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Wollney EN, Bylund CL, Bedenfield N, Parker ND, Rosselli M, Curiel Cid RE, Kitaigorodsky M, Armstrong MJ. Persons living with dementia and caregivers' communication preferences for receiving a dementia diagnosis. PEC INNOVATION 2024; 4:100253. [PMID: 38298558 PMCID: PMC10828581 DOI: 10.1016/j.pecinn.2024.100253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/19/2023] [Accepted: 01/08/2024] [Indexed: 02/02/2024]
Abstract
Objective As the number of individuals diagnosed with dementia increases, so does the need to understand the preferences of persons living with dementia (PLWD) and caregivers for how clinicians can deliver a dementia diagnosis effectively, which can be a difficult process. This study describes the diagnostic communication preferences of PLWD and caregivers. Methods We conducted semi-structured individual phone interviews with two groups: PLWD who were diagnosed in the past two years (n = 11) and family caregivers of PLWD (n = 19) living in Florida. PLWD and caregivers were not recruited/enrolled as dyads. Results The groups' communication preferences were largely similar. Data were analyzed thematically into five themes: communicate the diagnosis clearly, meet information needs, discuss PLWD/caregiver resources, prepare for continued care, and communicate to establish and maintain relationships. Conclusion Participants wanted clear communication, information, and support, but differed in some details (e.g. the language used to describe the diagnosis and the amount/type of desired information). Clinicians can apply general principles but will need to tailor them to individual preferences of PLWD and caregivers. Innovation Limited research has elicited PLWD and caregivers' communication preferences for receiving dementia diagnoses, particularly through an individualized data collection method allowing for richer descriptions and deeper understanding.
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Affiliation(s)
- Easton N. Wollney
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Carma L. Bylund
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Noheli Bedenfield
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Naomi D. Parker
- College of Journalism & Communication, University of Florida, Gainesville, FL, United States of America
| | - Mónica Rosselli
- Department of Psychology, Florida Atlantic University, Boca Raton, FL, United States of America
| | - Rosie E. Curiel Cid
- Department of Psychiatry & Behavioral Sciences, Center for Cognitive Neuroscience and Aging, Miller School of Medicine, University of Miami, Miami, FL, United States of America
| | | | - Melissa J. Armstrong
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States of America
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, United States of America
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Naik AD, Shanahan ML, Dindo L, Mecca MC, Arney J, Amspoker AB, Wydermyer S, Banks J, Street RL, Kiefer L, Zenoni M, Rosen T, Gonzalez RD, Catic A, Fried TR. An innovative approach to aligning healthcare with what matters most to patients: A hybrid type 1 trial protocol of patient priorities care for older adults with multiple chronic conditions. Contemp Clin Trials 2024; 143:107613. [PMID: 38914308 DOI: 10.1016/j.cct.2024.107613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Providing healthcare for older adults with multiple chronic conditions (MCC) is challenging. Polypharmacy and complex treatment plans can lead to high treatment burden and risk for adverse events. For clinicians, managing the complexities of patients with MCC leaves little room to identify what matters and align care options with patients' health priorities. New care approaches are needed to navigate these challenges. In this clinical trial, we evaluate implementation and effectiveness outcomes of an innovative, structured, patient-centered care approach (Patient Priorities Care; PPC) for reducing treatment burden and aligning health care decisions with the health priorities of older adults with MCC. METHODS This is a multisite, assessor-blind, two-arm, parallel hybrid type 1 randomized controlled trial. We are enrolling 396 older (65+) Veterans with MCC who receive primary care at the Veterans Affairs Medical Center. Veterans are randomly assigned to either PPC or usual care. In the PPC arm, Veterans have a brief telephone call with a study facilitator to identify their personal health priorities. Then, primary care providers use this information to align healthcare with Veteran priorities during their established clinic appointments. Data are collected at baseline and 4-month follow up to assess for changes in treatment burden and use of home and community services. Formative and summative evaluations are also collected to assess for implementation outcomes according to Proctor's implementation framework. CONCLUSIONS This work has the potential to significantly improve the standard of care by personalizing healthcare and helping patients achieve what is most important to them.
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Affiliation(s)
- Aanand D Naik
- Institute on Aging, University of Texas Health Science Center, Houston, TX, United States of America; Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, United States of America.
| | - Mackenzie L Shanahan
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America
| | - Lilian Dindo
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Marcia C Mecca
- Center for Innovation for Pain Research, Informatics, Multi-morbidities, and Education, VA Connecticut Healthcare System, West Haven, CT, United States of America; Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Jennifer Arney
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Sociology, University of Houston-Clear Lake, Houston, TX, United States of America
| | - Amber B Amspoker
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Sheena Wydermyer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Jack Banks
- Institute on Aging, University of Texas Health Science Center, Houston, TX, United States of America; Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, United States of America
| | - Richard L Street
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Communication and Journalism, Texas A&M University, College Station, TX, United States of America
| | - Lea Kiefer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Maria Zenoni
- Center for Innovation for Pain Research, Informatics, Multi-morbidities, and Education, VA Connecticut Healthcare System, West Haven, CT, United States of America; Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Tracey Rosen
- Institute on Aging, University of Texas Health Science Center, Houston, TX, United States of America; Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, United States of America; Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, United States of America
| | - Raquel D Gonzalez
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Angela Catic
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Terri R Fried
- Center for Innovation for Pain Research, Informatics, Multi-morbidities, and Education, VA Connecticut Healthcare System, West Haven, CT, United States of America; Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
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Samper-Ternent R, Razjouyan J, Dindo L, Halaszynski J, Silva J, Fried T, Naik AD. Patient Priorities Care Increases Long-Term Service and Support Use: Propensity Match Cohort Study. J Am Med Dir Assoc 2024; 25:751-756. [PMID: 38320742 PMCID: PMC11137700 DOI: 10.1016/j.jamda.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/11/2023] [Accepted: 12/25/2023] [Indexed: 02/29/2024]
Abstract
OBJECTIVES Patient priorities care (PPC) is an evidence-based approach designed to help patients achieve what matters most to them by identifying their health priorities and working with clinicians to align the care they provide to the patient's priorities. This study examined the impact of the PPC approach on long-term service and support (LTSS) use among veterans. DESIGN Quasi-experimental study examining differences in LTSS use between veterans exposed to PPC and propensity-matched controls not exposed to PPC adjusting for covariates. SETTING AND PARTICIPANTS Fifty-six social workers in 5 Veterans Health Administration (VHA) sites trained in PPC in 2018, 143 veterans who used the PPC approach, and 286 matched veterans who did not use the PPC approach. METHODS Veterans with health priorities identified through the PPC approach were the intervention group (n = 143). The usual care group included propensity-matched veterans evaluated by the same social workers in the same period who did not participate in PPC (n = 286). The visit with the social worker was the index date. We examined LTSS use, emergency department (ED), and urgent care visits, 12 months before and after this date for both groups. Electronic medical record notes were extracted with a validated natural language processing algorithm (84% sensitivity, 95% specificity, and 92% accuracy). RESULTS Most participants were white men, mean age was 76, and 30% were frail. LTSS use was 48% higher in the PPC group compared with the usual care group [odds ratio (OR), 1.48; 95% CI, 1.00-2.18; P = .05]. Among those who lived >2 years after the index date, new LTSS use was higher (OR, 1.69; 95% CI, 1.04-2.76; P = .036). Among nonfrail individuals, LTSS use was also higher in the PPC group (OR, 1.70; 95% CI, 1.06-2.74; P = .028). PPC was not associated with higher ED or urgent care use. CONCLUSIONS AND IMPLICATIONS PPC results in higher LTSS use but not ED or urgent care in these veterans. LTSS use was higher for nonfrail veterans and those living longer. The PPC approach helps identify health priorities, including unmet needs for safe and independent living that LTSS can support.
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Affiliation(s)
- Rafael Samper-Ternent
- Department of Management, Policy, and Community Health, UTHealth Houston, Houston, TX, USA; Institute on Aging, UTHealth Houston, Houston, TX, USA.
| | - Javad Razjouyan
- VA Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Big Data Scientist Training Enhancement Program (BD-STEP), VA Office of Research and Development, Washington, DC, USA
| | - Lilian Dindo
- VA Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jaime Halaszynski
- Social Work Service, Butler VA Health Care System, Butler, PA, USA; VA National Social Work Program, Care Management and Social Work Services, Office of Patient Care Services, Department of Veterans Affairs, Washington, DC, USA
| | - Jennifer Silva
- VA National Social Work Program, Care Management and Social Work Services, Office of Patient Care Services, Department of Veterans Affairs, Washington, DC, USA; Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Terri Fried
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA; Connecticut Veterans Administration Health System, West Haven, CT, USA
| | - Aanand D Naik
- Department of Management, Policy, and Community Health, UTHealth Houston, Houston, TX, USA; Institute on Aging, UTHealth Houston, Houston, TX, USA; VA Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Hladek MD, Wilson D, Krasnansky K, McDaniel K, Shanbhag M, McAdams-DeMarco M, Crews DC, Brennan DC, Taylor J, Segev D, Walston J, Xue QL, Szanton SL. Using Photovoice to Explore the Lived Environment and Experience of Older Adults with Frailty on their Kidney Transplant Journey. KIDNEY360 2024; 5:589-598. [PMID: 38379153 PMCID: PMC11093540 DOI: 10.34067/kid.0000000000000380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/29/2024] [Indexed: 02/22/2024]
Abstract
Key Points Photovoice, a qualitative method, visually depicted the daily lives of participants with frailty, providing insights into independence and symptom management to guide clinicians and researchers. This photovoice study uncovered subthemes of home safety and organization, revealing potential safety hazards like dialysis fluid storage, and suggests its potential use in geriatric nephrology. The findings emphasize the importance of integrating participant values and goals into care decisions and interventional design in the context of kidney transplant journeys for frail adults. Background Older adults with frailty and kidney failure face higher waitlist mortality and are more likely to be listed as inactive on the kidney transplant (KT) waitlist. Photovoice is a qualitative participatory research method where participants use photographs to represent their environment, needs, and experiences. It offers unique insight into the lived environment and experience of patients and may offer direction in how to improve functional independence, symptom burden, and KT outcomes in adults with frailty. Methods This photovoice study was embedded within a larger intervention adaptation project. Participants with prefrailty or frailty awaiting a KT or recently post-transplant took photographs with Polaroid cameras and wrote short descriptions for 11 prompts. Each participant completed a semistructured interview wherein their photographs were discussed. The team coded and discussed photographs and interviews to determine overarching themes and implications. Focus groups were used to triangulate visual data findings. Results Sixteen participants completed both the photovoice and the interview. Participants were a mean age of 60.5 years, 31.2% female, 43.4% self-identifying as Black, and 69% were frail. Outcomes were categorized into seven themes: functional space, home safety, medication management, adaptive coping, life-changing nature of dialysis, support, and communication. Visual data clarified and sometimes changed the interpretations of the text alone. Especially within the themes of home safety and functional space, safety hazards not previously recognized in the literature, like dialysis fluid storage, were identified. Conclusions Photovoice contextualizes the living conditions and experiences of adults with frailty on the KT journey and could be a useful tool in geriatric nephrology and transplant. Addressing issues of home storage, organization, and accessibility should be explored as potential intervention targets. Incorporating participant values and goals into care decisions and interventional design should be further explored.
