To treat patients with multiple chronic conditions well, clinicians will need to move away from disease-focused metrics and toward patient-centric ones.
An op-ed published in the Annals of Internal Medicine makes the case that, despite some progress, care for patients with multiple chronic conditions still suffers from a misalignment of clinician and patient priorities. Specifically, doctors need to embrace the idea that they care for patients, rather than diseases, according to Mary Tinetti, M.D., chief of geriatrics at Yale School of Medicine.
“Most decision-making and care is still focused on the individual diseases, and not what patients want necessarily or need,” she explains, adding that although treatment has improved, “We still have a very long way to go.”
The relative lack of progress may say more about the difficulty involved in changing long-entrenched attitudes and incentives. Dr. Tinetti points out that, historically speaking, a disease-focused approach to patient care makes a lot of sense. In fact, if you go back far enough, the majority of patients with acute diseases only had one chance: They either responded to treatment or died. As people began living longer and as the medical community developed ways to manage diseases over time, formerly acute conditions became chronic diseases.
Other elements of the healthcare system have generated incentives to view conditions in individual silos as opposed to viewing patients’ health in a more holistic way. The rise of value-based or quality-based care incentives appears to offer at least one opportunity to shift incentive structures. Despite some limited attempts to incorporate patient-reported outcomes into quality measures, however, a lot of the incentives haven’t changed.
“Most of the metrics for value-based care remain disease-based,” Dr. Tinetti points out.
The other problem involves a change to the way doctors and patients interact with each other. Patients need to drive the conversation about their care, but without stripping physicians of their authority.
“Patients need to be much more aware of what they want from their healthcare and what outcomes matter most to them,” says Dr. Tinetti. “They need to get us a better sense of what their outcome goals are and which part of their healthcare they’re willing and able to do and which they aren’t, and really push their clinicians to work with them on that decision-making,” she adds.
The op-ed describes practical steps clinicians can take immediately to change their attitudes and practices in small but significant ways:
- Incorporate patients’ health priorities into decision-making. The authors recommend a set of tools and guides that can help physicians navigate the important and sometimes difficult conversations necessary to establish a patient’s wants and needs.
- Consider the patient’s prognosis and the general trajectory of their health. This helps to identify the most practical mix of beneficial outcomes while minimizing patient harm, using the bigger picture to inform decisions about discrete elements of care.
- Deprescribe. Clinicians need to consider a patient’s medications in total, as opposed to only the ones that physician prescribes.
The bottom line involves listening to the patient and working to elicit their priorities, a balance Dr. Tinetti admits is likely to be difficult to achieve.
“I think the ideal is that patients are the experts in the outcomes that matter most to them and what they’re willing to do to accomplish those outcomes. Clinicians are the experts in what kind of treatments and testing and healthcare is most likely to get the patient what they want. So each becomes the expert in what they know best,” she says.