To get the most out of patient priorities care, Boyd recommended that clinicians focus on 'the 4 M's': what matters most, mentation, mobility, and medications.

In an effort to address the last of these on a broad scale, Boyd is co-leading the US Deprescribing Research Network (USDeN), which aims to "improve medication use among older adults and the outcomes that are important to them," according to the USDeN website.

To encourage deprescribing on a day-to-day level, Boyd called for strong communication between co–managing providers.

In an ideal world, there would be a better way to communicate than largely via electronic health records, she said.

"We need more than the EHR to connect us. That's why it's really important for primary care providers and specialists to be able to have time to actually talk to each other. This gets into how we reimburse and organize the communication and cognitive aspects of care," Boyd noted.

Tinetti disclosed support from the John A. Hartford Foundation, the Donaghue Foundation, the National Institute on Aging, and the Institute for Healthcare Improvement. Boyd disclosed a relationship with UpToDate, for which she coauthored a chapter on multimorbidity.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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