Adapting what is known

Abstract

With ever increasing pressure on doctors’ time, Iona Heath (doi: 10.1136/bmj.39532.671319.94) wonders whether primary care really meets the needs of elderly people at all, while John Wasson suggests ways for doctors to improve the care of older patients that don’t require extra resources or staffing

Multiple health problems are not unique to older persons; they are, however, more prevalent in this group. Furthermore, as a person ages, what was once a reasonable choice in treatment may be less appropriate, even harmful. In making clinical decisions about the health of older patients and in quality improvement for managing care, what are the trade-offs between benefit and risk? What are the opportunities for, and the barriers against, putting such knowledge into practice?

A 78 year old woman with complex health problems visits her doctor. Although in younger patients clinical recommendations may include screening mammography or intensive control of diabetes, this woman may not actually live long enough to benefit from these interventions. The issues that are most important to her may bear little relation to the bioclinical problems her doctor has been trained to diagnose and treat. Collaborative decision making by clinicians and older patients such as this woman is almost always made in a grey zone of unavailable evidence and divergent expectations. Yet tools are becoming available to help weigh the trade-offs between treatment benefits and competing risks.¹ As these tools become more sophisticated and easier to use in the everyday clinical setting, they will help in clarifying the choices that must be made by older patients with multiple health problems.

The environment in which care is offered and decisions made—the system of “usual care”—is often bad for health. Its toxicity may be a consequence of too many health workers providing fragmented care, too many drugs having adverse side effects, or too much intensive treatment leading to dangerous complications.^{2 3} And usual care suffers by being fast paced, reimbursed according to volume, and focused too much on what the matter is with the patient, rather than what matters to the patient.⁴ Many alternatives to this usual care are better, but most of these add additional workforce—nurses, case managers, “coaches,” and “teams”—in bewildering combinations called “disease management, case management, transition management, [and] geriatric evaluation and management.”^{5 6} Other effective alternatives to usual care, such as routine telephone calls to the patient from an identified primary care clinician, need no additional workforce.⁷

That there are so many things wrong with the usual care and so many ways to improve it raises an obvious question: why hasn’t quality improvement already resulted in better usual care for older persons with multiple health problems?

One reason commonly given for the persistence of poor care is that most studies of successful interventions for elderly patients, when compared with usual care, have not provided clear evidence of cost savings.⁸ However, saving costs seems a poor reason for not improving care, and indeed many of the attributes of good quality care may not require extra staff or money. In fact, within the range of usual care about a fifth of older patients with multiple health problems are already receiving the high levels of access, continuity, communication, and self management that are associated with successful alternatives.^{5 6 7 8}

The fact that these crucial attributes of quality care are already available to some patients raises a second question: can this high quality care be generalised to more patients? An affirmative answer to this question is provided by one innovative US example of a quality improvement project: an online collaboration involving a group of primary care practices across the country.⁹ In these practices, the percentage of older patients with complex health problems who are attaining attributes of high quality care as listed on the website is more than twice that in non-participating practices, even though they receive no special reimbursement.

The thrust of future research into quality improvement for older patients with multiple health conditions should be directed towards two objectives. The first is research into how to adapt and adopt what is known. The existing literature on quality improvement demonstrates numerous ways to improve health care for these patients through timely assessment of “what matters,” easy access to care, continuity of care with an identifiable clinician, and understandable, relevant information and support for condition management and collaborative decision making.^{4 5 6 7} Although no particular setting, patient population, or disease mix will be identical to those reported in the published literature, many essential elements are constant. For example, it is not surprising to clinicians that their patients’ confidence in self management, financial status, and managing pain and psychosocial problems affects their healthcare outcomes. What is surprising is that clinicians don’t systematically evaluate these factors when assessing older patients and placing them into categories for the delivery of planned care.¹⁰ Technologies and methods are already freely available to help busy health professionals capture these valuable opportunities.⁹

The second area is research into how to overcome the most conspicuous barrier to the improvement of care: the current healthcare culture. The current culture induces dysfunctional workforce expectations, unwanted variation in practice patterns, ineffective training venues, counterproductive payment incentives that are often based on inappropriate measures, and excessive technological imperatives.^{2 3} Only in a very few clinical practices are measures of “what matters” to the patient really at the centre of care.⁹ At a minimum, the prevailing culture has to change to enable “breathing room” from oppressive volumes of consultations and paperwork so that the few motivated health professionals implementing patient centred, collaborative care can become the many.