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Affiliation(s)
| | - Deborah Wilson
- Johns Hopkins School of Nursing, Baltimore, Maryland
- Auckland University of Technology School of Clinical Sciences, Auckland, New Zealand
| | | | | | - Meera Shanbhag
- University of Central Florida College of Medicine, Orlando, Florida
| | - Mara McAdams-DeMarco
- New York University Grossman School of Medicine Lagoune Health, New York, New York
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deidra C. Crews
- Johns Hopkins School of Nursing, Baltimore, Maryland
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Dorry Segev
- New York University Grossman School of Medicine Lagoune Health, New York, New York
| | - Jeremy Walston
- Johns Hopkins School of Nursing, Baltimore, Maryland
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Geriatric Medicine and Gerontology, Baltimore, Maryland
| | - Qian-Li Xue
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah L. Szanton
- Johns Hopkins School of Nursing, Baltimore, Maryland
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
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De Coninck L, Declercq A, Bouckaert L, Döpp C, Graff MJL, Aertgeerts B. Promoting meaningful activities by occupational therapy in elderly care in Belgium: the ProMOTE intervention. BMC Geriatr 2024; 24:275. [PMID: 38509458 PMCID: PMC10953191 DOI: 10.1186/s12877-024-04797-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 02/08/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Older people want to age in place. Despite advancing functional limitations and their desire of aging in place, they are not always faithful to therapy that maintains independence and promotes safety. Occupational therapists can facilitate aging in place. Occupational therapy is defined as the therapeutic use of everyday life occupations with persons, groups, or populations for the purpose of enhancing or enabling participation. AIM To describe the content a high-adherence-to-therapy and evidence-based occupational therapy intervention to optimize functional performance and social participation of home-based physically frail older adults and wellbeing of their informal caregiver, and the research activities undertaken to design this intervention. METHODS A roadmap was created to develop the occupational therapy intervention. This roadmap is based on the Medical Research Council (MRC) framework and is supplemented with elements of the Intervention Mapping approach. The TIDieR checklist is applied to describe the intervention in detail. A systematic review and two qualitative studies substantiated the content of the intervention scientifically. RESULTS The application of the first two phases of the MRC framework resulted in the ProMOTE intervention (Promoting Meaningful activities by Occupational Therapy in Elderly). The ProMOTE intervention is a high-adherence-to-therapy occupational therapy intervention that consists of six steps and describes in detail the evidence-based components that are required to obtain an operational intervention for occupational therapy practice. CONCLUSION This study transparently reflects on the process of a high-quality occupational therapy intervention to optimize the functional performance and social participation of the home-based physically frail older adult and describes the ProMOTE intervention in detail. The ProMOTE intervention contributes to safely aging in place and to maintaining social participation. The designed intervention goes beyond a description of the 'what'. The added value lies in the interweaving of the 'why' and 'how'. By describing the 'how', our study makes the concept of 'therapeutic use-of-self' operational throughout the six steps of the occupational therapy intervention. A further rigorous study of the effect of the ProMOTE intervention on adherence, functional performance and social participation is recommended based to facilitate the implementation of this intervention on a national level in Belgium.
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Affiliation(s)
- Leen De Coninck
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, Leuven, 3000, Belgium.
- CEBAM Belgian Center for Evidence-based Medicine vzw, Kapucijnenvoer 7, Leuven, 3000, Belgium.
| | - Anja Declercq
- LUCAS Center for Care Research and Consultancy & CESO Center for Sociological Research, KU Leuven, Minderbroedersstraat 8, Leuven, 3000, Belgium
| | - Leen Bouckaert
- Department of Occupational Therapy, Artevelde University of Applied Sciences, Voetweg 66, Ghent, 9000, Belgium
| | - Carola Döpp
- Scientific Institute for Quality of Health Care, Department of Rehabilitation, Radboudumc Research Institute, Radboud University Medical Center, Houtlaan 4, Nijmegen, 6525 XZ, The Netherlands
| | - Maud J L Graff
- Scientific Institute for Quality of Health Care, Department of Rehabilitation, Radboudumc Research Institute, Radboud University Medical Center, Houtlaan 4, Nijmegen, 6525 XZ, The Netherlands
| | - Bert Aertgeerts
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, Leuven, 3000, Belgium.
- CEBAM Belgian Center for Evidence-based Medicine vzw, Kapucijnenvoer 7, Leuven, 3000, Belgium.
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Tinetti ME, Hashmi A, Ng H, Doyle M, Goto T, Esterson J, Naik AD, Dindo L, Li F. Patient Priorities-Aligned Care for Older Adults With Multiple Conditions: A Nonrandomized Controlled Trial. JAMA Netw Open 2024; 7:e2352666. [PMID: 38261319 PMCID: PMC10807252 DOI: 10.1001/jamanetworkopen.2023.52666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/01/2023] [Indexed: 01/24/2024] Open
Abstract
Importance Older adults with multiple conditions receive health care that may be burdensome, of uncertain benefit, and not focused on what matters to them. Identifying and aligning care with patients' health priorities may improve outcomes. Objective To assess the association of receiving patient priorities care (PPC) vs usual care (UC) with relevant clinical outcomes. Design, Setting, and Participants In this nonrandomized controlled trial with propensity adjustment, enrollment occurred between August 21, 2020, and May 14, 2021, with follow-up continuing through February 26, 2022. Patients who were aged 65 years or older and with 3 or more chronic conditions were enrolled at 1 PPC and 1 UC site within the Cleveland Clinic primary care multisite practice. Data analysis was performed from March 2022 to August 2023. Intervention Health professionals at the PPC site guided patients through identification of values, health outcome goals, health care preferences, and top priority (ie, health problem they most wanted to focus on because it impeded their health outcome goal). Primary clinicians followed PPC decisional strategies (eg, use patients' health priorities as focus of communication and decision-making) to decide with patients what care to stop, start, or continue. Main Outcomes and Measures Main outcomes included perceived treatment burden, Patient-Reported Outcomes Measurement Information System (PROMIS) social roles and activities, CollaboRATE survey scores, the number of nonhealthy days (based on healthy days at home), and shared prescribing decision quality measures. Follow-up was at 9 months for patient-reported outcomes and 365 days for nonhealthy days. Results A total of 264 individuals participated, 129 in the PPC group (mean [SD] age, 75.3 [6.1] years; 66 women [48.9%]) and 135 in the UC group (mean [SD] age, 75.6 [6.5] years; 55 women [42.6%]). Characteristics between sites were balanced after propensity score weighting. At follow-up, there was no statistically significant difference in perceived treatment burden score between groups in multivariate models (difference, -5.2 points; 95% CI, -10.9 to -0.50 points; P = .07). PPC participants were almost 2.5 times more likely than UC participants to endorse shared prescribing decision-making (adjusted odds ratio, 2.40; 95% CI, 0.90 to 6.40; P = .07), and participants in the PPC group experienced 4.6 fewer nonhealthy days (95% CI, -12.9 to -3.6 days; P = .27) compared with the UC participants. These differences were not statistically significant. CollaboRATE and PROMIS Social Roles and Activities scores were similar in the 2 groups at follow-up. Conclusions and Relevance This nonrandomized trial of priorities-aligned care showed no benefit for social roles or CollaboRATE. While the findings for perceived treatment burden and shared prescribing decision-making were not statistically significant, point estimates for the findings suggested that PPC may hold promise for improving these outcomes. Randomized trials with larger samples are needed to determine the effectiveness of priorities-aligned care. Trial Registration ClinicalTrials.gov Identifier: NCT04510948.
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Affiliation(s)
- Mary E. Tinetti
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Ardeshir Hashmi
- Center for Geriatric Medicine, Cleveland Clinic, Cleveland, Ohio
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Henry Ng
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Margaret Doyle
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Toyomi Goto
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
| | - Jessica Esterson
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Aanand D. Naik
- Institute on Aging, University of Texas Health Science Center, Houston
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Lilian Dindo
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut
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Wang J, Shen JY, Yu F, Nathan K, Caprio TV, Conwell Y, Moskow MS, Brasch JD, Simmons SF, Mixon AS, Norton SA. Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home. J Am Med Dir Assoc 2024; 25:138-145.e6. [PMID: 37913819 PMCID: PMC10843747 DOI: 10.1016/j.jamda.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients. DESIGN Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. SETTING AND PARTICIPANT Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MEASURES Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. RESULTS We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. CONCLUSIONS AND IMPLICATIONS Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, NY, USA.
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; University of Rochester-Home Care, University of Rochester Medical Center, Rochester, NY, USA; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sally A Norton
- School of Nursing, University of Rochester, Rochester, NY, USA
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Mroz EL, Hernandez-Bigos K, Esterson J, Kiwak E, Naik A, Tinetti ME. Acceptability and use of an online health priorities self-identification tool for older adults: A qualitative investigation. PEC INNOVATION 2023; 3:100242. [PMID: 38161685 PMCID: PMC10757242 DOI: 10.1016/j.pecinn.2023.100242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/11/2023] [Accepted: 12/02/2023] [Indexed: 01/03/2024]
Abstract
Objective To examine the use of a web-based, self-directed health priorities identification tool for older adults with multiple chronic conditions (MCCs). Methods We recruited a gender- and racially-diverse, highly educated sample of older adults with MCCs to engage with our My Health Priorities tool, then complete a semi-structured interview. Thematic analysis was used to examine interview transcripts. Results Twenty-one participants shared perspectives on the acceptability and use of the tool. Three themes (with eleven subthemes) were generated to describe: website user experience feedback, the content of the health priorities identification process, and the tool's capacity to empower communication and decision making. Conclusion Participants found this tool acceptable and easy to use, describing a variety of benefits of the priorities self-identification process and offered suggestions for refinement and broader implementation. Older adults with limited internet navigation abilities or misconceptions about the self-directed process may benefit from clinicians clarifying the purpose of the process or initiating priorities-aligned discussions. Innovation This novel tool can help older adults with MCCs define what matters most for their health and healthcare, informing a variety of health decisions. This tool may enable and motivate patients to lead health priorities decision-making discussions with clinicians and care partners.
