An emerging approach to health care that focuses decision-making on older patients’ health goals and care preferences can reduce unwanted and unhelpful treatment, such as medications and diagnostic tests, say Yale researchers. It can also lessen treatment burden, according to their new study, published in JAMA Internal Medicine.
Adults age 65 and older are likely to need health care to cope with multiple chronic conditions rather than one isolated disease. Yet it’s not clear that the care they receive actually benefits them or aligns with their health goals. Research shows that many older patients and their caregivers spend an average of two hours per day on health-care activities, such as office visits or diagnostic tests. Older patients may also struggle with adverse effects of taking multiple medications.
To close the gap between what older adults want from their health care and the care they receive, Yale researchers and their collaborators at New York University and Baylor College of Medicine developed an approach to health decision-making called patient priorities care or PPC. This approach defines both older patients’ health priorities in terms of specific health goals — for example, sufficient improvement in fatigue to be able to garden and walk one-half mile daily — and the care they are willing and able to do to achieve these goals. Priorities-driven care is important, said lead author Mary Tinetti, M.D., because older adults with multiple conditions vary in their health outcome goals and the care they are able and willing to do.
Last year, the research team published two studies showing that the PPC model could be successfully implemented in a busy primary care practice in Connecticut. In the current paper, they focused their study on how the care approach impacted specific treatment outcomes, including health decision-making, perceived burden of treatments, medications, self-care tasks, diagnostic tests, referrals, and procedures.
The researchers assessed care at two sites of the primary care practice. At one site, 163 older patients received PPC; at the other, 203 got care as usual. To hone in on health priorities, trained facilitators engaged patients in conversations about their values, goals, helpful versus burdensome care, and perceptions of well-being. Researchers also used questionnaires and reviewed electronic health records.
Comparing results for the two groups, the researchers found that PPC patients perceived their health care to be less of a burden. Analysis of health records also showed that PPC patients were more likely to have stopped certain medications, and less likely to have diagnostic tests and tasks related to their health care than the usual-care patients.
“In this population, with multiple different conditions and health outcomes that matter to them, one of the most effective approaches to optimizing care is to align their care with outcomes that matter to them,” said Tinetti, who is Geriatrics Section Chief at Yale School of Medicine.
PPC can address issues such as multiple medication use, or polypharmacy, as well as patient adherence to medical advice. “If we identify what medications older people are willing to take, adherence will improve,” Tinetti noted. “This approach has potential for decreasing unwanted health care without withholding care that people want or find helpful.”
The Yale team and their collaborators are now looking at testing PPC in a larger health system in the Midwest and the South, and planning to incorporate the approach into training for medical students. “It’s promising. We need to study it in other populations,” she said.
Other authors are Aanand D. Naik, Lilian Dindo, Darce M. Costello, Jessica Esterson, Mary Geda, Jonathan Rosen, Kizzy Hernandez-Bigos, Cynthia Daisy Smith, Gregory M. Ouellet, Gina Kang, Yungah Lee, and Caroline Blaum.
The study was supported by grants from The John A. Hartford Foundation, The Gordon and Betty Moore Foundation, and The Robert Wood Johnson Foundation. Investigators received additional support and resources from the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (#P30AG021342 NIH/NIA), and the Houston VA Health Services Research & Development Center for Innovations grant (CIN13-413).
More information about the Patient Priorities Care approach can be found at the Patient Priorities Care website.