Caring for older adults with multiple health problems can be a challenge for internists.
“You might have wondered how you were ever going to get to address all the issues you're supposed to in a 20-minute visit. I'm sure you have many times—I certainly have. … And you might have thought, ‘There's got to be a better way,’” said ACP Member Mary Tinetti, MD, during her session at Internal Medicine Meeting 2021: Virtual Experience on managing multimorbidity in this population.
A new and better way is possible, she said, and there's evidence to support it. Dr. Tinetti's research has focused on potential solutions to this time crunch and other challenges in caring for patients with multiple conditions, such as uncertain benefits and unintentional harms of treatment, conflicting recommendations from different clinicians, and the health care burden on the patient.
“If the benefits and harms of addressing each condition in isolation is of uncertain benefit … and we know that patients vary in their health priorities, what matters most to them, then what else would you want to focus on in your 20-minute visit, or 40-minute or 60-minute visit, except each patient's priorities?” she said. “This is one solution to the challenge.”
What's the priority?
Over the past several years, Dr. Tinetti's group has developed, tested, implemented, and published results on Patient Priorities Care (PPC), an approach to decision making in older adults with multiple chronic conditions. The approach begins with identifying the patient's health priorities—health outcome goals and health care preferences—before deciding which treatments to continue, stop, or start to align care with these individual goals.
Ideally, information on patients' priorities would be disseminated to everyone caring for them, both within and outside the health system, Dr. Tinetti said. “Each person does that from their own expertise,” she said. “The social worker would do something different from the cardiologist, physical therapist, endocrinologist, but everybody is aiming at the same outcome: the patient's priorities.”
Priorities will vary by individual. Studies have shown that older adults with multimorbidity have varying preferences regarding the outcome that matters most to them and the tradeoffs they are willing to make, noted Dr. Tinetti, who is the Gladys Phillips Crofoot Professor of Medicine (Geriatrics) and Public Health and chief of geriatrics at Yale School of Medicine in New Haven, Conn.
“Some will maximize the focus on function, regardless of how long they are likely to live,” she 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.”
Since patients' health status and priorities change over time, this decision-making tool becomes an ongoing way to decide how best to manage their conditions, Dr. Tinetti said. “This is not a model of care; it's a way to take the information we have and make decisions that are most appropriate for each of our patients,” she said.
Dr. Tinetti contrasted the approach to what is currently the standard in medical decision making: The patient needs (insert treatment) for (insert disease). “We move that conversation to, ‘Knowing all your health conditions and your health status and what matters most to you, I suggest we try …’ and then you fill in the care options that you think are going to be most helpful given that particular patient's combination of conditions and health priorities,” she said.
PPC allows the patient (and caregiver, if applicable) to be the experts in the health care outcomes that matter most, Dr. Tinetti said, “And we as the clinicians are the experts in, of all the treatments and interventions available to us, those that are most likely to help with what matters most to this patient given his or her conditions.”
Focusing on patients' priorities is associated with changes in care. One study found that patients cared for by clinicians trained in PPC received less unwanted care and more wanted care compared with those who received usual care, said Dr. Tinetti. Patients in the PPC group had, on average, significantly fewer medications added, more referrals to community services and supports, and more priorities-aligned self-management tasks added, according to results published as a brief report last July by the Journal of the American Geriatrics Society.
This kind of decision making is also associated with improved patient-reported outcomes. In a nonrandomized clinical trial of 366 adults ages 65 years and older with multiple chronic conditions, patients receiving PPC reported a five-point greater decrease in Treatment Burden Questionnaire score than those who received usual care, according to results published in October 2019 by JAMA Internal Medicine. Decisions based on health priorities were mentioned in clinical visit notes for 108 of 163 (66%) PPC participants versus 0 of 203 (0%) in the usual-care group.
The time commitment associated with the approach is relatively modest, said Dr. Tinetti, adding that the primary care physicians and cardiologists she has worked with in studies of PPC have reported that it took only a few extra minutes for the first couple of visits to explain the decision-making approach to patients.
“After the first few visits, there was no change in the amount of time required for usual care versus decision making based on patients' own priorities,” she said. “The commitment of IT resources was also relatively modest, only requiring minimal adjustments to incorporate patients' priorities,” including a template and phrases clinicians can use in the EHR to document their decision making for billing purposes.
Focus on one thing
But aligning decision making with patients' priorities is not without its challenges. In one study, published in June 2019 by PLOS One, physicians who were trained in PPC reported the uncertainty, complexity, and multiplicity of problems and treatments as a challenge, as well as difficulty switching to this type of decision making and differing perspectives between patients and clinicians and among clinicians.