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Affiliation(s)
- Emily L. Mroz
- Section of Geriatrics, Department of Internal Medicine Yale School of Medicine, New Haven, CT, USA
| | - Kizzy Hernandez-Bigos
- Section of Geriatrics, Department of Internal Medicine Yale School of Medicine, New Haven, CT, USA
| | - Jessica Esterson
- Section of Geriatrics, Department of Internal Medicine Yale School of Medicine, New Haven, CT, USA
| | - Eliza Kiwak
- Section of Geriatrics, Department of Internal Medicine Yale School of Medicine, New Haven, CT, USA
| | - Aanand Naik
- Institute on Aging, University of Texas Health Science Center, Houston, TX, USA
- Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Mary E. Tinetti
- Section of Geriatrics, Department of Internal Medicine Yale School of Medicine, New Haven, CT, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
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9
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Ng XR, Tey YXS, Lew KJ, Lee PSS, Lee ES, Sim SZ. Cross-sectional study assessing health outcome priorities of older adults with multimorbidity at a primary care setting in Singapore. BMJ Open 2023; 13:e079990. [PMID: 38081675 PMCID: PMC10729092 DOI: 10.1136/bmjopen-2023-079990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES Managing older adults with multimorbidity may be challenging due to the conflicting benefits and harms of multiple treatments. Thus, it is important to identify patients' health outcome priorities to align treatment goals with their health preferences. This study aimed to use the Outcome Prioritisation Tool (OPT) to describe the health outcome priorities of older adults with multimorbidity and determine the factors associated with these priorities. Additionally, it aimed to assess the ease of completing the OPT in Singapore's primary care population. DESIGN Cross-sectional study conducted from January to March 2022. SETTING A public primary care centre in Singapore. PARTICIPANTS 65 years and older with multimorbidity. OUTCOME MEASURES Primary outcome measure was the most important health outcome priorities on the OPT. Secondary outcome measures were factors affecting these priorities and ease of completing the OPT. RESULTS We enrolled 180 participants (mean age: 73.2±6.1 years). Slightly more than half (54.4%) prioritised 'staying alive', while the remainder (45.6%) prioritised 'maintaining independence' (25.6%), 'relieving pain' (10.6%) and 'relieving other symptoms' (9.4%). Participants with six or more chronic conditions were three times (OR 3.03 (95% CI1.09 to 8.42)) more likely to prioritise 'staying alive' compared with participants with three conditions. Most participants (69.4%) agreed that the OPT was easy to complete, and the mean time taken to complete the OPT was 3.8±1.6 minutes. CONCLUSION 'Staying alive' was the most important health outcome priority, especially for older adults with six or more chronic conditions. The OPT was easily completed among older adults with multimorbidity in primary care. Further qualitative studies can be conducted to understand the factors influencing patients' priorities and explore the relevance of the OPT in guiding treatment decisions.
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Affiliation(s)
- Xin Rong Ng
- National Healthcare Group Polyclinics, Singapore
| | | | - Kaiwei Jeremy Lew
- Clinical Research Unit, National Healthcare Group Polyclinics, Singapore
| | | | - Eng Sing Lee
- Clinical Research Unit, National Healthcare Group Polyclinics, Singapore
| | - Sai Zhen Sim
- National Healthcare Group Polyclinics, Singapore
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McMenamin A, Turi E, Schlak A, Poghosyan L. A Systematic Review of Outcomes Related to Nurse Practitioner-Delivered Primary Care for Multiple Chronic Conditions. Med Care Res Rev 2023; 80:563-581. [PMID: 37438917 PMCID: PMC10784406 DOI: 10.1177/10775587231186720] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Multiple chronic conditions (MCCs) are more common and costly than any individual health condition in the United States. The growing workforce of nurse practitioners (NPs) plays an active role in providing primary care to this patient population. This study identifies the effect of NP primary care models, compared with models without NP involvement, on cost, quality, and service utilization by patients with MCCs. We conducted a literature search of six databases and performed critical appraisal. Fifteen studies met inclusion criteria (years: 2003-2021). Overall, most studies showed reduced or similar costs, equivalent or better quality, and similar or lower rates of emergency department use and hospitalization associated with NP primary care models for patients with MCCs, compared with models without NP involvement. No studies found them associated with worse outcomes. Thus, NP primary care models, compared with models without NP involvement, have similar or positive impacts on MCC patient outcomes.
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Affiliation(s)
- Amy McMenamin
- Columbia University in the City of New York, New York City, USA
| | - Eleanor Turi
- Columbia University in the City of New York, New York City, USA
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Ritchey KC, Solberg LM, Citty SW, Kiefer L, Martinez E, Gray C, Naik AD. Guiding Post-Hospital Recovery by 'What Matters:' Implementation of Patient Priorities Identification in a VA Community Living Center. Geriatrics (Basel) 2023; 8:74. [PMID: 37489322 PMCID: PMC10366719 DOI: 10.3390/geriatrics8040074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/01/2023] [Accepted: 06/25/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Patient priorities care (PPC) is an effective age-friendly health systems (AFHS) approach to aligning care with goals derived from 'what matters'. The purpose of this quality improvement program was to evaluate the fidelity and feasibility of the health priorities identification (HPI) process in VA Community Living Centers (CLC). METHODS PPC experts worked with local CLC staff to guide the integration of HPI into the CLC and utilized a Plan-Do-Study-Act (PDSA) model for this quality improvement project. PPC experts reviewed health priorities identification (HPI) encounters and interdisciplinary team (IDT) meetings for fidelity to the HPI process of PPC. Qualitative interviews with local CLC staff determined the appropriateness of the health priorities identification process in the CLC. RESULTS Over 8 months, nine facilitators completed twenty HPI encounters. Development of a Patient Health Priorities note template, staff education and PPC facilitator training improved fidelity and documentation of HPI encounters in the electronic health record. Facilitator interviews suggested that PPC is appropriate in this setting, not burdensome to staff and fostered a person-centered approach to AFHS. CONCLUSIONS The HPI process is an acceptable and feasible approach to ask the 'what matters' component of AFHS in a CLC setting.
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Affiliation(s)
- Katherine C Ritchey
- Puget Sound Veterans Health Care System, Geriatric Research and Education Clinical Center (GRECC), Tacoma, WA 98498, USA
- Division of Geriatrics and Gerontology, Department of Medicine, University of Washington, Seattle, WA 98109, USA
| | - Laurence M Solberg
- North Florida/South Georgia Veterans Health System, Geriatric Research and Education Clinical Center (GRECC), Gainesville, FL 32608, USA
| | - Sandra Wolfe Citty
- North Florida/South Georgia Veterans Health System, Geriatric Research and Education Clinical Center (GRECC), Gainesville, FL 32608, USA
- College of Nursing, University of Florida, Gainesville, FL 32611, USA
| | - Lea Kiefer
- Michael E. DeBakey Veterans Health Care System, Houston, TX 77030, USA
| | - Erica Martinez
- Puget Sound Veterans Health Care System, Geriatric Research and Education Clinical Center (GRECC), Tacoma, WA 98498, USA
| | - Caroline Gray
- Palo Alto Veterans Health Care System, Palo Alto, CA 94304, USA
| | - Aanand D Naik
- Michael E. DeBakey Veterans Health Care System, Houston, TX 77030, USA
- Institute on Aging, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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12
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. How "age-friendly" are deprescribing interventions? A scoping review of deprescribing trials. Health Serv Res 2023; 58 Suppl 1:123-138. [PMID: 36221154 DOI: 10.1111/1475-6773.14083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To assess how age-friendly deprescribing trials are regarding intervention design and outcome assessment. Reduced use of potentially inappropriate medications (PIMs) can be addressed by deprescribing-a systematic process of discontinuing and/or reducing the use of PIMs. The 4Ms-"Medication", "Mentation", "Mobility", and "What Matters Most" to the person-can be used to guide assessment of age-friendliness of deprescribing trials. DATA SOURCE Published literature. STUDY DESIGN Scoping review. DATA EXTRACTION METHODS The literature was identified using keywords related to deprescribing and polypharmacy in PubMed, EMBASE, Web of Science, ProQuest, CINAHL, and Cochrane and snowballing. Study characteristics were extracted and evaluated for consideration of 4Ms. PRINCIPAL FINDINGS Thirty-seven of the 564 trials identified met the review eligibility criteria. Intervention design: "Medication" was considered in the intervention design of all trials; "Mentation" was considered in eight trials; "Mobility" (n = 2) and "What Matters Most" (n = 6) were less often considered in the design of intervention. Most trials targeted providers without specifying how matters important to older adults and their families were aligned with deprescribing decisions. OUTCOME ASSESSMENT "Medication" was the most commonly assessed outcome (n = 33), followed by "Mobility" (n = 13) and "Mentation" (n = 10) outcomes, with no study examining "What Matters Most" outcomes. CONCLUSIONS "Mentation" and "Mobility", and "What Matters Most" have been considered to varying degrees in deprescribing trials, limiting the potential of deprescribing evidence to contribute to improved clinical practice in building an age-friendly health care system.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Kobi Nathan
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Arizona State University, Edson College of Nursing and Health Innovation, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- University of Rochester Medical Center, Department of Medicine, Division of Hematology/Oncology, Rochester, New York, USA
| | - Donna M Fick
- Penn State University, Ross and Carol Nese College of Nursing, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Division of Geriatrics & Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Elliott MJ, Ravani P, Quinn RR, Oliver MJ, Love S, MacRae J, Hiremath S, Friesen S, James MT, King-Shier KM. Patient and Clinician Perspectives on Shared Decision Making in Vascular Access Selection: A Qualitative Study. Am J Kidney Dis 2023; 81:48-58.e1. [PMID: 35870570 DOI: 10.1053/j.ajkd.2022.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/30/2022] [Indexed: 12/24/2022]
Abstract
RATIONALE & OBJECTIVE Collaborative approaches to vascular access selection are being increasingly encouraged to elicit patients' preferences and priorities where no unequivocally superior choice exists. We explored how patients, their caregivers, and clinicians integrate principles of shared decision making when engaging in vascular access discussions. STUDY DESIGN Qualitative description. SETTING & PARTICIPANTS Semistructured interviews with a purposive sample of patients, their caregivers, and clinicians from outpatient hemodialysis programs in Alberta, Canada. ANALYTICAL APPROACH We used a thematic analysis approach to inductively code transcripts and generate themes to capture key concepts related to vascular access shared decision making across participant roles. RESULTS 42 individuals (19 patients, 2 caregivers, 21 clinicians) participated in this study. Participants identified how access-related decisions follow a series of major decisions about kidney replacement therapy and care goals that influence vascular access preferences and choice. Vascular access shared decision making was strengthened through integration of vascular access selection with dialysis-related decisions and timely, tailored, and balanced exchange of information between patients and their care team. Participants described how opportunities to revisit the vascular access decision before and after dialysis initiation helped prepare patients for their access and encouraged ongoing alignment between patients' care priorities and treatment plans. Where shared decision making was undermined, hemodialysis via a catheter ensued as the most readily available vascular access option. LIMITATIONS Our study was limited to patients and clinicians from hemodialysis care settings and included few caregiver participants. CONCLUSIONS Findings suggest that earlier, or upstream, decisions about kidney replacement therapies influence how and when vascular access decisions are made. Repeated vascular access discussions that are integrated with other higher-level decisions are needed to promote vascular access shared decision making and preparedness.
