Republished from: https://www.nextavenue.org/multiple-chronic-conditions-treatment/
Some doctors are rethinking the
treatment of chronic conditions
By Edie
Grossfield
Health and Caregiving Editor
May 24, 2019
Health and Caregiving Editor
May 24, 2019
(Editor’s
note: This story is part of a series for The John A. Hartford Foundation.)
Harold
Peterson’s* cardiologist prescribes medications for his heart disease. His
primary care physician prescribes medications for his high blood pressure and
also determined that his hip pain needed to be addressed. He referred Peterson
to an orthopedist, who recommended surgery.
Peterson,
who is in his 80s, lives with a variety of chronic conditions, and he’s far
from alone. One in
four Americans has multiple chronic conditions — ones that last at least a
year and require ongoing medical attention, limit activities or both. The
already high ratio of Americans with more than one chronic condition jumps to
three out of four people ages 65 and older. Some of the most common chronic
conditions: high blood pressure, arthritis and diabetes.
Someone who
deals with chronic conditions is typically treated by a variety of specialists,
as Peterson is. Each doctor runs tests and prescribes different medications and
self-care homework. It’s not long before a person can feel overwhelmed and
overburdened by his or her long list of appointments and care routines, says
Dr. Mary Tinetti, an internist and chief of geriatrics at Yale School of
Medicine.
“People with multiple chronic conditions
will often begin to skip some of their health tasks due to what’s called
‘burden of treatment.'”
“Once you
get three, four or five and six diseases, several things happen: Number one,
almost guaranteed, trying to get one of those diseases under control is going
to make one of the other diseases worse,” Tinetti says. “Number two: The more
we ask people to do, the more overwhelmed they get and the less they are likely
to do.”
People with
multiple chronic conditions will often begin to skip some of their health tasks
due to what’s called “burden of treatment,” says Dr. Victor Montori, an
endocrinologist and professor of medicine at the Mayo Clinic in Rochester,
Minn.
Lessening Burden of Treatment
In an
attempt to lessen that burden, Tinetti leads an initiative called Patient Priorities Care. This
model empowers people to express their health care priorities — things like
function, longevity, social activities or symptom relief — and work with their
physicians to develop treatment plans that focus on those goals and let them
live the lives they desire.
Patient
Priorities Care complements a health care approach introduced by Montori and
his colleagues about a decade ago called Minimally Disruptive Medicine. The basis
for the approach is the same as Patient Priorities Care: to lessen the burden
of treatment by asking patients about their health care goals.
But Montori
says Minimally Disruptive
Medicine lacked an effective process for identifying what really mattered
to patients in their present-day lives.
“It’s very
much like when you get hired for a job and somebody asks you, ‘How do you see
yourself in the next five years?’ And then you make stuff up, because five
years later you’re doing something completely different from what you thought
you’d be doing,” Montori says, adding that the same thing happens when you ask
patients a general question like, “What are your goals for care?”
“Either they
respond with quite generic statements that are not very helpful like, ‘Oh, I
would like to live longer and feel better,’ or they become exercises in
fiction: ‘I would like to be able to play the piano,'” Montori says.
Patient
Priorities Care’s questions are designed to identify what patients want to be
able to do in their everyday lives. For example: “What brings you the most
enjoyment or pleasure in your life?” and “When taking care of yourself, what is
most important to you now?”
Identifying What Really Matters
The Patient
Priorities Care approach worked well for Peterson as a patient at ProHealth
Physicians Group in Bristol, Conn., where a two-year pilot of the initiative
wrapped up last year.
Peterson
enrolled in that study and shared his feelings about his health and treatment.
During the process, his doctors learned that he didn’t actually want surgery
for his hip, despite the pain he suffered and the difficulty he had walking.
Much more
troubling to him were the dizziness and fatigue he experienced every day
because of his heart and blood pressure pills. Those side effects prevented him
from playing poker with his friends — something he loves to do once or twice a
week.
Peterson’s
primary care doctor and cardiologist worked with him to adjust his medication
regimen so he’d no longer feel dizzy and tired. Once again, he was able to
enjoy the social time with his friends playing poker.
Patient
Priorities Care doesn’t come without trade-offs, though. For example, because
Peterson has cut down on some of his medications, there’s a chance he might not
live as long as he would if he had kept taking them. But today, he feels well
enough to enjoy the things he wants to do in life — and that’s what matters to
him.
Less Unwanted Care
The pilot
project at ProHealth (which was funded in part by The John A. Hartford
Foundation, a Next Avenue funder) involved about 350 patients. It compared the
Patient Priorities Care group with ProHealth patients receiving standard
primary care.
It found
that those involved in the study felt less burdened by their treatment because
there was less “unwanted care,” including medications, diagnostic testing,
procedures and self-management tasks that patients either didn’t believe helped
them or thought was just too much.
“And that’s
really important to know,” Tinetti says, “because one of the things we’re
learning more and more is that people with multiple chronic conditions are
feeling almost as burdened by their care as they are by the chronic conditions
they have.”
Pushback From Physicians
Tinetti and
her colleagues are realizing it’s rare to find a physician or clinic that works
this way, however. So, they’re working on ways to spread the concept to more
health care providers and organizations. The team also is developing
self-directed materials that help patients and their family caregivers work
through the process of identifying health care priorities so they can
communicate these to their physicians.
Tinetti has
run into some pushback against Patient Priorities Care from physicians who say
they already are stretched too far in terms of the number of patients they are
expected to see per day and the documentation tasks they are expected to
perform.
In response,
she refers to the pilot study at ProHealth which found that Patient Priorities
Care doesn’t add much time to doctor visits. After patients discussed their
priorities with a nurse or case manager, their first couple of visits with
physicians were usually about 10 minutes longer. Visits beyond that returned to
the normal length of time.
The Patient
Priorities Care process simplifies caring for people with multiple chronic
conditions because it narrows the focus to what is troubling them the most,
Tinetti says.
Physicians
point out that they are required to follow specific disease treatment
guidelines that the Centers for Medicare & Medicaid Services requires
health care organizations to meet for reimbursement. Many physicians’
performance reviews also are based, in part, on their patients’ adherence to
treatment guidelines.
Many of
these guidelines have age limits and don’t apply to people over the age of 75
or 80. However, if a guideline does apply but a physician feels it is not in
the best interest of a patient, the physician only needs to document his or her
reason for not following it and that the patient was involved in the
decision-making, Tinetti says.
Montori says
many guidelines, meant to ensure high-quality and efficient care based on the
results of clinical trials, often interfere with what actually is best for an
individual patient. He says the guidelines recommend care for “patients like
this” rather than “this patient.”
He’s written
a book that addresses the idea and has spoken on it at health care conferences,
including the 2018 Lown Institute Conference in Washington, D.C. and the 2019
Cleveland Clinic’s Patient Experience Summit.
With regard
to setting personal health goals, as Patient Priorities Care and Minimally
Disruptive Medicine try to do, Montori says the discussion about health care in
the U.S. needs to move away from treating people like they are all the same to
“treating each person and responding to each person’s situation in a careful
and kind way that is maximally supportive and minimally disruptive.”
It’s an
approach that’s good for all patients, not only those with multiple chronic
conditions, Montori says.
Edie has been a journalist for more than 20
years, reporting and editing for newspapers and magazines. She also worked in
communications for a large health care organization. She holds a bachelor’s
degree in communications and media and a master’s degree in journalism, both
from the University of Wisconsin in Madison. Reach her by email at
egrossfield@nextavenue.org.
