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Papers identified based on full text screening
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| No. |
Year |
Authors |
Title |
Study design + method |
| 1 |
1991 |
Mold, Blake, Lorne, Becker [13] |
Goal-oriented medical care. |
Position paper |
| 2 |
2011 |
De Maeseneer, Boeckxstaens [25] |
Care for non-communicable diseases (NCD’s): time for a paradigm-shift. |
Opinion paper |
| 3 |
2012 |
Reuben, Tinetti [10] |
Goal-oriented patient care- an alternative health outcomes paradigm. |
Perspective |
| 4 |
2014 |
Bayliss, Bonds, Boyd, Davis, Finke, Fox, Stange [26] |
Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters. |
Forty-five experts met to critically consider four aspects of incorporating context into research on multiple chronic conditions. |
| 5 |
2014 |
Kramer, Bauer, Dicker, Durusu-Tranriover, Ferreira, Rigby, van Hulsteijn [8] |
The changing face of internal medicine: patient- centered care. |
Position paper |
| 6 |
2015 |
Bernsten, Gammon, Steinsbekk, Salamonsen, Foss, Ruland, Fonnebo [27] |
How do we deal with multiple goals for care within an individual patient trajectory? A document content analysis of health service research papers on goals for care. |
Document content analysis of seventy health service research papers on the topic of ‘goals of care’. |
| 7 |
2016 |
Blom, Elzen, Houwelingen, Heijmans, Stijnen, Van Den Hout, Gussekloo [28] |
Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomized controlled trial: integrated systematic care for older people-the ISCOPE study. |
Cluster randomized controlled trial–intervention group: general practitioners made an integrated care plan using functional geriatric approach; control group: care as usual; 59 general practices were included (30 intervention, 29 control); outcome measures on quality of life, activities of daily living, satisfaction with delivered healthcare, and cost-effectiveness of the intervention 1-year follow-up. |
| 8 |
2016 |
Boeckxstaens, Willems, Lanssens, Decuypere, Brusselle, Kühlein, Sutter [29] |
A qualitative interpretation of challenges associated with helping patients with multiple chronic diseases identify their goals. |
Qualitative research–qualitative interviews with nineteen patients diagnosed with chronic, obstructive pulmonary disease and comorbidities to explore goal-setting in patients with multimorbidity. |
| 9 |
2016 |
Mangin, Stephen, Bismah, Risdon [30] |
Making patient values visible in healthcare: a systematic review of tools to assess patient treatment priorities and preferences in the context of multimorbidity. |
Systematic review–data sources: Medline, Embase, Cochrane databases; citations were included if they reported a tool to use a record patient priorities or preferences for treatment, and quantitative or qualitative results following administration of the tool. |
| 10 |
2016 |
Schimdt, Babac, Pauer, Damm, von der Schulenberg [31] |
Measuring patients priorities using the Analytic hierarchy process in comparison with best-worst scaling and rating cards: methodological aspects and ranking tasks. |
Analysis of the results of non-standardized Analytic Hierarchy Process (AHP)for different consistency ration threshold, aggregation methods, and sensitivity analysis; comparison of rakings criteria of AHP with best-worst-scaling and ranking cards results by Kendall’s tau b. |
| 11 |
2016 |
Tinetti, Esterson, Ferris, Posner, Blaum [1] |
Patient priority-directed decision making and care for older adults with multiple chronic conditions. |
Review |
| 12 |
2018 |
Bernsten, Hoyem, Lettrem, Rul, Rumpsfeld, Gammon [6] |
A person-centered integrated care quality framework, based on qualitative study of patient’s evaluation of care in light of chronic care ideals. |
Qualitative evaluative review of the individual patient pathways experiences of nineteen strategically chosen persons with multimorbidity. |
| 13 |
2019 |
Feder, Kiwak, Costello, Dindo, Hern, Bigos, Naik [3] |
Perspective of patients in identifying their values-based health priorities. |
Qualitative study using in-depth semi structured telephone and in-person interviews; open-ended questions about patient perceptions of the patient health priorities identification process, perceived benefits of the process, enables and barriers to PHPI, and recommendation for process enhancement. |
| 14 |
2019 |
Franklin, Lewis, Willis, Roger, Venville, Smith [32] |
Controlled, constrained or flexible? How self-management goals are shaped by patient-provider interactions. |
Conversation analysis; observations of consultations for chronic care management between patients and their health professionals. |
| 15 |
2019 |
Tinetti, Dindo, Smith, Blaum, Costello, Ouellet, Naik [33] |
Challenges and strategies in patient’s health priorities-aligned decision-making for older adults with multiple chronic conditions. |