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Affiliation(s)
- Meghan J Elliott
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Pietro Ravani
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Robert R Quinn
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shannan Love
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer MacRae
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Swapnil Hiremath
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Friesen
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T James
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn M King-Shier
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Carpenter CR, Southerland LT, Lucey BP, Prusaczyk B. Around the EQUATOR with clinician-scientists transdisciplinary aging research (Clin-STAR) principles: Implementation science challenges and opportunities. J Am Geriatr Soc 2022; 70:3620-3630. [PMID: 36005482 PMCID: PMC10538952 DOI: 10.1111/jgs.17993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 12/24/2022]
Abstract
The Institute of Medicine and the National Institute on Aging increasingly understand that knowledge alone is necessary but insufficient to improve healthcare outcomes. Adapting the behaviors of clinicians, patients, and stakeholders to new standards of evidence-based clinical practice is often significantly delayed. In response, over the past twenty years, Implementation Science has developed as the study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners and policymakers. One important advance in Implementation Science research was the development of Standards for Reporting Implementation Studies (StaRI), which provided a 27-item checklist for researchers to consistently report essential elements of the implementation and intervention strategies. Using StaRI as a framework, this review discusses specific Implementation Science challenges for research with older adults, provides solutions for those obstacles, and opportunities to improve the value of this evolving approach to reduce the knowledge translation losses that exist between published research and clinical practice.
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Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Brendan P Lucey
- Department of Neurology, Washington University in St Louis School of Medicine, St. Louis, Missouri, USA
| | - Beth Prusaczyk
- Department of Medicine Institute for Informatics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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15
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Schuttner L, Lee JR, Hockett Sherlock S, Ralston JD, Rosland AM, Nelson K, Simons C, Sayre GG. Primary Care Physician Perspectives on the Influence of Patient Values, Health Priorities, and Preferences on Clinical Decision-Making for Complex Patients with Multimorbidity: A Qualitative Study. Risk Manag Healthc Policy 2022; 15:2135-2146. [PMID: 36415219 PMCID: PMC9675988 DOI: 10.2147/rmhp.s380021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/20/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction The prevalence of patients with multimorbidity (ie, multiple chronic conditions) is increasing. Clinical decision-making guided by patients' values, health priorities and goals, and treatment preferences is particularly important in the context of interacting diseases and psychosocial needs. Physicians face challenges incorporating patient perspectives into care plans. We examined primary care physician (PCP) views on the influence of patients' values, health priorities and goals, and preferences on clinical decisions for patients with multimorbidity and increased psychosocial complexity. Methods We conducted semi-structured telephone interviews with 23 PCPs within patient-centered medical home teams in a nationally integrated health system in the United States between May and July 2020. Data were analyzed via thematic analysis with deductive and inductive coding. Results Three major themes emerged: 1. Patient personal values were rarely explicitly discussed in routine clinical encounters but informed more commonly discussed concepts of patient priorities, goals, and preferences; 2. Patient values, health priorities and goals, and preferences were sources of divergent views about care plans between healthcare teams, patients, and families; 3. Physicians used explicit strategies to communicate and negotiate about patient values, health priorities and goals, and preferences when developing care plans, including trust-building; devoting extra effort to individualizing care; connecting patient values to healthcare recommendations; deliberate elicitation and acknowledgement of patient concerns; providing "space" for patient perspectives; incorporating family into care planning; pairing physician to patient priorities; and collaborative teamwork. Conclusion Primary care physicians perceive patient values, health priorities and goals, and preferences as influential during clinical decision-making for complex patients with multimorbidity. Participants used concrete strategies to negotiate alignment of these aspects when physician-patient divergence occurred. While rarely discussed directly in clinical encounters, personal values affected patient health priorities, goals, and preferences during care planning, suggesting a clinical role for more deliberate elicitation and discussion of patient values for this population.
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Affiliation(s)
- Linnaea Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jenney R Lee
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Stacey Hockett Sherlock
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System, Iowa City, IA, USA
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Karin Nelson
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Carol Simons
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
| | - George G Sayre
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
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Etkind SN. Uncertainty in multimorbidity: a shared experience we should recognise, acknowledge and communicate. Br J Community Nurs 2022; 27:540-544. [PMID: 36327210 DOI: 10.12968/bjcn.2022.27.11.540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Multimorbidity is increasingly common and inevitably results in uncertainties about health, care and the future. Such uncertainties may be experienced by patients, carers and health professionals. Given the ubiquitous presence of uncertainty, all professionals should be prepared to approach and address it in clinical practice. Uncertainty in multimorbidity can rarely be eliminated, and so, must be carefully addressed and communicated; however, there is little evidence on how to approach it. Key areas are: recognising the existence of uncertainty, acknowledging it, and communicating to achieve a shared understanding. Evaluation of what has been discussed, and preparedness to repeat such conversations are also important. Future research should explore optimal communication of uncertainty in multimorbidity.
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Affiliation(s)
- Simon Noah Etkind
- Academic Clinical Lecturer, Department of Public Health and Primary Care, University of Cambridge
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17
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Etkind SN, Li J, Louca J, Hopkins SA, Kuhn I, Spathis A, Barclay SIG. Total uncertainty: a systematic review and thematic synthesis of experiences of uncertainty in older people with advanced multimorbidity, their informal carers and health professionals. Age Ageing 2022; 51:6670562. [PMID: 35977149 PMCID: PMC9385183 DOI: 10.1093/ageing/afac188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES uncertainty pervades the complex illness trajectories experienced by older adults with multimorbidity. Uncertainty is experienced by older people, their informal carers and professionals providing care, yet is incompletely understood. We aimed to identify and synthesise systematically the experience of uncertainty in advanced multimorbidity from patient, carer and professional perspectives. DESIGN systematic literature review of published and grey qualitative literature from 9 databases (Prospero CRD 42021227480). PARTICIPANTS older people with advanced multimorbidity, and informal carers/professionals providing care to this group. Exclusion criteria: early multimorbidity, insufficient focus on uncertainty. ANALYSIS weight-of-evidence assessment was used to appraise included articles. We undertook thematic synthesis of multi-perspective experiences and response to uncertainty. RESULTS from 4,738 unique search results, we included 44 articles relating to 40 studies. 22 focused on patient experiences of uncertainty (n = 460), 15 on carer experiences (n = 197), and 19 on health professional experiences (n = 490), with 10 exploring multiple perspectives. We identified a shared experience of 'Total Uncertainty' across five domains: 'appraising and managing multiple illnesses'; 'fragmented care and communication'; 'feeling overwhelmed'; 'uncertainty of others' and 'continual change'. Participants responded to uncertainty by either active (addressing, avoiding) or passive (accepting) means. CONCLUSIONS the novel concept of 'Total Uncertainty' represents a step change in our understanding of illness experience in advanced multimorbidity. Patients, carers and health professionals experienced uncertainty in similar domains, suggesting a shared understanding is feasible. The domains of total uncertainty form a useful organising framework for health professionals caring for older adults with multimorbidity.
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Affiliation(s)
| | - Jiaqi Li
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - John Louca
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Sarah A Hopkins
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK,Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Isla Kuhn
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Anna Spathis
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen I G Barclay
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Vonnes C, Gallenstein D, Poiley L, McDaniel GA, Mason TM. Perspectives on implementing an ambulatory age-friendly health system pilot project. J Geriatr Oncol 2022; 13:1287-1290. [DOI: 10.1016/j.jgo.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 06/13/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
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Ambulatory Medication Safety in Primary Care: A Systematic Review. J Am Board Fam Med 2022; 35:610-628. [PMID: 35641040 PMCID: PMC9730343 DOI: 10.3122/jabfm.2022.03.210334] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/27/2021] [Accepted: 01/10/2022] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To review the literature on medication safety in primary care in the electronic health record era. METHODS Included studies measured rates and outcomes of medication safety in patients whose prescriptions were written in primary care clinics with electronic prescribing. Four investigators independently reviewed titles and analyzed abstracts with dual-reviewer review for eligibility, characteristics, and risk of bias. RESULTS Of 1464 articles identified, 56 met the inclusion criteria. Forty-three studies were noninterventional and 13 included an intervention. The majority of the studies (30) used their own definition of error. The most common outcomes were potentially inappropriate prescribing/medications (PIPs), adverse drug events (ADEs), and potential prescribing omissions (PPOs). Most of the studies only included high-risk subpopulations (39), usually older adults taking > 4 medications. The rate of PIPs varied widely (0.19% to 98.2%). The rate of ADEs was lower (0.47% to 14.7%). There was poor correlation of PIP and PPO with documented ADEs leading to physical harm. CONCLUSIONS This literature is limited by its inconsistent and highly variable outcomes. The majority of medication safety studies in primary care were in high-risk populations and measured potential harms rather than actual harms. Applying algorithms to primary care medication lists significantly overestimates rate of actual harms.
