Goal Setting and Health-Related Outcomes in Chronic Diseases: A Systematic Review and Meta-Analysis of the Literature From 2000 to 2020

Implementing Patient-Centred Goal-Setting in Practice: Perspectives of Primary Care Nurses

BACKGROUND

As a component of goal-oriented care, goal-setting is an important strategy to improve self-management and reduce the economic and personal burden of chronic illness. Primary care nurses, as integral members of the healthcare team, play a pivotal role in providing self-management support to patients with multiple chronic illnesses. Yet, little is known about their perspectives on partnering with patients to set meaningful goals within self-management support programmes.

AIM

To explore perspectives of primary care nurses about their practice of goal-setting with patients to improve self-management.

METHODS

For this qualitative exploratory study, we conducted semi-structured interviews with 28 primary care nurses who provided self-management support to patients with multiple chronic illnesses. Data were analysed using inductive thematic analysis. This research was approved by the Mayo Clinic Institutional Review Board.

RESULTS

Key themes from interviews focused on: (1) goal-setting practices; (2) challenges encountered in goal-setting; and (3) the perceived value-add of using a patient-centred goal-setting approach. Nurses described practices that empower patients to take charge of goal-setting, emphasising that the opportunity to create personal goals enhances motivation and enables the development of realistic action plans. Key challenges faced were patients' lack of familiarity with personal goal-setting, competing life stressors and patients' reluctance to change.

CONCLUSION

Our findings contribute valuable insights about how primary care nurses approach goal-setting within a self-management support program. Notably, unlike previous studies where clinicians reported that time-limited appointments and institutional expectations hindered patient-centred goal-setting, our participants practicing in an institutionally supported goal-oriented patient-centred model of care did not report time constraints or pressures to prioritise clinical goals over patient goals. Instead, they described patient-centred goal-setting practices that are associated with positive patient and clinical outcomes. To potentially corroborate and expand upon our findings and inform practice and training, future research should include qualitative and survey studies to explore primary care RNs perspectives about goal-setting and observational research to evaluate nurse-patient goal-setting interactions.

A meta-analysis of behaviour change techniques in social interventions targeting improved cognitive function in older adults

BACKGROUND

Limited social networks in older adults are linked with increased dementia risk. However, there is a lack of knowledge on whether socially-based behavioural interventions (i.e., programs designed to increase individual's social opportunities, engagement or networks) can improve cognitive function, as well as the role of applied behaviour change techniques (BCTs) in effective interventions. This systematic review and meta-analysis aimed to (i) quantify the effectiveness of social-based behavioural interventions in improving cognition in older adults, and (ii) identify which BCTs increase social activity behaviour of older adults.

METHODS

Six electronic databases were searched with restrictions for age (>65 years) and English language from inception to July 2023 (PROSPERO:CRD42021283382) for articles reporting social-based behavioural randomised controlled trials and using a measured outcome of cognitive function. Behaviour change techniques were mapped to the BCT V1 model and risk of bias was assessed. Pooled effect sizes from eligible studies were synthesised using RevMan.

RESULTS

We identified 9528 records and included 15 studies (N=1785 participants). Meta-analyses showed that social-based interventions had a medium effect on global cognition (d=0.80, 95% CI 0.58 to 1.02, p<0.01), but not executive function. The most frequently used intervention components were social-based communication (e.g., chatting, boosting social engagement), group arts-based tasks (e.g., knitting, music, craft) and guided reminiscence. The BCT demonstration of behaviour predicted significant cognitive effects and explained 94.6% of inter-study variation.

DISCUSSION

Findings carry implications for developing comprehensive strategies to promote social initiatives supporting cognitive health, particularly in addressing the challenges faced by older adults.

A nurse driven care management program to engage older diabetes patients in personalized goal setting and disease management

Background and Aims

Multiple diabetes care guidelines have called for the personalization of risk factor goals, medication management, and self-care plans among older patients. Study of the implementation of these recommendations is needed. This study aimed to test whether a patient survey embedded in the Electronic Healthcare Record (EHR), coupled with telephonic nurse care management, could engage patients in personalized goal setting and chronic disease management.

Methods

We conducted a single-center equal-randomization delayed comparator trial at the primary care clinics of the University of Chicago Medicine from 2018.6 to 2019.12. Patients over the age of 65 years with type 2 diabetes with an active patient portal account were recruited and randomized to receive an EHR embedded goal setting and preference survey immediately in the intervention arm or after 6 months in the delayed intervention control arm. In the intervention arm, nurses reviewed American Diabetes Association recommendations for A1C goals based on health status class, established personalized goals, and provided monthly telephonic care management phone calls for a maximum of 6 months. Our primary outcome was the documentation of a personalized A1C goal in the EHR.

Results

A total of 100 patients completed the trial (mean age, 72.51 [SD, 5.22] years; mean baseline A1C, 7.14% [SD, 1.06%]; 68% women). The majority were in the Healthy (59%) followed by Complex (30%) and Very Complex (11%) health status classes. Documentation of an A1C goal in the EHR increased from 42% to 90% (p < 0.001) at 6 months in the intervention group and from 54% to 56% in the control group. Across health status classes, patients set similar A1C goals.

Conclusions

Older patients can be engaged in personalized goal setting and disease management through an embedded EHR intervention. The clinical impact of the intervention may differ if deployed among older patients with more complex health needs and higher glucose levels.

Trial Registration

ClinicalTrials.gov Identifier: NCT03692208.

An umbrella review of the literature on the effectiveness of goal setting interventions in improving health outcomes in chronic conditions

PURPOSE

To identify the contexts in which goal setting has been used in chronic disease management interventions and to estimate the magnitude of its effect on improvement of health outcomes.

METHODS

The strength of evidence and extent of potential bias in the published systematic reviews of goal setting interventions in chronic conditions were summarized using AMSTAR2 quality appraisal tool, number of participants, 95% prediction intervals, and between-study heterogeneity. Components of goal setting interventions were also extracted.

RESULTS

Nine publications and 35 meta-analysis models were identified, investigating 25 health outcomes. Of the 35 meta-analyses, none found strong evidence and three provided some suggestive evidence on symptom reduction and perceived well-being. There was weak evidence for effects on eight health outcomes (HbA1c, self-efficacy, depression, anxiety, distress, medication adherence, health-related quality of life and physical activity), with the rest classified as non-significant. Half of the meta-analyses had high level of heterogeneity.

CONCLUSION

Goal setting by itself affects outcomes of chronic diseases only to a small degree. This is not unexpected finding as changing outcomes in chronic diseases requires a complex and individualized approach. Implementing goal setting in a standardized way in the management of chronic conditions would seem to be a way forward.IMPLICATIONS FOR REHABILITATIONThe link between goal setting and health outcomes seems to be weak.Some levels of positive behavioural change could be of benefits to patients as seen by improved self-efficacy, patients' satisfaction and overall quality of life.Systematic and consistent application of personalized goal-oriented interventions considering patient's readiness to change could better predict improved outcomes.Incorporation of various goal setting components while actively engaging patient and/or their care givers in the process could appraise how goal setting could help with challenges in faced by people living with chronic conditions in different areas.