Clinician Perspectives on Incorporating Patients’ Values-Based Health Priorities in Decision-Making

INTRODUCTION

Guideline-recommended treatments are of uncertain benefit for the numerous older adults with multiple chronic conditions (MCC). Disease-based decision-making may lead to treatment burden while failing to meet the health priorities of these patients, who vary both in the health outcomes they value most and the healthcare they will accept to achieve them.^1,2 In response to these limitations, a multi-stakeholder group developed Patient Priorities Care (PPC), an approach to eliciting patients’ priorities and translating them into clinical care.^3,4 This approach was shown to be feasible and demonstrated promise in reducing burdensome and unwanted care.^5,6

To translate PPC to diverse clinical settings, it is critical to understand how the approach was perceived and what factors impeded its optimal implementation. Clinicians’ individual views about interventions and systems-level factors (e.g., dominant clinical norms and financial incentives) have been recognized to impact sustainability.⁷ With this qualitative study, we assessed the perspectives of clinicians who participated in the PPC demonstration study about benefits of the approach and challenges to its implementation.

METHODS

Development of PPC has been previously reported.^3,4 Nine primary care clinicians and five cardiologists were eligible to participate (i.e., they participated in the PPC demonstration study and cared for ≥5 participating patients). This study was approved by the Yale Institutional Review Board.

Interviews were performed from April 2017 to January 2018 by one experienced interviewer (G.M.O.) using a semi-structured interview guide, recorded, professionally transcribed, and uploaded to Dedoose^® (V8.3.17, Los Angeles, 2019). Clinicians were asked about perceived benefits of the PPC approach and challenges to implementing it.

Thematic analysis was used to identify themes from reported experiences.⁸ The coding team included G.M.O. (geriatrician), E.K. (research associate), and D.M.C. (doctoral trained researcher in human development and psychology with qualitative methodology expertise). Each independently identified concepts in two transcripts without a pre-existing coding key, then worked together to develop one. With subsequent interviews, the team iteratively refined the coding key and adjudicated discrepancies by consensus. After the final coding key was applied to all transcripts, themes were identified.

RESULTS

Among eligible participants, eight of nine primary care clinicians and four of five cardiologists participated. Median interview duration was 15 minutes (interquartile range, 12–25 minutes). Two clinicians were female (16.7%) and two were nonwhite (16.7%).

Perceived benefits included improvements in (1) patient care (more patient centered and less burdensome), (2) patient knowledge and activation, (3) patient-clinician interactions (communication focused on patients’ own priorities and enhanced relationships), and (4) clinician workflows (focusing visits and facilitating consensus between primary care clinicians and specialists). Challenges to implementation included (1) poor patient understanding (of health trajectories and tradeoffs), (2) high patient acuity, (3) health system pressures (metrics and time), and (4) conflict with other decision-makers (other clinicians and patients’ families). Exemplary quotes for each category are in Table 1.

Table 1.

Perceived Benefits of the Patient Priorities Care Approach and Challenges to Implementation