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Boeykens D, Boeckxstaens P, De Sutter A, Lahousse L, Pype P, De Vriendt P, Van de Velde D. Goal-oriented care for patients with chronic conditions or multimorbidity in primary care: A scoping review and concept analysis. PLoS One 2022; 17:e0262843. [PMID: 35120137 PMCID: PMC8815876 DOI: 10.1371/journal.pone.0262843] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/06/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The healthcare system is faced by an ageing population, increase in chronic conditions and multimorbidity. Multimorbid patients are faced with multiple parallel care processes leading to a risk of fragmented care. These problems relate to the disease-oriented paradigm. In this paradigm the treatment goals can be in contrast with what patients value. The concept of goal-oriented care is proposed as an alternative way of providing care as meeting patients' goals could have potential benefits. Though, there is a need to translate this concept into tangible knowledge so providers can better understand and use the concept in clinical practice. The aim of this study is to address this need by means of a concept analysis. METHOD This concept analysis using the method of Walker and Avant is based on a literature search in PubMed, Embase, Cochrane Library, PsychInfo, CINAHL, OTSeeker and Web of Science. The method provides eight iterative steps: select a concept, determine purpose, determine defining attributes, identify model case, identify additional case, identify antecedents and consequences and define empirical referents. RESULTS The analysis of 37 articles revealed that goal-oriented care is a dynamic and iterative process of three stages: goal-elicitation, goal-setting, and goal-evaluation. The process is underpinned by the patient's context and values. Provider and patient preparedness are required to provide goal-oriented care. Goal-oriented care has the potential to improve patients' experiences and providers' well-being, to reduce costs, and improve the overall population health. The challenge is to identify empirical referents to evaluate the process of goal-oriented care. CONCLUSION A common understanding of goal-oriented care is presented. Further research should focus on how and what goals are set by the patient, how this knowledge could be translated into a tangible workflow and should support the development of a strategy to evaluate the goal-oriented process of care.
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Affiliation(s)
- Dagje Boeykens
- Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences, Occupational Therapy, Ghent University, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Department of Public Health and Primary Care, Center for Family Medicine, Ghent University, Ghent, Belgium
| | - Pauline Boeckxstaens
- Faculty of Medicine and Health Sciences, Department of Public Health and Primary Care, Center for Family Medicine, Ghent University, Ghent, Belgium
| | - An De Sutter
- Faculty of Medicine and Health Sciences, Department of Public Health and Primary Care, Center for Family Medicine, Ghent University, Ghent, Belgium
| | - Lies Lahousse
- Faculty of Pharmaceutical Sciences, Department of Bioanalysis, Ghent University, Ghent, Belgium
| | - Peter Pype
- Faculty of Medicine and Health Sciences, Department of Public Health and Primary Care, Center for Family Medicine, Ghent University, Ghent, Belgium
- Faculty of Medicine and Health Sciences, End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Ghent, Belgium
| | - Patricia De Vriendt
- Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences, Occupational Therapy, Ghent University, Ghent, Belgium
- Department of Occupational Therapy, Artevelde University of Applied Sciences, Ghent, Belgium
- Faculty of Medicine and Pharmacy, Department of Gerontology and Mental Health and Wellbeing (MENT) Research Group, Frailty in Ageing (FRIA) Research Group, Vrije Universiteit Brussel, Brussel, Belgium
| | - Dominique Van de Velde
- Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences, Occupational Therapy, Ghent University, Ghent, Belgium
- Department of Occupational Therapy, Artevelde University of Applied Sciences, Ghent, Belgium
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21
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Tuzzio L, Berry AL, Gleason K, Barrow J, Bayliss EA, Gray MF, Delate T, Bermet Z, Uratsu CS, Grant RW, Ralston JD. Aligning care with the personal values of patients with complex care needs. Health Serv Res 2021; 56 Suppl 1:1037-1044. [PMID: 34363205 PMCID: PMC8515216 DOI: 10.1111/1475-6773.13862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To identify opportunities to align care with the personal values of patients from three distinct groups with complex medical, behavioral, and social needs. DATA SOURCES/STUDY SETTING Between June and August 2019, we conducted semi-structured interviews with individuals with complex care needs in two integrated health care delivery systems. STUDY DESIGN Qualitative study using semi-structured interviews. DATA COLLECTION METHODS We interviewed three groups of patients at Kaiser Permanente Washington and Kaiser Permanente Colorado representing three distinct profiles of complex care needs: Group A ("obesity, opioid prescription, and low-resourced neighborhood"), Group B ("older, high medical morbidity, emergency department, and hospital use"), and Group C ("older, mental and physical health concerns, and low-resourced neighborhood"). These profiles were identified based on prior work and prioritized by internal primary care stakeholders. Interview transcripts were analyzed using thematic analysis. PRINCIPAL FINDINGS Twenty-four patients participated; eight from each complex needs profile. Mean age across groups was 71 (range 48-86) years. We identified five themes common across the three groups that captured patients' views regarding values-aligned care. These themes focused on the importance of care teams exploring and acknowledging a patient's values, providing access to nonphysician providers who have different perspectives on care delivery, offering values-aligned mental health care, ensuring connection to community-based resources that support values and address needs, and providing care that supports the patient plus their family and caregivers. CONCLUSIONS Our results suggest several opportunities to improve how care is delivered to patients with different complex medical, behavioral, and social needs. Future research is needed to better understand how to incorporate these opportunities into health care.
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Affiliation(s)
- Leah Tuzzio
- Kaiser Permanente Washington Health Research InstituteSeattleWAUSA
| | - Andrew L. Berry
- Department of Biomedical Informatics & Medical EducationUniversity of WashingtonSeattleWashingtonUSA
| | - Kathy Gleason
- Kaiser Permanente Colorado Institute for Health ResearchAuroraColoradoUSA
| | - Jennifer Barrow
- Kaiser Permanente Colorado Institute for Health ResearchAuroraColoradoUSA
| | | | | | - Thomas Delate
- Pharmacy Outcomes Research Group, Kaiser Permanente National PharmacyAuroraColoradoUSA
| | - Zoe Bermet
- Kaiser Permanente Washington Health Research InstituteSeattleWAUSA
| | - Connie S. Uratsu
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Richard W. Grant
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - James D. Ralston
- Kaiser Permanente Washington Health Research InstituteSeattleWAUSA
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22
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Davenport C, Ouellet J, Tinetti ME. Use of the Patient-Identified Top Health Priority in Care Decision-making for Older Adults With Multiple Chronic Conditions. JAMA Netw Open 2021; 4:e2131496. [PMID: 34709390 PMCID: PMC8554637 DOI: 10.1001/jamanetworkopen.2021.31496] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
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.
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Affiliation(s)
- Claire Davenport
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer Ouellet
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mary E. Tinetti
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
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23
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Abstract
Age is an independent risk factor for cardiovascular disease. With the accelerated growth of the population of older adults, geriatric and cardiac care are becoming increasingly entwined. Although cardiovascular disease in younger adults often occurs as an isolated problem, it is more likely to occur in combination with clinical challenges related to age in older patients. Management of cardiovascular disease is transmuted by the context of multimorbidity, frailty, polypharmacy, cognitive dysfunction, functional decline, and other complexities of age. This means that additional insight and skills are needed to manage a broader range of relevant problems in older patients with cardiovascular disease. This review covers geriatric conditions that are relevant when treating older adults with cardiovascular disease, particularly management considerations. Traditional practice guidelines are generally well suited for robust older adults, but many others benefit from a relatively more personalized therapeutic approach that allows for a range of medical circumstances and idiosyncratic goals of care. This requires weighing of risks and benefits amidst the patient's aggregate clinical status and the ability to communicate effectively about this with patients and, where appropriate, their care givers in a process of shared decision making. Such a personalized approach can be particularly gratifying, as it provides opportunities to optimize an older patient's function and quality of life at a time in life when these often become foremost therapeutic priorities.