A strategy they identified to support the approach was beginning with the one thing that matters most to each patient. “It's the one thing that person most wants to focus on first. … It could be a symptom, health problem or condition, or a burdensome task that patients feel most interferes with their ability to achieve their health outcome goals,” said Dr. Tinetti.
Whatever a patient's one thing is, start there. “It really helps focus and get people comfortable with this approach to decision making rather rapidly,” she said. “It also simplifies the process because there's literally so much going on, it's really unclear otherwise where to start. And importantly, it engages the patients immediately.”
Focusing on one thing also engages clinicians. “They get some easy and quick successes, and they realize pretty quickly that this approach to decision making isn't as difficult as it might seem,” said Dr. Tinetti.
Her group looked at 129 older adults to see if there were any patterns in the one thing they chose as their health priority. “What we found, by far, the one thing they identified they most wanted to focus on were symptoms, of which pain was most common,” Dr. Tinetti said. “Also common were fatigue and dizziness or balance. Also relatively common were medications that they felt were impeding them, through their adverse effects, from achieving their outcome goals.”
Only a few participants mentioned specific diseases they wanted to focus on, most commonly diabetes and hypertension, because they were interfering with their outcome goals, she added. A few patients also mentioned that health care visits and glucose monitoring were burdensome tasks, said Dr. Tinetti.
“The interesting thing here is there really is a disconnect between what we as clinicians tend to focus on, which are the diseases we're trying to manage, and what patients are focused on, [which are] the symptoms that they experience,” she said.
More than half of these patients were able to directly link the one thing they wanted to focus on to their health goals, said Dr. Tinetti. “The thing they wanted to focus on—that symptom, that health problem, that medication—they really felt this is what interfered with their health outcome goals,” she said, offering an example of one patient who wanted to be taking less medication and seeing fewer specialists to allow more time to spend with their spouse and children.
Quality time is the thing many older patients want the most from their health care. Another study of 163 older adults found that the most commonly reported goals involved meals and other activities with family and friends (24%), followed by shopping (6%), exercising (5%), and living independently (4%), according to results published in March by JAMA Network Open. The most commonly reported helpful medications were nonopioid pain medications (66% of users), sleep medications (53% of users), and inhalants (42% of users), whereas the most commonly reported bothersome medications were statins (26% of users) and antidepressants (33% of users).
Some patients may have inaccurate ideas of the problems keeping them from their goals, but the vast majority of things patients report as impeding their goals are realistic, said Dr. Tinetti, “And they're all actionable with the current treatments that we offer to people all the time.”
She offered several advantages of asking older patients about the one thing they would like to focus on. “First, focusing on patients' priorities, beginning with the one thing, makes patients feel listened to and less rushed,” Dr. Tinetti said.
Second, it's important to know the patient's perspective. “If they are inaccurate in their perspective of what they think is keeping them from doing what they want to do, this is a wonderful opportunity to help educate your patients within the perspective of their own priorities. … And importantly, if they are correct, it really does help guide decisions in what can often be a very complicated situation,” she said.
Third, focusing on one thing provides the opportunity for patients to set the agenda for some encounters ahead of time, making the visit much more efficient, said Dr. Tinetti.
With the COVID-19 pandemic and the ensuing surge in telehealth, many more patients (including older adults with multimorbidity) are now on the patient portal, she noted, “So we can use that as a way to communicate between visits with our patients to make the visit much more efficient.” In addition, Dr. Tinetti said her group is going to be testing out OurNotes, a new initiative by the group who started OpenNotes that allows patients to declare two or three things they want the clinician to focus on during their next visit. (See sidebar at right for this and other PPC resources, including an online curriculum launched in 2019 in collaboration with ACP.)
Fourth, clinicians who tie their recommendations to the one thing may see improved patient adherence. “We are likely to improve adherence if we choose a regimen that is consistent with the patient's priorities, avoiding medications that patients feel are the cause of the symptoms that get in their way,” Dr. Tinetti said.
The fifth advantage of the one thing is that it provides a single target for all clinicians. “I may be looking at their heart failure, you may be looking at their depression, their social worker may be looking at their home situation, physical therapists may be looking at their muscle weakness,” she said. “But if everybody's [aiming for] the same outcome, it puts everybody on the same page and makes the care much more integrated.”
Finally, the one thing is one of the best ways to address the uncertainty of benefits and harms in an older population, said Dr. Tinetti. “There's so much going on, it's hard to know where to start,” she said. “If you don't know where to start, why not start where the patient wants to start?”