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

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.^1-4 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.

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.

Of 236 eligible patients, 163 (69.1%) agreed to participate. This study included the 129 participants who were enrolled after the patient-identified top health priority was added. The mean (SD) patient age was 78 (7.6) years. Of the 129 participants, 125 (96.9%) self-reported as White and 86 (66.9%) were women, with a median of 4 chronic conditions (IQR, 3-5) and 7 prescription medications (IQR, 5-9).

Of the 129 participants, 127 (98.4%) identified the health-related problems on which they most wanted to focus (Table 1). Eighteen participants (14.0%) mentioned 2 problems. Eighty-two participants (64.6%) linked their health problem to actionable health outcome goals. Some patients identified specific interventions that they thought would address their top health priority and 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”).

Table 2 displays the ways in which the patient-identified top health priority (1) addresses challenges in caring for persons with multiple chronic conditions and (2) facilitates patient priorities–aligned decisions.

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.

Accepted for Publication: August 25, 2021.

Published: October 28, 2021. doi:10.1001/jamanetworkopen.2021.31496

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Davenport C et al. JAMA Network Open.

Corresponding Author: Mary E. Tinetti, MD, Department of Medicine, Yale School of Medicine, 333 Cedar St, PO Box 208025, New Haven, CT 06520 (mary.tinetti@yale.edu).

Author Contributions: Drs Davenport and Tinetti had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Tinetti.

Drafting of the manuscript: Davenport, Ouellet.

Critical revision of the manuscript for important intellectual content: Ouellet, Tinetti.

Statistical analysis: Ouellet.

Obtained funding: Tinetti.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by grants from the John A. Hartford Foundation, the Gordon and Betty Moore Foundation, and the Robert Wood Johnson Foundation. The investigators received additional support and resources from the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (through grant P30AG021342 from the National Institutes of Health National Institute on Aging).

Role of the Funder/Sponsor: The John A. Hartford Foundation, the Gordon and Betty Moore Foundation, the Robert Wood Johnson Foundation, and the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors acknowledge Jessica Esterson, MPH, Yale School of Medicine, for providing project management support; Eliza Kiwak, BA, Yale School of Medicine, for preparing the manuscript; and Lauren Vo, APRN, Bristol Prohealth Primary Care, and Kizzy Hernandez-Bigos, BA, Yale School of Medicine, for facilitating patient priorities identification, all of whom were compensated for their contributions. The authors also acknowledge the clinicians of Bristol ProHealth and Bristol Cardiology for participating in this project.