	Exemplary quotes
Perceived benefits of the Patient Priorities Care approach
Patient care
Patient-centered care	Just to make sure that we’re equally talking about benefits to them and their life, as opposed to benefits that may have no effect at all on lifestyle. I think it has heightened my sensitivity towards patients at large, about their need to make their own decisions. To have empowerment over their own decision making. I think that’s been a real positive influence on my clinical practice.
Ability to prevent burdensome care	The guy who has multiple medical problems who has a good potential within the next several years of having a problem. It’s trying to find those people, so that we stop going down these rabbit holes. It’s once you start going down a rabbit hole, with aggressive cardiology care or aggressive nephrology care, dialysis, things like that, then it’s hard to take it back.
Patient knowledge and motivation
Patient education	It helps the patients be aware that their lifestyle is being affected by a medical condition and vice-versa.
Patient activation	I think that the individual goals I like. [...] Because that, you know, kind of gives us something to shoot for—and it’s a way for us to kind of motivate patients as well.
Clinician-patient interactions
Linking recommendations to patients’ own priorities	“Take your medication, so you have less shortness of breath, so you can do X,” rather than, “Take your medication period because I’m the doctor,” which doesn’t really work.
Enhanced relationship	The visit was different in that we took her patient priority care discussion and went through it point-by-point and spent a good amount of time talking about it.
	I thought it was a very nice visit. We really connected.
Clinicians’ workflows
Focuses visit	Yeah, it did help to focus the conversation much better, I think than normally. You know, normally, we just go over the list of problems they’ve had and try and work through each one in isolation. I was a little bit more careful, in terms of assessing where he’s at in terms of his clinical status, his medications. He was on a full dose anticoagulant, and I saw that [primary care clinician] had cut back on his anticoagulant, in terms of the dose. I appreciated that and I continued it.
Enables consensus between primary care and specialist clinicians	Once I realized that I said, okay, I definitely see his point of view, and I understood it a little bit better. I think that it’s been very good in certain instances.
Perceived challenges to implementing the Patient Priorities Care approach
Poor patient understanding
Poor understanding of health trajectory	We’re trying to get their—at their idea of their likely trajectory. And everybody thinks they’re gonna live forever. And they’re not gonna get sick.
Poor understanding of tradeoffs	I’m just trying to be respectful of a patient’s wishes, but if a patient doesn’t understand what it is that they don’t wanna do and what the outcome is gonna be...
Patient disease acuity
Acute exacerbations	I could not get to that other stuff [discussing goals] only because things were, you know, the acuity of everything was so much.
Health system pressures
Conflict with metrics	There are—there are priorities that are given to us and then there are patient’s priorities, which may not align.
Time pressure	That’s the goal of our care is the right treatment for the right patient at the right time - and do everything that they need. And that’s easier said than done when you—when it’s a busy practice.
Conflict with other decision-makers
Conflict with other clinicians	Anyway, before this, I spoke to one of the cardiologists about stopping Coumadin. And he felt that it’s not a good idea. Even though she’s 97 years old. So,
	I think it’s a good idea, but, you know, you’re obviously gonna have differences.
Conflict with family	They’re gonna tell a son or daughter that they don’t want something done. And the son or daughter is gonna think like, “Why? Are you just dying?”

DISCUSSION

In the demonstration study of PPC, clinicians noted several perceived benefits of the approach and perceived challenges to optimal implementation.

The perceived benefits of PPC were well aligned with the initial goals for the approach’s development.³ In particular, the perceptions that this approach improves patient-centeredness, prevents burdensome care, and enhances clinician-patient relationships are encouraging. The perception that PPC streamlines visits and facilitates inter-professional communication may combat concerns about investing time to learn patients’ priorities.

The challenges noted by clinicians in this study present opportunities to refine the process. Future work is needed to address how to discuss tradeoffs in situations where patients have poor understanding of their likely health trajectories, a well-recognized challenge in providing care to older adults irrespective of PPC.^9,10 Each clinical site will also need to evaluate the effects of implementing PPC on workflow and metrics. In this demonstration study of PPC, there were no reported detrimental effects on performance metrics and clinical time was minimally prolonged (20–30 minutes for priorities identification and 30 minutes total for the following two visits).⁵ While PPC was perceived to facilitate consensus about the care plan overall, there is room for continued improvement, given the report that disagreements between patients and family members and between clinicians continue to occur, albeit less frequently.

This study is limited by the single practice site, the small number of participants, and limited sociodemographic diversity. Attention to identifying additional challenges will be necessary as this approach is scaled.

Clinicians viewed the PPC approach as beneficial to their patients and themselves and identified challenges to implementation. This information will be critical to developing individualized implementation strategies to ensure optimal effectiveness in practices with varying workflows, payment structures, and populations served.