Participant observation qualitative study–clinicians followed a training and had experiences in providing patient priorities care (PPC), clinicians and PPC implementation team participated in 21 case-based, group discussions. Using emergent learning, participants discussed challenges, posed solutions, and worked together to determine how to align care options with the health priorities of 35 patients participating in the patient priorities care pilot. |
| Papers identified through snowballing |
| No. |
Year |
Authors |
Title |
Study design |
| 16 |
2006 |
Hurn, Kneebone, Cropley [34] |
Goal setting as an outcome measure: a systematic review |
Systematic review–data sources included a computer-aid literature search of studies examining the reliability, validity, and sensitivity of goal-setting/ goal-attainment scaling, with snowballing. |
| 17 |
2009 |
Bodenheimer, Handley [35] |
Goal-setting for behavior change in primary care: an exploration and status report. |
Exploration and Status report–literature search on goal-setting interventions for promoting behavior change; resulting in eight articles. |
| 18 |
2011 |
Junius-Walker, Stolberg, Steinke, Theile, Hummers-Pradier, Dierks [36] |
Health and treatment priorities of older patients and their general practitioners: a cross-sectional study. |
Cross-sectional study– 123 older patients and 11 general practitioners evaluated the importance and severity of patients’ individual health problems. Patients received a geriatric assessment, then GPS rated the importance and components of severity of each problem; assessing proportion of important problems and the chance corrected agreement; multilevel logistic regression models were used to relate the importance of a problem with its severity components. |
| 19 |
2012 |
Rijken, Bekkema, Boeckxstaens, Schellevis, De Maeseneer, Groenewegen [2] |
Chronic disease management programs: an adequate response to patients’ needs? |
Survey among country-experts resulting in information about existing disease management programs; in addition scientific literature. |
| 20 |
2014 |
Lenzen, Daniëls, van Bokhoven, der Weijden, Beurskens [37] |
Setting goals in chronic care: shared decision making as self-management support by the family physician. |
Background paper to contribute to the understanding of goal-setting within self-management and to identify elements that need further development for practical use. |
| 21 |
2016 |
Steel Gray, Wodchis, Upshur, Cott, McKinstry, Mercer, Palen, Ramsay, Thavorn [38] |
Supporting goal-oriented primary health care for seniors with complex care needs using mobile technology: evaluation and implementation of the health system performance research network, Bridgepoint electronic patient reported outcome tool. |
Pragmatic cluster randomized controlled trial–intervention groups using ePRO tool compared with control groups on measure of quality of life, patient experience, and cost-effectiveness; evaluating of tool. |
| 22 |
2017 |
Kangovi, Mitra, Smith, Kulkarni, Turr, Huo, Glanz, Grande, Long [39] |
Decision-making and goal-setting in chronic disease management: baseline findings of a randomized controlled trial. |
Randomized controlled trial–patients used low-literacy aid to prioritize one of their chronic conditions and then set a goal for that condition with their primary care provider; patients created patient-driven action plans for reaching these goals. |
| 23 |
2017 |
Mold [40] |
Goal-directed health care: redefining health and health care in the era of value-based care. |
Review |
| 24 |
2017 |
Schellinger, Anderson, Frazer, Cain [41] |
Patient self-defined goals: essentials of person-centered care for serious illness. |
Descriptive qualitative analysis–initial inquiry to describe self-defined goals patients living with advanced heart failure, cancer, and dementia; goals were entered in electronic health record flow sheet using patients’ quotes; analysis of 160 flow sheets with a deductive approach. |
| 25 |
2017 |
Vermunt, Harmsen, Elwyn, Westert, Burgers, Rikkert, Faber [42] |
A three-goal model for patients with multimorbidity: a qualitative approach. |
Qualitative study–qualitative interviews with general practitioners and clinical geriatricians and analyzed following a thematic approach. |
| 26 |
2017 |
Vermunt, Harmsen, Westert, Rikkert, Faber [17] |
Collaborative goal setting with elderly patients with chronic disease or multimorbidity: a systematic review. |
Systematic review based on EPOC, PRISMA and MOOSE guidelines; Pubmed, PsychInfo, CINAHL, Web of Science, Embase, Cochrane Central Register of Controlled Trials were searched systematically; eligibility criteria: 1) Randomized (cluster) controlled trials, non-randomized controlled trials, controlled before-after studies, interrupted time series or repeated measures study design; 2) Single intervention directed specifically at collaborative goal setting or health priority setting or a multifactorial intervention including these elements; 3) Study population of patients with multimorbidity or at least one chronic disease (mean age ± standard deviation (SD) incl. age 65). 4) Studies reporting on outcome measures reducible to outcomes for collaborative goal setting or health priority setting. |
