Prioritize the goals of elderly patients with multimorbidities

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When caring for older adults with multiple chronic conditions, prioritizing patients ’goals is more effective and efficient than trying to address each condition in isolation, he said. Mary Tinetti, MD, Gladys Phillips Crofoot, professor of medicine and public health and head of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians ’annual internal medicine meeting, the gerontologist noted that primary care providers face a variety of challenges when it comes to managing elderly patients with multimorbidity. These challenges include lack of representative data in clinical trials, conflicting guideline recommendations, lack of patient adherence, and decreased benefit of therapies due to competing conditions, he said.

“Trying to follow various guidelines can cause unintentional harm to these people with various conditions,” Tinetti said. He gave examples of the broad goals that patients can have.

“Some [patients] “It will maximize the focus on function, no matter how long they have a chance to live,” Tinetti said. “Others will say that managing the load of symptoms is the most important thing for them. And others will say they want to live as long as possible and survival is the most important thing, even if that means a reduction in their function. These individuals they also vary in the care they are willing and able to receive to achieve the results that interest them most. “

For these reasons, Tinetti recommended paying attention to the patient’s priorities, which she and her colleagues have been developing and implementing over the past 5-6 years.

“If the benefits and harms of addressing each condition in isolation have an uncertain and potentially heavy benefit for both the clinician and the patient, and we know that patients vary in their health priorities … then what more? Would you like to focus on your 20 -Minute visit … except for each patient’s priorities? ”Tinetti asked. “This is a solution to the challenge.”

What is attention to patient priorities?

Attention to patient priorities is a citrus and multidisciplinary approach to clinical decision-making consisting of three steps, Tinetti explained. First, a clinician identifies the patient’s health priorities. Second, this information is passed on to control providers, who decide which of their respective treatments are consistent with the patient’s priorities. And third, these decisions are disseminated to everyone involved in patient care, both inside and outside the health care system, allowing all caregivers to align with patient priorities, he noted.

“Each person does it from their own experience,” Tinetti said. “The social worker will do something different than the cardiologist, the physiotherapist, the endocrinologist, but everyone points to the same outcome, the patient’s priorities.”

In 2019, Tinetti led a nonrandomized clinical trial to test the feasibility of caring for patient priorities. The study included 366 elderly adults with multimorbidity, of whom 203 received regular care, while 163 received this type of care. Patients in the latter group were twice as likely to stop medication and significantly less likely to have added self-management tasks and order diagnostic tests.

How electronic medical records can help

In an interview, Tinetti suggested that cohabiting physicians communicate through electronic health records (EHRs), first to make sure all caregivers understand a patient’s goals and then determine if therapies. recommended fit these goals.

“It would be a bit of a culture change to do that,” Tinetti said, “but technology is there and it doesn’t consume too much time.”

He went on to suggest that primary care providers are usually the most appropriate to coordinate this process; however, if a patient receives most of their care from a particular specialist, this clinician may be the most appropriate coordinator.

Obstacles and systemic solutions

In accordance with Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, physicians may encounter obstacles in implementing care to patients’ priorities.

“Our healthcare system doesn’t always make that easy,” Boyd said. “It’s important to recognize that because it can be hard to do. There’s no doubt about it,” Boyd said in an interview.

Among the headwinds that doctors may face are clinical practice guidelines, the structure of electronic health records, and quality metrics focused on specific conditions, he explained.

“There are a lot of things that take us away (in primary care and other parts of medicine) from the section that is best for people with multiple chronic conditions,” Boyd said.

Tinetti stated that the challenge of providing this care he expects is that doctors, regardless of specialty, “feel uncomfortable” moving away from a conventional approach.

Among Tinetti’s arguments in favor of providing attention to patients’ priorities is that “it will bring more joy to the practice because it is really addressing what matters to that person, while providing good care.”

To get the most out of caring for patients’ priorities, Boyd recommended that clinicians focus on the “4 M’s”: what matters most, mentality, mobility, and medications.

In an effort to address the latter of these on a large scale, Boyd is co-leader of the United States Prescription Research Network (USDeN), which aims to “improve medication use among older adults and the outcomes that are important to them,” according to the USDeN website.

To encourage day-to-day depression, Boyd called for strong communication between co-management providers.

In an ideal world, there would be a better way to communicate than largely through electronic health records, he said.

“We need more than EHR to connect. That’s why it’s so important that primary care providers and specialists have time to really talk to each other. This will be reimbursed and we organize the communication and cognitive aspects of the attention. ”Boyd noted.

Tinetti revealed the support of the John A. Hartford Foundation, the Donaghue Foundation, the National Institute on Aging, and the Institute for Health Improvement. Boyd revealed a relationship with UpToDate, for which she co-authored a chapter on multimorbidity.

This article originally appeared on MDedge.com, which is part of the Medscape professional network.





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