Moving From Disease-Centered to Patient Goals–Directed Care for Patients With Multiple Chronic Conditions

Abstract

Decision making in cardiology concentrates on diseasespecific outcomes following practice guidelines for specific conditions. Quality metrics implemented for valuebased purchasing and public reporting also largely focus on individual diseases. Disease-centered approaches are appropriate when individuals have a single predominant disease and everyone with the disease desires the same outcome, such as prolonged survival or stroke prevention. 1 This disease-centered framework is illsuited, however, for persons with multiple chronic conditions, including most older adults with cardiovascular conditions and the majority of adult health care users of all ages. 2 Disease-centered decision making for this population results in treatment burden when patients must adhere to multiple guidelines and harm when guideline recommendations conflict. 3 Furthermore, disease-centered recommendations may not address what matters most to these patients who vary in their health priorities. 4 To consider an alternative to disease-centered decision making that better aligns care with what matters most to patients and reduces treatment burden, it is helpful to think of health care decisions as value propositions in which value = health outcome / cost. From the population perspective, health care value is defined as survival or disease benefit (output) per dollar spent (input). From patients' perspective, however, the personal health outcomes that they hope to achieve are more appropriate outputs. 4 The appropriate inputs may include financial costs, but often more relevant are costs in terms of the time, discomfort, harms, and workload required to achieve their health outcomes. 3 When defined as what patients are willing and able to do for their health, these broader costs inform care preferences. An alternative approach to decision making, therefore, is predicated on achieving patients' specific health outcome goals within the context of their acceptable workload. High-value care is defined as achievement of each patient's highest-level health outcome goals given the workload each is willing and able to perform. This is not as daunting a task as it may seem; patients implicitly consider trade-offs between outcome and workload even if it is not explicitly discussed. 3 Examples of health outcome goals and patient workload are shown in the Box. This approach represents a shift from diseasecentered to patient goals-directed care. The idea that health care decisions should include patients' health

The Learning Healthcare System and Cardiovascular Care: A Scientific Statement From the American Heart Association

“…There have been recent calls for shifting the orientation of healthcare delivery away from a disease-centered construct to a patient goals-centered one. 210 Doing so would require elicitation of patient goals for their health and the workload necessary to achieve it. For example, patients would need to specify goals for functional status, symptom burden, life prolongation (often linked to specific life events, eg, to see a child get married), well-being, and ability to fulfill occupational or social roles.…”

Engagement, Empowerment and Patient Generated Health Data

“…PGHD use is not just pathophysiological (Kaplan, Greenfield, & Ware, 1989), it incorporates a significant emotional component that has not been explored in contemporary healthcare literature. PGHD is about radical change in medicine, caused by the shift of the patient role from passive recipient to active consumer (Tinetti, et al, 2016). This research clearly demonstrates that PGHD produces emotional engagement and this is critical for patients.…”

“…This could indicate patient centeredness is giving way to 'patient directed care' (Tinetti, et al, 2016), a new paradigm where patients control decision making, which will have significant implications for healthcare services management and provider autonomy. The overarching model incorporates a process…”

“…Patient engagement is more than just focussing on psycho-cognitive needs and the patho-physiological needs of the patient and measuring patient engagement through doctor-patient communication (Kaplan, Greenfield, & Ware, 1989); it is about radical change in medicine, caused by the shift of the patient role from passive recipient to active consumer (Bardes, 2012;Bragazzi, 2013;Hood & Weston, 2004). Indeed some scholars are now suggesting that technology has facilitated a new healthcare paradigm called patient directed medicine (Tinetti, et al, 2016).…”

“…Patient engagement in credence services is an important topic to consider as it has "refocused attention on patient outcomes, even if efforts to ensure more consistently positive outcomes sometimes reduce the physician's prized autonomy" (Bardes, 2012, p. 782). This radical change in medicine, caused by the shift of the patient role from passive recipient to active consumer (Bragazzi, 2013;Hood & Weston, 2004) and the addition of technology has facilitated a new healthcare paradigm, namely patient directed medicine (Tinetti, et al, 2016). Hence the implications of patient engagement in credence services in relation to the providers' autonomy and service viability are an important managerial problem to consider.…”