| 27 |
2018 |
Kessler, Walker, Sauvé-Schenk, Egan [24] |
Goal setting dynamics that facilitate or impede a client-centered approach. |
Conversation analysis on goal-setting conversations; purposively selected from a pilot randomized controlled trial of OPC-stroke |
| 28 |
2018 |
Naik, Dindo, Van Liew, Hundt, Vo, Hernandez-Bigos, Esterson, Geda, Rosen, Blaum, Tinetti [4] |
Development of a clinically feasible process for identifying individual health priorities. |
Prospective development and feasibility study–development team of patients, caregivers, clinicians using a user-centered design to develop and refine value-based patient priorities care process and medical record template; descriptive statistics and qualitative analysis of barriers and enablers. |
| 29 |
2019 |
De Groot, Schönrock-Adema, Zwart, Damoiseaux, Jaarsma, Mol, Bombeke [43] |
Learning from patients about patient-centeredness: a realist review: BEME guide No.60 |
Realist review–realist review approach; literature search in scoping phase, deductive and inductive coding to extent rough program theory. |
| 30 |
2019 |
Kuluski, Guilcher [44] |
Towards a person-centred learning health system: understanding value from the perspectives of patients and caregivers. |
Commentary; call to action to combine the tenets from person-centered care, value-based healthcare, and learning health systems. |
| 31 |
2019 |
Kuluski, Peckham, Gill, Gagnon, Wong-Cornall, McKillop, Parsons, Sheridan [9] |
What is important to older people with multimorbidity and their caregivers? Identifying attributes of person centered care from the user perspective. |
Qualitative descriptive study; 1–1 interviews semi-structured interviews with 172 patients and caregivers from 9 community based primary healthcare. |
| 32 |
2019 |
Reuben, Jennings [12] |
Putting goal-oriented patient care into practice. |
Review |
| 33 |
2019 |
Salter, Shiner, Lenaghan, Murdoch, Ford, Winterburn, Steel [23] |
Setting goals with patients living with multimorbidity: qualitative analysis of general practice consultations. |
Qualitative analysis of general practice consultations–analysis of video recorded doctor-patient interactions; focus groups to identify core challenges of goal-setting. |
| 34 |
2019 |
Tinetti, Naik, Dindo, Costello, Esterson, Geda, Rosen, Hernandez-Bigos, Smith, Ouellet, Kang, Lee, Blaum [45] |
Association of patient priorities-aligned decision-making with patient outcomes and ambulatory health care burden among older adults with multiple chronic conditions. |
Nonrandomized clinical trial with propensity adjustment conducted at one patient priorities care (PPC)and one usual care; participants included 163 adults aged 65 years or older who had three or more chronic conditions care for by ten primary care practitioners (PCP) trained in PPC and 203 similar patients who received usual care from 7 PCPs not trained in PPC. |
| 35 |
2020 |
Eckhoff, Weiss [46] |
Goal-setting: a concept analysis |
Concept analysis–method of Walker and Avant, articles and book chapters were reviewed from Cumulative Index to Nursing and Allied Health Literature, Education Resources Information Center, Psych Index. |
| 36 |
2020 |
Purkaple, Nagyaldi, Todd, Mold [47] |
Physician’s response to patient’s quality-of-life goals. |
Randomized controlled trial–patients were given a previsit questionnaire that included quality of life questions; physicians in the control were given no further prompting; intervention physicians were prompted to ask quality of life questions; a two-pronged design was used: prepost group where three physicians participated in 5 control and 5 intervention encounters (n = 30) and a randomized group in which 11 physicians and their patients were randomly assigned to control or intervention groups (n = 30). Video recordings of the encounters were reviewed to determine if QOL goals were mentioned and if they were utilized in decision making. |
| 37 |
2020 |
Sathanpally, Sidhu, Fahami, Gillies, Kadam, Davies, Khunti, Seidu [48] |
Priorities of patients with multimorbidity and of clinicians regarding treatment and health outcomes: a systematic mixed studies review. |
Systematic review–MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched; included studies reported health outcome and treatment priorities of adults with multimorbidity, defined as suffering from two or more chronic conditions, or of clinicians in the context of multimorbidity or both; no restriction by study design, and studies using quantitative and/ or qualitative methodologies were included. |
