ABSTRACT
BACKGROUND/OBJECTIVES: Aligning healthcare decisions with patients' priorities may improve care for older adults with multiple chronic conditions (MCCs). We conducted a pilot study to assess the feasibility of identifying patient priorities in routine geriatrics care and to compare clinicians' recommendations for patients who did or did not have their priorities identified. DESIGN: Retrospective chart review. SETTING: Veterans Administration Medical Center Geriatrics Clinic. PARTICIPANTS: Older adults with MCCs receiving Patient Priorities Care (PPC; n = 35) were matched with patients receiving usual care (UC; n = 35). Both PPC and UC patients were cared for by three primary care providers (PCPs) in an ambulatory geriatric clinic. INTERVENTION: In the PPC group, a clinician facilitator met with each patient to identify their healthcare priorities and transmitted patients' priorities in the electronic health record (EHR). Trained PCPs then sought to align healthcare decisions with patients' priorities. In the UC group, patients received usual care from the same PCPs. MEASUREMENTS: We matched patients by clinician seen, patient's age, number of active conditions, medications, hospitalizations, functional status, and prior hospitalizations. EHRs were reviewed to identify care decisions including medications added or stopped, referrals and consults added or avoided, referrals to community services and supports, self-management activities added or avoided, and total number of changes to care. Mean differences in recommended care between PPC and UC patients from the same PCPs were examined. RESULTS: Clinician facilitators could identify patient priorities during routine clinic encounters. Compared with patients in the UC group, those in the PPC group had, on average, fewer medications added (P = .05), more referrals to community services and supports (P = .03), and more priorities-aligned self-management tasks added (P = .005). CONCLUSION: These findings support the feasibility of identifying and documenting patient priorities during routine encounters. Results also suggest that clinicians use patient priorities in recommending care.
Subject(s)
Ambulatory Care , Delivery of Health Care , Electronic Health Records , Geriatrics , Health Priorities , Multiple Chronic Conditions/therapy , Aged, 80 and over , Feasibility Studies , Female , Humans , Male , Pilot Projects , Primary Health Care , Retrospective Studies , United States , United States Department of Veterans AffairsABSTRACT
BACKGROUND: Few studies have examined meaning in life, a novel existential outcome, in patients with advanced cancer across countries. OBJECTIVES: We examined differences in meaning in life across 5 countries and identified factors associated with meaning in life. METHODS: This is a pre-planned secondary analysis of a prospective longitudinal multicenter observational study of patients with advanced cancer. Meaning in life was assessed using a validated scale which examined four domains of meaning: values, purpose, goals, and reflection. The total score ranged from 8 to 32, with a higher score indicating greater meaning in life. RESULTS: Among 728 patients, the median meaning in life score was 25/32 (interquartile range 23, 28). There was no significant difference in the total meaning in life score among 5 countries (P = 0.11), though there were differences in domain sub-scores. In the univariate analysis, patients with higher intensity of physical symptoms by ESAS score (pain, fatigue, drowsiness, dyspnea, insomnia), depression, anxiety, spiritual pain, and financial distress had significantly lower meaning in life. However, patients with higher levels of education, who were married, and who had higher optimism had significantly higher meaning in life. In the multivariate analysis, higher total meaning in life scores were significantly associated with greater optimism (multivariate estimate = 0.33, p < 0.001), lower depression (- 0.26, < 0.001), spiritual pain (- 0.19, < 0.001), and financial distress (- 0.16, < 0.001). CONCLUSION: Country of origin was not a determinant of meaning in life. However, meaning in life was significantly associated with optimism, depression, spiritual pain, and financial distress, underscoring the multidimensional nature of this construct and potential opportunities for improvement in addressing meaning in life of patients with advanced cancer.
