Novel Care Model May Improve Outcomes for Older Adults With Multiple Chronic Conditions

A recent study published in JAMA Network Open explores the benefits of a novel, deeply personal approach to managing older adults with multiple chronic conditions. Co-led by Cleveland Clinic geriatrician Ardeshir Hashmi, MD, and Yale researcher Mary E. Tinetti, MD, the trial revealed how Patient Priorities Care (PPC) may improve shared decision-making, decrease treatment burden, and reduce the number of days older patients spend in the hospital, emergency department, skilled nursing facility or ambulatory facility.

“Patient Priorities Care is based on the idea that older adults should set their own treatment priorities,” says Dr. Hashmi. “This is a critical departure for providers accustomed to relying on standard treatment recommendations, which are typically based on evidence that excludes geriatric patients with chronic comorbidities and may not be relevant to their care. For instance, diabetes guidelines indicate the patient’s A1C should be below a certain number. But if getting an older patient to that number increases hypoglycemia and their associated risk of falling, is that really a worthy goal?”

Furthermore, he adds, clinicians are held accountable for (and paid based on) the achievement of quality outcome metrics that may be discordant with the goals and care preferences of patients with multiple chronic conditions. This can sometimes lead to decisions that are not based on what matters most to patients – a disconnect that can precipitate unwanted interventions and unnecessary medical expenses. In prior studies, PPC has been shown to improve patient satisfaction and outcomes and reduce healthcare costs.

“Given all the challenges and modifications we had to make because of the pandemic — including cutting our sample size in half — we were pleasantly surprised we were able to find trends that highlight the benefits of patient priorities-aligned care,” says Dr. Tinetti.

Expanding on a proven approach

Almost 2.5 times as many study participants receiving PPC as opposed to usual care felt clinicians involved them in decisions regarding their prescription medications. For Cleveland Clinic’s Accountable Care Organization, shared decision-making is a quality metric.

“I didn’t realize PPC would be the one thing that would really move the needle on patient engagement,” says Dr. Hashmi. “It’s an encouraging sign that gives us the impetus to scale the model across our healthcare system.”

A 2019 clinical study led by Dr. Tinetti also found decreased treatment burden using the PPC model.

“This is a major outcome for people with multiple chronic conditions, who often spend substantial time and effort managing their healthcare,” she explains. “The fact that we found similar effects in both studies is important.”

Although the reduction in the number of patients’ nonhealthy days was modest, Dr. Tinetti notes that the evidence implies that outcomes can be improved with fewer healthcare resources.

Results of the nonrandomized clinical trial reached marginal statistical significance, largely attributable to reduced study enrollment and protocol changes required by the COVID-19 pandemic, which coincided with the planned initiation of the study in 2020.

Happier, healthier patients

Although some primary care physicians initially responded to PPC with skepticism, viewing the approach as “just one more thing,” Dr. Hashmi says none of the physicians wanted to stop the project, even at the height of the COVID-19 pandemic.

"Participating in Patient Priorities Care changed how I relate to my patients at a fundamental level,” says study participant Henry Ng, MD, Section Head of Internal Medicine at Lakewood Family Health Center.

“Identifying, discussing, and aligning care plan recommendations has become a central part of my communication to patients and families of all ages,” he explains. “Using PPC tools has helped me discover and support my patients' health needs and overall life goals – and they have responded by telling me they feel seen and heard."

Dr. Hashmi notes that further research, especially in larger and more diverse settings, is needed to substantiate these trends.

“Patient Priorities Care as a paradigm was durable enough to survive the height of the pandemic and still show positive trends,” he says. “We’re just seeing the tip of the iceberg. Because providers have been so receptive to this approach, it is becoming a national movement.”