Standardised approach to measuring goal-based outcomes among older disabled adults: results from a multisite pilot

Using health values to inform collaborative goal-setting for chronic care of older adults

This editorial comments on the article by Shwayder et al.

Utilising patient-reported outcomes for goal-directed therapy of hip fracture patients: a sequential controlled trial

BACKGROUND

Hip fracture patients (HFPs) frequently have multiple underlying conditions, necessitating that agreed-upon goals take these complications into consideration. Communication regarding goals between medical-personnel and patients is not always effective. Patient-reported outcomes (PROs) can outline personal goals and help promote quality health care in HFPs. Few studies have been published on this topic. The study's aim was to outline the process of using PROs for goal-directed therapy among HFPs.

METHODS

This sequential controlled trial was conducted among HFPs from two medical centres. The control and the intervention group received integrative rehabilitation. PROs were measured in both groups using the SF36 questionnaire three times postsurgery: 24-48 hours, 2 weeks and 3 months. During the first round of questioning, only the intervention group was asked 'what matters most to you?' during the rehabilitative process. Accordingly, agreed-upon goals that were determined by the SF36's eight topics and were incorporated into the HFP's rehabilitative process. A Likert scale of 1-5, '1' indicating no-achievement and '5' full-achievement, was used to assess the goal achievement 4-6 months post-fracture.

RESULTS

84 HFPs participated in the study: 40 and 44 in the intervention and control group, respectively. In both groups, PROs declined after the HF, then improved somewhat 3 months later, but did not return to prefracture scores. Among the intervention group, 39% reached their specific goals (Likert level 5). Patients who achieved their goals had better PROs in comparison to others. The intervention group indicated PROs helped them articulate their desires and introduced them to new areas of care.

CONCLUSIONS

Shifting from asking 'what's the matter?' to 'what matters most to you?' can improve the understanding of HFPs' own priorities, promote quality outcomes and enhance patient-centred care. Using PROs as a guide for goal-directed therapy can create a more inclusive process that includes the patients' most important health determinants and needs.

Feasibility of Goal Attainment Scaling as a patient-reported outcome measure for older patients in primary care

BACKGROUND

Goal Attainment Scaling (GAS) is an outcome measure that reflects the perspectives and experiences of patients, consistent with patient-centred care approaches and with the aims of patient-reported outcome measures (PROMs). GAS has been used in a variety of clinical settings, including in geriatric care, but research on its feasibility in primary care practice has been limited. The time required to complete GAS is a barrier to its use by busy primary care clinicians. In this study, we explored the feasibility of lay interviewers completing GAS with older primary care patients.

METHODS

Older adults were recruited from participants of a larger study in five primary care clinics in Alberta and Ontario, Canada. GAS guides were developed based on semi-structured telephone interviews completed by a non-clinician lay interviewer; goals were reviewed in a follow-up interview after six months.

RESULTS

Goal-setting interviews were conducted with 41 participants. GAS follow-up guides could be developed for 40 patients (mean of two goals/patient); follow-up interviews were completed with 29 patients. Mobility-focused goals were the most common goal areas identified.

CONCLUSIONS

Study results suggest that it is feasible for lay interviewers to conduct GAS over the telephone with older primary care patients. This study yielded an inventory of patient goal areas that could be used as a starting point for future goal-setting interviews in primary care. Recommendations are made for use of GAS and for future research in the primary care context.

The Suitability of Measuring Patient-Reported Outcomes in Older Adults Following a Hip Fracture Using the Short-Form 36 Questionnaire: A Qualitative Description Approach

Hip-fractures (HF) in older adults are associated with poor outcomes and high costs. Measuring quality-of-care of HF patients has focused on clinical definitions rather than on measuring outcomes that are meaningful to the patient. Healthcare systems worldwide are increasingly interested in patient-reported outcome measures (PROs). The Short-form (SF36) questionnaire is a recommended measure among older adults however it's comprehensiveness and uniqueness for specific patients after a HF is not clear. The aims of this study were to: understand the perspective of the older adults experience following HF, to assess the suitability of the SF36 as a PRO for HF and to determine the best timing for questioning. A qualitative description approach was used. This took place in 2 large academic medical-centers in Israel. The inquiry was done in 2 parts by semi-structured interview. A total 15 HF patients were interviewed. Categories and themes emerging from their responses were similar to the 8 domains of the SF36 questionnaire, but the participants added clarity regarding their own needs for setting goals. In the second part, participants agreed that the SF36 reflected common issues and served as an adequate measure for personal-goal setting. The study encourages patient-centered care in older adults recovering from HF, providing evidence that the SF36 is a suitable tool for measuring PROs in HF patients. Healthcare systems focus on clinical-outcome indicators and do not reflect how the patient views his outcomes. This study provides evidence that care should be customized for each person.