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Affiliation(s)
| | - Daniel E Forman
- University of Pittsburgh, University of Pittsburgh Medical Center and VA Pittsburgh Geriatric, Research, Education and Clinical Center (GRECC), Pittsburgh, PA, USA
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24
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Schwabenbauer AK, Knight CM, Downing N, Morreale-Karl M, Mlinac ME. Adapting a whole health model to home-based primary care: Bridging person-driven priorities with veteran and family-centered geriatric care. FAMILIES, SYSTEMS & HEALTH : THE JOURNAL OF COLLABORATIVE FAMILY HEALTHCARE 2021; 39:374-393. [PMID: 34410781 PMCID: PMC8406673 DOI: 10.1037/fsh0000613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Through the integration of Whole Health for Life into the Department of Veterans Affairs (VA) health care system, the VA aims to transform health care delivery from a disease management approach to one that embraces person-centered care. The home-based primary care (HBPC) program is a care model that, within the VA, provides holistic primary care services to homebound veterans with multiple chronic medical conditions, mental health issues, and functional declines. These veterans may have limited access to VA programs delivered in a traditional outpatient format. This article describes adaptations to the whole health model of care that could improve its accessibility and applicability to HBPC veterans, caregivers, and the interdisciplinary teams that serve this population. These modifications are informed by whole-person geriatric and gerontological and family-systems theories and address population-based differences in the focus and approach to care. The focus on care is expanded to (a) reflect the importance of attending to caregiver needs and well-being and (b) shift from a preventative model to one that prioritizes resilience and maintenance. The approach to care emphasizes alternative modes of delivery, adaptations to interventions, and integration of geriatric-specific medical considerations into the self-care domains and more directly centers the collaboration between family, the VA, and community partners. This adapted model also addresses the unique needs of health care teams providing in-home services to medically complex veterans and offers suggestions for enhancing self-care and preventing burnout. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
| | - Cynthia M. Knight
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
| | - Nicole Downing
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
| | - Michelle Morreale-Karl
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
- Department of Medicine, Harvard Medical School
| | - Michelle E. Mlinac
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
- Department of Psychiatry, Harvard Medical School
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25
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Tinetti ME, Costello DM, Naik AD, Davenport C, Hernandez-Bigos K, Van Liew JR, Esterson J, Kiwak E, Dindo L. Outcome Goals and Health Care Preferences of Older Adults With Multiple Chronic Conditions. JAMA Netw Open 2021; 4:e211271. [PMID: 33760091 PMCID: PMC7991967 DOI: 10.1001/jamanetworkopen.2021.1271] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Mary E. Tinetti
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Darcé M. Costello
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Baylor College of Medicine, Houston, Texas
| | - Claire Davenport
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Julia R. Van Liew
- Department of Behavioral Medicine, Medical Humanities, and Bioethics, Des Moines University, Des Moines, Iowa
| | - Jessica Esterson
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Eliza Kiwak
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lilian Dindo
- Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Baylor College of Medicine, Houston, Texas
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26
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Menichetti J, Gerwing J, Borghi L, Gulbrandsen P, Vegni E. Saying "I Don't Know": A Video-Based Study on Physicians' Claims of No-Knowledge in Assisted Reproductive Technology Consultations. Front Psychol 2021; 11:611074. [PMID: 33510688 PMCID: PMC7835634 DOI: 10.3389/fpsyg.2020.611074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/15/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction The assisted reproductive technology (ART) field deals with consistent and predictable gaps in knowledge. Expressing lack of knowledge with a sentence like “I don’t know” can be challenging for doctors. This study examined physicians’ negative epistemic disclaimer “non lo so” in Italian ART doctor-couple interactions. In particular, it aimed to reveal specific features of “non lo so”: function, topic, temporality, responsibility, and interactional aspects. Methods This was a video-based observational study. We used microanalysis of face-to-face dialogue to analyze 20 purposively selected triadic consultations from a corpus of 85. This inductive analysis focused on the function, the content (topic and temporality) and some selected interactional aspects of the “non lo so”, quantifying and capturing the interaction between these qualitative features. Results We found 82 doctors’ “non lo so” in the corpus (mean = 4.4; range = 0–15). We discovered three main functions of this expression: propositional (n = 73/82), relational (n = 6/82), discursive (n = 3/82). The most frequent topics raising doctors’ “non lo so” were costs (n = 11/82), treatment-related aspects (n = 10/82), and timing issues (n = 9/82). In more than half of the cases (n = 44/82), present issues emerged. The majority (n = 70/82) of “non lo so” was framed using the “I,” with doctors’ taking personal responsibility. Patients played a role in these expressions from doctors: Patients initiated more than one third of them, and in one fourth of the cases, patients followed up immediately. Conclusion Our findings may be related to characteristics of the specific field of ART. Doctors in this setting must frequently express a direct lack of knowledge to their patients, and when they do, they mean it literally. Patients contribute to such disclosures, and their responses suggest that they find them acceptable, showing that they may expect limitations in their potential to conceive.
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Affiliation(s)
- Julia Menichetti
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jennifer Gerwing
- Health Services Research Unit - Akershus University Hospital, Lørenskog, Norway
| | - Lidia Borghi
- Clinical Psychology, Department of Health Sciences, University of Milan, Milan, Italy
| | - Pål Gulbrandsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Health Services Research Unit - Akershus University Hospital, Lørenskog, Norway
| | - Elena Vegni
- Clinical Psychology, Department of Health Sciences, University of Milan, Milan, Italy
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27
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Weir KR, Naganathan V, Carter SM, Tam CWM, McCaffery K, Bonner C, Rigby D, McLachlan AJ, Jansen J. The role of older patients' goals in GP decision-making about medicines: a qualitative study. BMC FAMILY PRACTICE 2021; 22:13. [PMID: 33419389 PMCID: PMC7796626 DOI: 10.1186/s12875-020-01347-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND To optimise medication use in older people, it is recommended that clinicians evaluate evidence on potential benefits and harms of medicines in light of the patients' overall health, values and goals. This suggests general practitioners (GPs) should attempt to facilitate patient involvement in decision-making. In practice this is often challenging. In this qualitative study, we explored GPs' perspectives on the importance of discussing patients' goals and preferences, and the role patient preferences play in medicines management and prioritisation. METHODS Semi-structured interviews were conducted with GPs from Australia (n = 32). Participants were purposively sampled to recruit GPs with variation in experience level and geographic location. Transcribed audio-recordings of interviews were coded using Framework Analysis. RESULTS The results showed that most GPs recognised some value in understanding older patients' goals and preferences regarding their medicines. Most reported some discussions of goals and preferences with patients, but often this was initiated by the patient. Practical barriers were reported such as limited time during busy consultations to discuss issues beyond acute problems. GPs differed on the following main themes: 1) definition and perception of patients' goals, 2) relationship with the patient, 3) approach to medicines management and prioritisation. We observed that GPs preferred one of three different practice patterns in their approach to patients' goals in medicines decisions: 1) goals and preferences considered lower priority - 'Directive'; 2) goals seen as central - 'Goal-oriented'; 3) goals and preferences considered but not explicitly elicited - 'Tacit'. CONCLUSIONS This study explores how GPs differ in their approach to eliciting patients' goals and preferences, and how these differences are operationalised in the context of older adults taking multiple medicines. Although there are challenges in providing care that aligns with patients' goals and preferences, this study shows how complex decisions are made between GPs and their older patients in clinical practice. This work may inform future research that investigates how GPs can best incorporate the priorities of older people in decision-making around medicines. Developing practical support strategies may assist clinicians to involve patients in discussions about their medicines.
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Affiliation(s)
- Kristie Rebecca Weir
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, 2006, Australia.
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia.
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Ageing and Alzheimer's Institute, Concord Repatriation General Hospital, Concord West, New South Wales, 2139, Australia
| | - Stacy M Carter
- Australian Centre for Health Engagement, Evidence and Values (ACHEEV), School of Health and Society, Faculty of the Arts, Humanities and Social Sciences, University of Wollongong, Keiraville, New South Wales, 2522, Australia
| | - Chun Wah Michael Tam
- Primary and Integrated Care Unit, South Western Sydney Local Health District, Liverpool, New South Wales, 2170, Australia
- School of Population Health, The University of New South Wales, Sydney, New South Wales, 2052, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Carissa Bonner
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Debbie Rigby
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane City, Queensland, 4000, Australia
| | - Andrew J McLachlan
- Centre for Education and Research on Ageing (CERA), Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - Jesse Jansen
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
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28
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Mohammed TJ, Albahri AS, Zaidan AA, Albahri OS, Al-Obaidi JR, Zaidan BB, Larbani M, Mohammed RT, Hadi SM. Convalescent-plasma-transfusion intelligent framework for rescuing COVID-19 patients across centralised/decentralised telemedicine hospitals based on AHP-group TOPSIS and matching component. APPL INTELL 2021; 51:2956-2987. [PMID: 34764579 PMCID: PMC7820530 DOI: 10.1007/s10489-020-02169-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 01/31/2023]
Abstract
As coronavirus disease 2019 (COVID-19) spreads across the world, the transfusion of efficient convalescent plasma (CP) to the most critical patients can be the primary approach to preventing the virus spread and treating the disease, and this strategy is considered as an intelligent computing concern. In providing an automated intelligent computing solution to select the appropriate CP for the most critical patients with COVID-19, two challenges aspects are bound to be faced: (1) distributed hospital management aspects (including scalability and management issues for prioritising COVID-19 patients and donors simultaneously), and (2) technical aspects (including the lack of COVID-19 dataset availability of patients and donors and an accurate matching process amongst them considering all blood types). Based on previous reports, no study has provided a solution for CP-transfusion-rescue intelligent framework during this pandemic that has addressed said challenges and issues. This study aimed to propose a novel CP-transfusion intelligent framework for rescuing COVID-19 patients across centralised/decentralised telemedicine hospitals based on the matching component process to provide an efficient CP from eligible donors to the most critical patients using multicriteria decision-making (MCDM) methods. A dataset, including COVID-19 patients/donors that have met the important criteria in the virology field, must be augmented to improve the developed framework. Four consecutive phases conclude the methodology. In the first phase, a new COVID-19 dataset is generated on the basis of medical-reference ranges by specialised experts in the virology field. The simulation data are classified into 80 patients and 80 donors on the basis of the five biomarker criteria with four blood types (i.e., A, B, AB, and O) and produced for COVID-19 case study. In the second phase, the identification scenario of patient/donor distributions across four centralised/decentralised telemedicine hospitals is identified 'as a proof of concept'. In the third phase, three stages are conducted to develop a CP-transfusion-rescue framework. In the first stage, two decision matrices are adopted and developed on the basis of the five 'serological/protein biomarker' criteria for the prioritisation of patient/donor lists. In the second stage, MCDM techniques are analysed to adopt individual and group decision making based on integrated AHP-TOPSIS as suitable methods. In the third stage, the intelligent matching components amongst patients/donors are developed on the basis of four distinct rules. In the final phase, the guideline of the objective validation steps is reported. The intelligent framework implies the benefits and strength weights of biomarker criteria to the priority configuration results and can obtain efficient CPs for the most critical patients. The execution of matching components possesses the scalability and balancing presentation within centralised/decentralised hospitals. The objective validation results indicate that the ranking is valid.
