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Original Investigation
October 7, 2019

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

Author Affiliations
  • 1Department of Medicine, Yale School of Medicine, New Haven, Connecticut
  • 2Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
  • 3Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas
  • 4Department of Medicine (Health Services Research and Geriatrics), Baylor College of Medicine, Houston, Texas
  • 5Connecticut Center for Primary Care, Farmington, Connecticut
  • 6American College of Physicians, Philadelphia, Pennsylvania
  • 7Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 8Department of Medicine, New York University School of Medicine, New York
JAMA Intern Med. Published online October 7, 2019. doi:10.1001/jamainternmed.2019.4235
Key Points

Question  Is care for older adults with multiple chronic conditions that is aligned with their health priorities associated with improved patient-reported outcomes and reduced unwanted care?

Findings  This nonrandomized clinical trial of 366 adults 65 years or older with multiple chronic conditions found that, although there was no difference in perception of whether their care was goal-directed or coordinated, participants receiving patient priorities care vs usual care reported a greater reduction in treatment burden, and their health records reflected more medications stopped and fewer self-management tasks and diagnostic tests added.

Meaning  This study’s findings suggest that aligning care with patients’ priorities may improve outcomes for patients with multiple chronic conditions.

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

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