Patient and provider perspectives on using goal attainment scaling in care planning for older adults with complex needs

BACKGROUND

Assess the feasibility of using goal attainment scaling (GAS) in care planning for older adults with complex needs. GAS is an individualized approach to goal setting and follow up using a quantified scale. To date, little is known about the feasibility of GAS among this population.

METHODS

We conducted a qualitative study with a sample of 28 older adults and 23 providers from diverse settings to evaluate the value and challenges of this approach. We conducted semi-structured interviews and iteratively coded and analyzed interview transcripts for themes related to value, challenges, and implementation.

RESULTS

Most older adults and providers reported that the GAS approach added value to the care encounter. GAS supported collaboration and patient accountability for their goals, though it could be demotivating to some patients. Some older adults and providers noted that GAS could be confusing and that it was uncomfortable to talk about negative outcomes (i.e., the - 2 and - 1 boxes of the scale). Factors that facilitated implementation included using visual copies of the GAS forms, having an established patient-provider relationship, practicing the approach, and having previous goal-related clinical training.

CONCLUSIONS

GAS was feasible to implement across diverse settings, and, despite challenges, both older adults and providers reported that it added value to care planning encounters with the potential to improve delivery of person-centered care. Further efforts to demonstrate the applicability and benefit of this method for older adults are warranted, particularly to address implementation of the approach.

Use of standardized brief geriatric evaluation compared with routine care in general practice for preventing functional decline: a pragmatic cluster-randomized trial

BACKGROUND

Although assessment of geriatric syndromes is increasingly encouraged in older adults, little evidence exists to support its systematic use by general practitioners (GPs). The aim of this study was to determine whether a systematic geriatric evaluation performed by GPs can prevent functional decline.

METHODS

We conducted a controlled, open-label, pragmatic cluster-randomized trial in 42 general practices in Switzerland. Participating GPs were expected to enrol an average of 10 community-dwelling adults (aged ≥ 75 yr) who understood French, and had visited their GP at least twice in the previous year. The intervention consisted of yearly assessment by the GP of 8 geriatric syndromes with an associated tailored management plan according to assessment results, compared with routine care. Our primary outcomes were the proportion of patients who lost at least 1 instrumental activity of daily living (ADL) and the proportion who lost at least 1 basic ADL, over 2 years. Our secondary outcomes were quality-of-life scores, measured using the older adult module of the World Health Organization Quality of Life Instrument, and health care use.

RESULTS

Forty-two GPs recruited 429 participants (63% women) with a mean age of 82.5 years (standard deviation 4.8 yr) at time of recruitment. Of these, we randomly assigned 217 participants to the intervention and 212 to the control arm. The proportion of patients who lost at least 1 instrumental ADL in the intervention and control arms during the course of the study was 43.6% and 47.6%, respectively (risk difference -4.0%, 95% confidence interval [CI] -14.9% to 6.7%, p = 0.5). The proportion of patients who lost at least 1 basic ADL was 12.4% in the intervention arm and 16.9% in the control arm (risk difference -5.1%, 95% CI -14.3% to 4.1%, p = 0.3).

INTERPRETATION

A yearly geriatric evaluation with an associated management plan, conducted systematically in GP practices, does not significantly lessen functional decline among community-dwelling, older adult patients, compared with routine care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02618291.

A Scoping Review of Person and Family Engagement in the context of Multiple Chronic Conditions

OBJECTIVE

To review definitions, concepts, and evidence regarding person and family engagement for persons with multiple chronic conditions (MCC) in order to identify opportunities to advance the field.

DATA SOURCE

Ovid MEDLINE STUDY DESIGN: We performed a two-step process: (1) a critical review of conceptual models of engagement to identify key concepts most pertinent to engagement among persons with MCC as a "launch pad" to our scoping review, and (2) a scoping review of reviews of engagement for persons living with MCC.