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Affiliation(s)
- Thura J. Mohammed
- grid.444506.70000 0000 9272 6490Department of Computing, Faculty of Arts, Computing and Creative Industry, Universiti Pendidikan Sultan Idris, 35900 Tanjung Malim, Malaysia ,Informatics Institute for Postgraduate Studies (IIPS), Iraqi Commission for Computers and Informatics (ICCI), Baghdad, Iraq
| | - A. S. Albahri
- Informatics Institute for Postgraduate Studies (IIPS), Iraqi Commission for Computers and Informatics (ICCI), Baghdad, Iraq
| | - A. A. Zaidan
- grid.444506.70000 0000 9272 6490Department of Computing, Faculty of Arts, Computing and Creative Industry, Universiti Pendidikan Sultan Idris, 35900 Tanjung Malim, Malaysia
| | - O. S. Albahri
- grid.444506.70000 0000 9272 6490Department of Computing, Faculty of Arts, Computing and Creative Industry, Universiti Pendidikan Sultan Idris, 35900 Tanjung Malim, Malaysia
| | - Jameel R. Al-Obaidi
- grid.444506.70000 0000 9272 6490Department of Biology, Faculty of Science and Mathematics, Universiti Pendidikan Sultan Idris, 35900 Tanjong Malim, Perak Malaysia
| | - B. B. Zaidan
- grid.444506.70000 0000 9272 6490Department of Computing, Faculty of Arts, Computing and Creative Industry, Universiti Pendidikan Sultan Idris, 35900 Tanjung Malim, Malaysia
| | - Moussa Larbani
- grid.34428.390000 0004 1936 893XSchool of Mathematics and Statistics, Carleton University, Ottawa, ON Canada
| | - R. T. Mohammed
- grid.11142.370000 0001 2231 800XFaculty of Computer Science and Information Technology, Universiti Putra Malaysia, Seri Kembangan, Malaysia
| | - Suha M. Hadi
- Informatics Institute for Postgraduate Studies (IIPS), Iraqi Commission for Computers and Informatics (ICCI), Baghdad, Iraq
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Kuluski K, Reid RJ, Baker GR. Applying the principles of adaptive leadership to person-centred care for people with complex care needs: Considerations for care providers, patients, caregivers and organizations. Health Expect 2020; 24:175-181. [PMID: 33340393 PMCID: PMC8077079 DOI: 10.1111/hex.13174] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 10/16/2020] [Accepted: 11/12/2020] [Indexed: 12/16/2022] Open
Abstract
Background Health systems in many countries see person‐centred care as a critical component of high‐quality care but many struggle to operationalize it in practice. We argue that models such as adaptive leadership can be a critical lever to support person‐centred care, particularly for people who have multiple complex care needs. Objective To reflect on two concepts: person‐centred care and adaptive leadership and share how adaptive leadership can advance person‐centred care at the front‐line care delivery level and the organizational level. Findings The defining feature of adaptive leadership is the separation of technical solutions (ie applying existing knowledge and techniques to problems) from adaptive solutions (ie requiring shifts in how people work together, not just what they do). Addressing adaptive challenges requires identifying key assumptions that may limit motivations for change and the behaviours influenced by these assumptions. Thus, effective care for patients, particularly those with multiple complex care needs, often entails helping care providers and patients to examine their relationships and behaviours not just identifying technical solutions. Addressing adaptive challenges also requires a supportive and enabling organizational context. We provide illustrative examples of how adaptive leadership principles can be applied at both the front line of care and the organization level in advancing person‐centred care delivery. Conclusions Advancing person‐centred care at both the clinical and organizational levels requires a growth mindset, a willingness to try (and fail) and try again, comfort in being uncomfortable and a commitment to figure things out, in partnership, in iterative ways. Patients, caregivers, care providers and organizational leaders all need to be adaptive leaders in this endeavour.
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Affiliation(s)
- Kerry Kuluski
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Robert J Reid
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - G Ross Baker
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Albahri AS, Hamid RA, Albahri OS, Zaidan AA. Detection-based prioritisation: Framework of multi-laboratory characteristics for asymptomatic COVID-19 carriers based on integrated Entropy-TOPSIS methods. Artif Intell Med 2020; 111:101983. [PMID: 33461683 PMCID: PMC7647899 DOI: 10.1016/j.artmed.2020.101983] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/02/2020] [Accepted: 11/03/2020] [Indexed: 12/19/2022]
Abstract
CONTEXT AND BACKGROUND Corona virus (COVID) has rapidly gained a foothold and caused a global pandemic. Particularists try their best to tackle this global crisis. New challenges outlined from various medical perspectives may require a novel design solution. Asymptomatic COVID-19 carriers show different health conditions and no symptoms; hence, a differentiation process is required to avert the risk of chronic virus carriers. OBJECTIVES Laboratory criteria and patient dataset are compulsory in constructing a new framework. Prioritisation is a popular topic and a complex issue for patients with COVID-19, especially for asymptomatic carriers due to multi-laboratory criteria, criterion importance and trade-off amongst these criteria. This study presents new integrated decision-making framework that handles the prioritisation of patients with COVID-19 and can detect the health conditions of asymptomatic carriers. METHODS The methodology includes four phases. Firstly, eight important laboratory criteria are chosen using two feature selection approaches. Real and simulation datasets from various medical perspectives are integrated to produce a new dataset involving 56 patients with different health conditions and can be used to check asymptomatic cases that can be detected within the prioritisation configuration. The first phase aims to develop a new decision matrix depending on the intersection between 'multi-laboratory criteria' and 'COVID-19 patient list'. In the second phase, entropy is utilised to set the objective weight, and TOPSIS is adapted to prioritise patients in the third phase. Finally, objective validation is performed. RESULTS The patients are prioritised based on the selected criteria in descending order of health situation starting from the worst to the best. The proposed framework can discriminate among mild, serious and critical conditions and put patients in a queue while considering asymptomatic carriers. Validation findings revealed that the patients are classified into four equal groups and showed significant differences in their scores, indicating the validity of ranking. CONCLUSIONS This study implies and discusses the numerous benefits of the suggested framework in detecting/recognising the health condition of patients prior to discharge, supporting the hospitalisation characteristics, managing patient care and optimising clinical prediction rule.
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Affiliation(s)
- A S Albahri
- Informatics Institute for Postgraduate Studies (IIPS), Iraqi Commission for Computers and Informatics (ICCI), Baghdad, Iraq.
| | - Rula A Hamid
- College of Business Informatics, University of Information Technology and Communications (UOITC), Baghdad, Iraq.
| | - O S Albahri
- Department of Computing, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia.
| | - A A Zaidan
- Department of Computing, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia.
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31
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Naik AD, Catic A. Achieving patient priorities: an alternative to patient-reported outcome measures (PROMs) for promoting patient-centred care. BMJ Qual Saf 2020; 30:92-95. [PMID: 33115850 DOI: 10.1136/bmjqs-2020-012244] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Aanand D Naik
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA .,Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Angela Catic
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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Aggarwal P, Woolford SJ, Patel HP. Multi-Morbidity and Polypharmacy in Older People: Challenges and Opportunities for Clinical Practice. Geriatrics (Basel) 2020; 5:E85. [PMID: 33126470 PMCID: PMC7709573 DOI: 10.3390/geriatrics5040085] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 11/16/2022] Open
Abstract
Multi-morbidity and polypharmacy are common in older people and pose a challenge for health and social care systems, especially in the context of global population ageing. They are complex and interrelated concepts in the care of older people that require early detection and patient-centred shared decision making underpinned by multi-disciplinary team-led comprehensive geriatric assessment (CGA) across all health and social care settings. Personalised care plans need to remain responsive and adaptable to the needs and wishes of the patient, enabling the individual to maintain their independence. In this review, we aim to give an up-to-date account of the recognition and management of multi-morbidity and polypharmacy in the older person.
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Affiliation(s)
- Pritti Aggarwal
- Southampton City Clinical Commissioning Group, Southampton SO16 4GX, UK;
- Living Well Partnership, Southampton SO19 9GH, UK
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton SO17 1BJ, UK
| | - Stephen J. Woolford
- Medicine for Older People, University Hospital Southampton NHS FT, Southampton SO16 6YD, UK;
| | - Harnish P. Patel
- Medicine for Older People, University Hospital Southampton NHS FT, Southampton SO16 6YD, UK;
- Academic Geriatric Medicine, University of Southampton, Southampton SO16 6YD, UK
- NIHR Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS FT, Southampton SO16 6YD, UK
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33
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Hamaker ME, van den Bos F, Rostoft S. Frailty and palliative care. BMJ Support Palliat Care 2020; 10:262-264. [PMID: 32709709 DOI: 10.1136/bmjspcare-2020-002253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/29/2020] [Indexed: 01/28/2023]
Affiliation(s)
- M E Hamaker
- Geriatric Medicine, Diakonessenhuis, Utrecht, The Netherlands
| | | | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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DuMontier C, Loh KP, Bain PA, Silliman RA, Hshieh T, Abel GA, Djulbegovic B, Driver JA, Dale W. Defining Undertreatment and Overtreatment in Older Adults With Cancer: A Scoping Literature Review. J Clin Oncol 2020; 38:2558-2569. [PMID: 32250717 PMCID: PMC7392742 DOI: 10.1200/jco.19.02809] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The terms undertreatment and overtreatment are often used to describe inappropriate management of older adults with cancer. We conducted a comprehensive scoping review of the literature to clarify the meanings behind the use of the terms. METHODS We searched PubMed (National Center for Biotechnology Information), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms undertreatment or overtreatment with regard to older adults with cancer. We included all types of articles, cancer types, and treatments. Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived through qualitative analysis. Within a random subset of articles, C.D. and K.P.L. independently performed this analysis to determine final categories and then independently assigned these categories to assess inter-rater reliability. RESULTS Articles using the terms undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion in our review (n = 256). Only 14 articles (5.5%) explicitly provided formal definitions; for the remaining, we inferred the implicit definitions from the terms' surrounding context. There was substantial agreement (κ = 0.81) between C.D. and K.P.L. in independently assigning categories of definitions within a random subset of 50 articles. Undertreatment most commonly implied less than recommended therapy (148; 62.7%) or less than recommended therapy associated with worse outcomes (88; 37.3%). Overtreatment most commonly implied intensive treatment of an older adult in whom the harms of treatment outweigh the benefits (38; 53.5%) or intensive treatment of a cancer not expected to affect an older adult in his/her remaining lifetime (33; 46.5%). CONCLUSION Undertreatment and overtreatment of older adults with cancer are imprecisely defined concepts. We propose new, more rigorous definitions that account for both oncologic factors and geriatric domains.
