Setting health priorities with older patients: What happens in multimorbidity-consultations ?

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Setting health priorities with older patients
What happens in multimorbidity-consultations ?

• Junius-Walker U.
• Hofmann W, Wiese B,Bleidorn J, Voigt I, Wrede J,
  Dierks ML

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• Urgent encounters
• disease centered
• reactive towards immediate relief
• treatment focussed on single diseases
• doctor as medical expert

Care for all relevant roblems overview of
health longitudinal, pro-active care treatment
according to mutual prioritization doctor as
facilitator
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Cluster RCT intervention arm
Patient How important for you?
GP How relevant for your care?
1) Step-assessment
Evidence on. 1. patient involvement 2. special
treatment attention for priority problems 3.
improved patient-doctor agreement on importance
importance ratings
2) priority cons.
consultation
importance ratings
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comprehensive assessment disentangles
complex health into defined problems

Ursus Wehrli Tidying up art Miro
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European STEP 46 items in 10 health domains
function in everyday life (4)
clock-drawing(1)











social and housing (6)
somatic symptoms (16)
medication (2)
Medical findings RR, DM, feet (6)
vaccination (4)
lifestyle (4)
mood (3)
Williams E et al. Evidence-based approach to
assessing older people. Occ Paper 82, R Coll Gen
Pract 2002
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2) priority-setting consultation

• 30 min training to use PrefCheck-guide
• Individual problem list with importance ratings
• Guidance on how to set mutual priorities
• Documenting priorities and treatment

mutual priorities
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Results 174 patients
Patients had. median IQR IQR
health problems 10 10 7-14
important problems (patient) 5 5 2-8
relevant problems (doctor) 6 6 3-8
problem uptake in consultation 4.5 4.5 3-8
mutual priorities 2 2 0-3
problems receiving treatment planning 4 4 2-8
gender 58 female age group 31 gt80 years low
income 36 lt1000
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Results 1827 health problems
925
857
902
369
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Patient involvement in priority setting
369 prioritised problems
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Important to patient alone Important to GP
alone Important to both Important to none
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Determined priorities (N369) important
to..
patient alone
doctor alone
mutual
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2. Priority setting treatment attention

• treatments planned for
• 86 of priority problems
• vs.
• 37 of all non-priority
• problems
• or 68 of discussed non-priority problems

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Special treatment attention to priority problems
N311 N546
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3. Sustained doctor-patient agreement on
importance?
Agree-ment Priorities (N 369) Priorities (N 369) Non-Priorities (N1458) Non-Priorities (N1458)
t0 t2 t0 t2
60.4 61.5 49.7 54.3
kappa 0.057 -0.085 -0.004 0.081
Multilevel log. regression analysis for all
patients (N 317) Affiliation to patient group
did not sig. predict agreement.
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Conclusions Priority setting consultation
has not helped
1.bridging the different views on the importance
of health problems
has helped

1. .. giving patients a voice (functional,social
   matters, symptoms)
2. .. identifying problems with unmet needs for
   active treatment

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Important dis-cussed priority set treatment planned
pain x x watch wait
fracture (after 60) x watch wait
chest pain x diagnostics
stroke (history) x watch wait
hearing x x watch wait
mourning
vaccination x x treatment
hypertension
arrhythmia
elevated cholesterol x
Unimportant
ADL-function
foot-examination
Mr. H. 12 problems, 10 important
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1. Patient involvement problems receiving
discussion priority setting treatment
925
343
692
Important to both Important to none Important to
GP Important to patient
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Problems receiving treatment planning (N857)
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Treatment patterns