DATA COLLECTION/EXTRACTION METHODS

First, we critically reviewed six models of engagement. Second, our scoping review identified 1297 citations, with 67 articles meeting criteria for inclusion. Of these, we focused on reviews, of which there were nine titles/abstracts retained for full text consideration. Six full-text reviews were included in the final analysis. The purpose, review type, population, number/type of included studies, theoretical framework, and findings of each study were extracted and analyzed thematically.

PRINCIPAL FINDINGS

Conceptual models of engagement differ with respect to areas of emphasis (e.g., systems or clinical encounters) as well as attention to vulnerable populations; involvement of family; consideration of cost-benefit tradeoffs; and attention to outcomes that matter most. Our scoping review of reviews identified just one article explicitly focused on engagement interventions for those with MCC. Other reviews examined elements of self-management and involvement in decision-making, conceptually related to engagement without explicit use of the word. We find that existing evidence has predominantly described individual-level strategies rather than targeting organizations, systems, or policies. Barriers to engagement are not well described, nor are potential downsides to engagement. Family engagement is rarely considered.

CONCLUSIONS

Promising areas of future work include attention to barriers to engagement including trust, goal-based care, the design of structural changes to care delivery, tradeoffs between benefits and costs, and family engagement. This article is protected by copyright. All rights reserved.

Outcome Goals and Health Care Preferences of Older Adults With Multiple Chronic Conditions

IMPORTANCE

Older adults with multiple chronic conditions (MCCs) vary in their health outcome goals and the health care that they prefer to receive to achieve these goals.

OBJECTIVE

To describe the outcome goals and health care preferences of this population with MCCs.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included participants in the Patient Priorities Care study who underwent health priorities identification from February 1, 2017, to August 31, 2018, in a primary care practice. Patients eligible to participate were 65 years or older, English speaking, and had at least 3 chronic conditions; in addition, they used at least 10 medications, saw at least 2 specialists, or had at least 2 emergency department visits or 1 hospitalization during the past year. Of 236 eligible patients, 163 (69%) agreed to participate in this study. Data were analyzed from August 1 to October 31, 2020.

EXPOSURES

Guided by facilitators, participants identified their core values, as many as 3 actionable and realistic outcome goals, health-related barriers to these goals, and as many as 3 helpful and 3 bothersome health care activities.

MAIN OUTCOMES AND MEASURES

Frequencies were ascertained for outcome goals and health care preferences. Preferences included health care activities (medications, health care visits, procedures, diagnostic tests, and self-management) reported as either helpful or bothersome.

RESULTS

Most of the 163 participants were White (158 [96.9%]) and women (109 [66.9%]), with a mean (SD) age of 77.6 (7.6) years. Of 459 goals, the most common encompassed meals and other activities with family and friends (111 [24.2%]), shopping (28 [6.1%]), and exercising (21 [4.6%]). Twenty individuals (12.3%) desired to live independently without specifying necessary activities. Of 312 barriers identified, the most common were pain (128 [41.0%]), fatigue (45 [14.4%]), unsteadiness (42 [13.5%]), and dyspnea (19 [6.1%]). Similar proportions of patients identified at least 1 medication that was helpful (130 [79.8%]) or bothersome (128 [78.5%]). Medications most commonly cited as helpful were pain medications, including nonopiods (36 of 55 users [65.5%]) and opioids (15 of 27 users [55.6%]); sleep medications (27 of 51 users [52.9%]); and respiratory inhalants (19 of 45 [42.2%]). Most often mentioned as bothersome were statins (25 of 97 users [25.8%]) and antidepressants (13 of 40 users [32.5%]). Thirty-two participants (19.6%) reported using too many medications. Health care visits were identified as helpful by 43 participants (26.4%); 15 (9.2%) reported too many visits. Procedures were named helpful by 38 participants (23.3%); 24 (14.7%) cited unwanted procedures. Among 48 participants with diabetes, monitoring of glucose levels was doable for 18 (37.5%) and too bothersome for 9 (18.8%).

CONCLUSIONS AND RELEVANCE

Participants identified realistic and actionable goals while varying in health care activities deemed helpful or bothersome. The goals and health care preferences of more diverse populations must be explored. Previous work suggests that clinicians can use this information in decision-making.