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Affiliation(s)
- Clark DuMontier
- Brigham and Women’s Hospital, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | | | | | - Tammy Hshieh
- Brigham and Women’s Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Jane A. Driver
- Brigham and Women’s Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Veterans Affairs Boston Healthcare System, New England Geriatric Research Education and Clinical Center, Boston, MA
| | - William Dale
- City of Hope Comprehensive Cancer Center, Duarte, CA
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Freytag J, Dindo L, Catic A, Johnson AL, Bush Amspoker A, Gravier A, Dawson DB, Tinetti ME, Naik AD. Feasibility of Clinicians Aligning Health Care with Patient Priorities in Geriatrics Ambulatory Care. J Am Geriatr Soc 2020; 68:2112-2116. [PMID: 32687218 DOI: 10.1111/jgs.16662] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Aligning healthcare decisions with patients' priorities may improve care for older adults with multiple chronic conditions (MCCs). We conducted a pilot study to assess the feasibility of identifying patient priorities in routine geriatrics care and to compare clinicians' recommendations for patients who did or did not have their priorities identified. DESIGN Retrospective chart review. SETTING Veterans Administration Medical Center Geriatrics Clinic. PARTICIPANTS Older adults with MCCs receiving Patient Priorities Care (PPC; n = 35) were matched with patients receiving usual care (UC; n = 35). Both PPC and UC patients were cared for by three primary care providers (PCPs) in an ambulatory geriatric clinic. INTERVENTION In the PPC group, a clinician facilitator met with each patient to identify their healthcare priorities and transmitted patients' priorities in the electronic health record (EHR). Trained PCPs then sought to align healthcare decisions with patients' priorities. In the UC group, patients received usual care from the same PCPs. MEASUREMENTS We matched patients by clinician seen, patient's age, number of active conditions, medications, hospitalizations, functional status, and prior hospitalizations. EHRs were reviewed to identify care decisions including medications added or stopped, referrals and consults added or avoided, referrals to community services and supports, self-management activities added or avoided, and total number of changes to care. Mean differences in recommended care between PPC and UC patients from the same PCPs were examined. RESULTS Clinician facilitators could identify patient priorities during routine clinic encounters. Compared with patients in the UC group, those in the PPC group had, on average, fewer medications added (P = .05), more referrals to community services and supports (P = .03), and more priorities-aligned self-management tasks added (P = .005). CONCLUSION These findings support the feasibility of identifying and documenting patient priorities during routine encounters. Results also suggest that clinicians use patient priorities in recommending care.
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Affiliation(s)
- Jennifer Freytag
- Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Lilian Dindo
- Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Angela Catic
- Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Adrienne L Johnson
- Center for Tobacco Research and Intervention, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Amber Bush Amspoker
- Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Anna Gravier
- Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Darius B Dawson
- Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Mary E Tinetti
- Yale University School of Medicine (Geriatrics) and Yale School of Public Health, New Haven, Connecticut, USA
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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36
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Mohile S, Dumontier C, Mian H, Loh KP, Williams GR, Wildes TM, Boyd K, Ramsdale E, Pyne S, Magnuson A, Tew W, Klepin HD, Dale W, Shahrokni A. Perspectives from the Cancer and Aging Research Group: Caring for the vulnerable older patient with cancer and their caregivers during the COVID-19 crisis in the United States. J Geriatr Oncol 2020; 11:753-760. [PMID: 32340908 PMCID: PMC7172832 DOI: 10.1016/j.jgo.2020.04.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 04/18/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Supriya Mohile
- University of Rochester Medical Center, Rochester, NY, United States of America.
| | - Clark Dumontier
- Brigham and Women's Hospital, Marcus Institute for Aging Research, Boston, MA, United States of America
| | | | - Kah Poh Loh
- University of Rochester Medical Center, Rochester, NY, United States of America
| | - Grant R Williams
- University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Tanya M Wildes
- Washington University School of Medicine, St Louis, MO, United States of America
| | - Kevin Boyd
- University of Rochester Medical Center, Rochester, NY, United States of America
| | - Erika Ramsdale
- University of Rochester Medical Center, Rochester, NY, United States of America
| | - Sonia Pyne
- University of Rochester Medical Center, Rochester, NY, United States of America
| | - Allison Magnuson
- University of Rochester Medical Center, Rochester, NY, United States of America
| | - William Tew
- Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Heidi D Klepin
- Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC, United States of America
| | - William Dale
- City of Hope National Cancer Center, Duarte, CA, United States of America
| | - Armin Shahrokni
- Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
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37
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Tinetti ME, Naik AD, Dindo L, Costello DM, Esterson J, Geda M, Rosen J, Hernandez-Bigos K, Smith CD, Ouellet GM, Kang G, Lee Y, Blaum C. 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. JAMA Intern Med 2019; 179:1688-1697. [PMID: 31589281 PMCID: PMC6784811 DOI: 10.1001/jamainternmed.2019.4235] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/03/2019] [Indexed: 01/14/2023]
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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Affiliation(s)
- Mary E. Tinetti
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Aanand D. Naik
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas
- Department of Medicine (Health Services Research and Geriatrics), Baylor College of Medicine, Houston, Texas
| | - Lilian Dindo
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas
- Department of Medicine (Health Services Research and Geriatrics), Baylor College of Medicine, Houston, Texas
| | - Darce M. Costello
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jessica Esterson
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mary Geda
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan Rosen
- Connecticut Center for Primary Care, Farmington, Connecticut
| | | | - Cynthia Daisy Smith
- American College of Physicians, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - Gina Kang
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yungah Lee
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Caroline Blaum
- Department of Medicine, New York University School of Medicine, New York
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Tonelli MR, Sullivan MD. Person-centred shared decision making. J Eval Clin Pract 2019; 25:1057-1062. [PMID: 31407417 DOI: 10.1111/jep.13260] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/31/2019] [Accepted: 08/02/2019] [Indexed: 01/08/2023]
Abstract
While multiple versions of shared decision making (SDM) have been advanced, most share two seemingly essential elements: (a) SDM is primarily focused on treatment choices and (b) the clinician is primarily responsible for providing options while the patient contributes values and preferences. We argue that these two elements render SDM suboptimal for clinical practice. We suggest that SDM is better viewed as collaboration in all aspects of clinical care, with clinicians needing to fully engage with the patient's experience of illness and participation in treatment. SDM can only take place within an ongoing partnership between clinician and patient, both respecting the other as a person, not as part of an isolated encounter. Respect for the patient as a person goes beyond respect for their choice. Non-interference is not the only way, or even the most important way, to respect patient autonomy. Knowing the patient as a person and providing an autonomy-supportive context for care are crucial. That is, the clinician must know the patient well enough to be able to answer the patient's question "What would you do, if you were me?" This approach acknowledges clinicians as persons, requiring them to understand patients as persons. We provide examples of such a model of SDM and assert that this pragmatic method does not require excessive time or effort on the part of clinicians or patients but does require direct and particular knowledge of the patient that is often omitted from clinical decisions.
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Affiliation(s)
- Mark R Tonelli
- Department of Medicine, University of Washington, Seattle, Washington
| | - Mark D Sullivan
- Department of Psychiatry, University of Washington, Seattle, Washington
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39
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Naik AD, Hundt NE, Vaughan EM, Petersen NJ, Zeno D, Kunik ME, Cully JA. Effect of Telephone-Delivered Collaborative Goal Setting and Behavioral Activation vs Enhanced Usual Care for Depression Among Adults With Uncontrolled Diabetes: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e198634. [PMID: 31390035 PMCID: PMC6686779 DOI: 10.1001/jamanetworkopen.2019.8634] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Depression symptoms are present in one-third of patients with diabetes, contributing to significant adverse consequences. Population screening of high-risk patients coupled with telephone delivery of evidence-based therapies for comorbid diabetes may address barriers to care. OBJECTIVE To evaluate the effectiveness of proactive population screening plus telephone delivery of a collaborative goal-setting intervention among high-risk patients with uncontrolled diabetes and depression. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, 225 participants (intervention [n = 136] and control [n = 89]) were enrolled from a regional Veterans Healthcare System serving Southeast Texas from November 1, 2012, through June 24, 2016. Data were gathered at baseline and 6 and 12 months after intervention. Patients selected had uncontrolled diabetes (hemoglobin A1c [HbA1c] >7.5%]) and clinically significant depression (Patient Health Questionnaire-9 scores [PHQ-9] ≥10) and were living more than 20 miles from the Veterans Affairs medical center. Data collection was completed on December 6, 2016, and final analyses were completed by January 25, 2018. All analyses were intent to treat. INTERVENTIONS Healthy Outcomes Through Patient Empowerment (HOPE) included 9 telephone sessions with 24 trained health care professionals using collaborative goal-setting and behavioral activation methods. The control group received enhanced usual care (EUC) and notification of high-risk status. MAIN OUTCOMES AND MEASURES Change in depression symptoms using PHQ-9 and glycemic control using HbA1c from baseline to 6 months and to 12 months. Secondary analyses evaluated clinically significant responses for these measures. RESULTS Among 225 participants, 202 (89.8%) were men, the mean (SD) age was 61.9 (8.3) years, 145 (64.4%) were married, and 156 (69.3%) had some education beyond high school. For the overall study, 38 participants (16.9%) were lost to follow-up or withdrew at 6 months and another 21 (9.3%) were lost to follow-up or withdrew at 12 months. Repeated-measures analysis with multiple imputation for missing data assessing the interaction of treatment group (HOPE vs EUC) and time (baseline, 6 months, and 12 months) found no significant improvement in PHQ-9 (β, 1.56; 95% CI, -0.68 to 3.81; P = .17) or HbA1c (β, -0.005; 95% CI, -0.73 to 0.72; P = .82). Analyses using t test for change from baseline to 12 months showed a HOPE vs EUC between-group mean difference for PHQ-9 of 2.14 (95% CI, 0.18 to 4.10; P = .03) and for HbA1c of -0.06% (95% CI, -0.61% to 0.50%; P = .83). A secondary analysis of patients experiencing a clinical response found that 52.1% of HOPE participants had clinically significant responses in PHQ-9 at 12 months vs 32.9% in EUC (difference, 0.19; 95% CI, 0.04-0.33; P = .01). CONCLUSIONS AND RELEVANCE Telephone-delivered, collaborative goal setting produced clinically significant reductions in depression symptoms but not glycemic control among patients who remained engaged at 12 months compared with EUC among a population screened sample of high-risk patients with diabetes and depression. Although the intervention created some lasting effect for depression, additional strategies are needed to maintain engagement of this high-risk population within an interprofessional team approach to primary care. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01572389.
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Affiliation(s)
- Aanand D. Naik
- Research Service Line, Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
- Alkek Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Natalie E. Hundt
- Research Service Line, Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
| | | | - Nancy J. Petersen
- Research Service Line, Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas
- Alkek Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Darrell Zeno
- Research Service Line, Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Mark E. Kunik
- Research Service Line, Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
- Alkek Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jeffrey A. Cully
- Research Service Line, Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- VA South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
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