Use of the Patient-Identified Top Health Priority in Care Decision-making for Older Adults With Multiple Chronic Conditions

This cross-sectional study assesses how patient-identified top health priorities can be incorporated into the care of older adults with multiple chronic conditions while facilitating decision-making that aligns with these priorities.


Introduction
Decision-making for older adults with multimorbidity is complicated by the uncertain benefits of many disease-based interventions. 1 Variability in health outcome goals and health care preferences further confounds decision-making for this population. 1,2 To address these issues, we developed Patient Priorities Care (PPC), which involves identifying and aligning care with patients' specific health priorities. [1][2][3][4] PPC has been associated with a reduced treatment burden and increased preference-concordant care. 1,5 The goals of this cross-sectional study were (1) to determine the top health priority that patients most wanted to focus on to achieve their goals and (2) to consider how this priority addresses challenges while facilitating decision-making that aligns with patients' priorities.

Methods
The details of the PPC study, which was conducted from February 1, 2017 to August 31, 2018, have been described previously. 1,3,4 This study comprised patients of 10 primary care clinicians in Connecticut. Patients were invited to participate if they were aged 65 years or older and had 3 or more chronic health conditions. An advanced practice registered nurse or case manager guided patients in identifying their health priorities, creating health priorities templates that included the following: (1) patients' values; (2) up to 3 specific, actionable, and realistic health outcome goals; (3) up to 3 health care tasks that patients thought were doable and could help achieve their goals; and (4) up to 3 health care tasks that patients found burdensome or unhelpful. The Yale University Institutional Review Board approved this study. Oral informed consent was obtained from all participants. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
The primary care clinicians were trained in aligning decisions with patients' health priorities.
After training, the clinicians and the PPC team participated in 21 case-based discussions. 3 The group discussed how best to align care with patients' health priorities, reported challenges, and suggested solutions to these challenges. One of the challenges identified was where to start aligning care. The proposed solution was to ask patients to identify the top health priority that they most wanted to focus on to achieve their goals. 1,3 To create this patient-identified top health priority, patients were asked, "What 1 [health-related problem] do you most want to focus on so that you can achieve [health outcome goal] more easily or often?" Their responses were included in the template for clinicians to use in communication and decision-making. All patient responses are listed in the eAppendix in the Supplement.
One author (M.E.T.) reviewed patients' responses, quantifying the health-related problems and suggesting how the patient-identified top health priority could address challenges and guide decision-making. Based on their review of the participants' self-identified priorities and health outcome goals and informed by their experience in caring for older adults with multiple chronic conditions, the authors identified, discussed, and agreed on clinical challenges and decisional guidance. All authors reviewed and edited these documents iteratively until consensus was reached.

+ Supplemental content
Author affiliations and article information are listed at the end of this article.  I want to be able to be more disciplined with my meals so that I can be able to take trips with the senior center and not worry about being hungry. I want to go out to eat without so much worry about how the food is prepared and how that affects my diabetes.
Abbreviation: NA, not applicable. a The number of health problems reported totals to more than 129 because some participants reported more than 1 health problem. Of the 129 participants, 2 did not identify an actionable health problem they most wanted to focus on to achieve their goals ("I want peace of mind and financial security so that I can continue to volunteer and have a social life" and "I wouldn't change a thing because I have such great doctors").
b Responses are to the following question posed by the member of the health team who guided participants in identifying their health priorities: "What symptom, health problem, or health care task do you most want to focus on to help you do [most desired goal activity] more easily or more often?" c Values are for the 129 participants who reported a health problem. All problems were included when participants reported more than 1. No participants mentioned more than 2 health-related problems.
d Gastrointestinal problems included nausea, diarrhea, or abdominal discomfort. e Lymphedema, renal function, cancer, and fibromyalgia were each reported by 1 participant.  Acknowledge that the symptom or impairment cannot be removed entirely but it may be possible to achieve health outcome goals: "We may not be able to completely resolve your foot pain and numbness, but the occupational therapist may be able to help with driving safety and other activities." Achievement of health goal activity is a reliable metric of treatment success Guide the patient to identify achievable goals based on the underlying value: "If a time comes that it won't be safe for you to drive, we can discuss how you can continue getting around to visit your family and friends, which is most important to you." a This information was derived through an iterative process aimed at identifying how the patientidentified top health priority address challenges in decision-making for older adults with multiple conditions while facilitating patient-aligned clinical decisions. The clinical challenges and decisional guidance were identified, discussed, and agreed on by the authors based on a review of patientidentified top health priorities and the health outcome goals of participants and were informed by experience caring for older adults with multiple chronic conditions. b All responses to the question "What 1 [health-related problem] do you most want to focus on so that you can achieve [health outcome goal] more easily or often?" are listed in the Supplement. achieve their outcome goal (eg, "I want less pain in my knees so that I can walk more…. If I am not able to have the knee replacement, I'm not sure what is next").

Discussion
Like the traditional chief concern, symptoms and impairments were the most frequently mentioned health-related problems in this study. Linking these health-related problems to actionable outcome goals provides a platform for cross-condition decision-making for persons with multimorbidity.
The primary limitation of this study is that participants were drawn from a single site; therefore, studies of more diverse populations are needed. Work is ongoing to better understand how to align care with patients' health priorities and to determine the effects of such alignment. Identifying the top health priority that patients want to focus on holds promise as an approach to initiating patient priorities-aligned decision-making, filtering all care through the lens of what matters most to each patient.