Association of Patient Priorities-Aligned Decision-Making With Patient Outcomes and Ambulatory Health Care Burden Among Older Adults With Multiple Chronic Conditions: A Nonrandomized Clinical Trial

Abstract

Importance: Health care may be burdensome and of uncertain benefit for older adults with multiple chronic conditions (MCCs). Aligning health care with an individual's health priorities may improve outcomes and reduce burden.

Objective: To evaluate whether patient priorities care (PPC) is associated with a perception of more goal-directed and less burdensome care compared with usual care (UC).

Design, setting, and participants: Nonrandomized clinical trial with propensity adjustment conducted at 1 PPC and 1 UC site of a Connecticut multisite primary care practice that provides care to almost 15% of the state's residents. Participants included 163 adults aged 65 years or older who had 3 or more chronic conditions cared for by 10 primary care practitioners (PCPs) trained in PPC and 203 similar patients who received UC from 7 PCPs not trained in PPC. Participant enrollment occurred between February 1, 2017, and March 31, 2018; follow-up extended for up to 9 months (ended September 30, 2018).

Interventions: Patient priorities care, an approach to decision-making that includes patients' identifying their health priorities (ie, specific health outcome goals and health care preferences) and clinicians aligning their decision-making to achieve these health priorities.

Main outcomes and measures: Primary outcomes included change in patients' Older Patient Assessment of Chronic Illness Care (O-PACIC), CollaboRATE, and Treatment Burden Questionnaire (TBQ) scores; electronic health record documentation of decision-making based on patients' health priorities; medications and self-management tasks added or stopped; and diagnostic tests, referrals, and procedures ordered or avoided.

Results: Of the 366 patients, 235 (64.2%) were female and 350 (95.6%) were white. Compared with the UC group, the PPC group was older (mean [SD] age, 74.7 [6.6] vs 77.6 [7.6] years) and had lower physical and mental health scores. At follow-up, PPC participants reported a 5-point greater decrease in TBQ score than those who received UC (ß [SE], -5.0 [2.04]; P = .01) using a weighted regression model with inverse probability of PCP assignment weights; no differences were seen in O-PACIC or CollaboRATE scores. Health priorities-based decisions were mentioned in clinical visit notes for 108 of 163 (66.3%) PPC vs 0 of 203 (0%) UC participants. Compared with UC patients, PPC patients were more likely to have medications stopped (weighted comparison, 52.0% vs 33.8%; adjusted odds ratio [AOR], 2.05; 95% CI, 1.43-2.95) and less likely to have self-management tasks (57.5% vs 62.1%; AOR, 0.59; 95% CI, 0.41-0.84) and diagnostic tests (80.8% vs 86.4%; AOR, 0.22; 95% CI, 0.12-0.40) ordered.

Conclusions and relevance: This study's findings suggest that patient priorities care may be associated with reduced treatment burden and unwanted health care. Care aligned with patients' priorities may be feasible and effective for older adults with MCCs.

Trial registration: ClinicalTrials.gov identifier: NCT03600389.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Smith reported receiving grants from Yale University, that her husband is employed by Merck & Co, and that she and her husband jointly own stock and stock options in Merck & Co. No other disclosures were reported.

Figures

Figure 1.. STROBE Patient Flow Diagram

Patients from both the patient priorities care (PPC) and usual care (UC) sites were prescreened using administrative data based on the eligibility criteria listed in the Methods section. Primary care clinicians at the PPC site decided which of the prescreened patients they would invite to participate. The UC site did not include the step of recruitment. Therefore, all potentially eligible participants were recruited from the UC site. Usual care clinicians did not review their prescreened patients; thus, all UC patients who met the administrative data screen were assumed to be eligible.

Figure 2.. Steps in Patient Priorities Care

aMember of the health care team who helps patients identify their health priorities. bHealth outcome goals are the health and life outcomes that patients desire from their health care. Health care preferences refers to the health care activities (eg, medications, self-management tasks, health care visits, testing, and procedures) that patients find helpful and doable or bothersome, unhelpful, or unwanted. Health priorities refers to the specific, actionable, and reliable health outcome goals that are consistent with their health care preferences.