Work

Clinician Perspectives on Incorporating Patients' Values‐Based Health Priorities in Decision‐Making

Year: 2020

Type: article

Abstract: Guideline-recommended treatments are of uncertain benefit for the numerous older adults with multiple chronic conditions (MCC). Disease-based decision-making may lead to treatment burden while failing to meet the health priorities of these patients, who vary both in the health outcomes they value most and the healthcare they will accept to achieve them.1, 2 In response to these limitations, a multi-stakeholder group developed Patient Priorities Care (PPC), an approach to eliciting patients' priorities and translating them into clinical care.3, 4 This approach was shown to be feasible and demonstrated promise in reducing burdensome and unwanted care.5, 6 To translate PPC to diverse clinical settings, it is critical to understand how the approach was perceived and what factors impeded its optimal implementation. Clinicians' individual views about interventions and systems-level factors (e.g., dominant clinical norms and financial incentives) have been recognized to impact sustainability.7 With this qualitative study, we assessed the perspectives of clinicians who participated in the PPC demonstration study about benefits of the approach and challenges to its implementation. Development of PPC has been previously reported.3, 4 Nine primary care clinicians and five cardiologists were eligible to participate (i.e., they participated in the PPC demonstration study and cared for ≥5 participating patients). This study was approved by the Yale Institutional Review Board. Interviews were performed from April 2017 to January 2018 by one experienced interviewer (G.M.O.) using a semi-structured interview guide, recorded, professionally transcribed, and uploaded to Dedoose® (V8.3.17, Los Angeles, 2019). Clinicians were asked about perceived benefits of the PPC approach and challenges to implementing it. Thematic analysis was used to identify themes from reported experiences.8 The coding team included G.M.O. (geriatrician), E.K. (research associate), and D.M.C. (doctoral trained researcher in human development and psychology with qualitative methodology expertise). Each independently identified concepts in two transcripts without a pre-existing coding key, then worked together to develop one. With subsequent interviews, the team iteratively refined the coding key and adjudicated discrepancies by consensus. After the final coding key was applied to all transcripts, themes were identified. Among eligible participants, eight of nine primary care clinicians and four of five cardiologists participated. Median interview duration was 15 minutes (interquartile range, 12–25 minutes). Two clinicians were female (16.7%) and two were nonwhite (16.7%). Perceived benefits included improvements in (1) patient care (more patient centered and less burdensome), (2) patient knowledge and activation, (3) patient-clinician interactions (communication focused on patients' own priorities and enhanced relationships), and (4) clinician workflows (focusing visits and facilitating consensus between primary care clinicians and specialists). Challenges to implementation included (1) poor patient understanding (of health trajectories and tradeoffs), (2) high patient acuity, (3) health system pressures (metrics and time), and (4) conflict with other decision-makers (other clinicians and patients' families). Exemplary quotes for each category are in Table 1. In the demonstration study of PPC, clinicians noted several perceived benefits of the approach and perceived challenges to optimal implementation. The perceived benefits of PPC were well aligned with the initial goals for the approach's development.3 In particular, the perceptions that this approach improves patient-centeredness, prevents burdensome care, and enhances clinician-patient relationships are encouraging. The perception that PPC streamlines visits and facilitates interprofessional communication may combat concerns about investing time to learn patients' priorities. The challenges noted by clinicians in this study present opportunities to refine the process. Future work is needed to address how to discuss tradeoffs in situations where patients have poor understanding of their likely health trajectories, a well-recognized challenge in providing care to older adults irrespective of PPC.9, 10 Each clinical site will also need to evaluate the effects of implementing PPC on workflow and metrics. In this demonstration study of PPC, there were no reported detrimental effects on performance metrics and clinical time was minimally prolonged (20–30 minutes for priorities identification and 30 minutes total for the following two visits).5 While PPC was perceived to facilitate consensus about the care plan overall, there is room for continued improvement, given the report that disagreements between patients and family members and between clinicians continue to occur, albeit less frequently. This study is limited by the single practice site, the small number of participants, and limited sociodemographic diversity. Attention to identifying additional challenges will be necessary as this approach is scaled. Clinicians viewed the PPC approach as beneficial to their patients and themselves and identified challenges to implementation. This information will be critical to developing individualized implementation strategies to ensure optimal effectiveness in practices with varying workflows, payment structures, and populations served. I, Gregory M. Ouellet, the corresponding author, affirm that all persons who contributed significantly to the work are listed among the authors. The authors have no conflicts. G.M.O.: overall study concept and design, data collection, interpretation of data, and preparation of manuscript. E.K.: Interpretation of data and critical revision of manuscript. D.M.C.: Interpretation of data and critical revision of manuscript. A.R.G.: study design, critical revision of manuscript. M.G.: study design, critical revision of manuscript. A.D.N.: overall study concept and design, interpretation of data, and critical revision of manuscript. M.E.T.: overall study concept and design, interpretation of data, and critical revision of manuscript. The sponsors had no role in the study design, recruitment, data collection, qualitative analysis, or preparation of this manuscript. This study was supported by grants from the John A. Hartford Foundation, the Gordon and Betty Moore Foundation, the Robert Wood Johnson Foundation, and the Patient Centered Outcomes Research Institute. Investigators received additional support and resources from the Yale Claude D. Pepper Older Americans Independence Center (NIA P30AG021342) and the Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety (CIN 13–413). During this work, Dr Ouellet received support from the Yale postdoctoral fellowship-training program in Geriatric Clinical Epidemiology and Aging-Related Research (T32AG19134) and a Pepper Scholar award from the Yale Claude D. Pepper Older Americans Independence Center (P30AG021342).

Source: Journal of the American Geriatrics Society

DOI: 10.1111/jgs.16914