Taking the Patient Into Consideration

I just read a very thought-provoking article in a recent New England Journal of Medicine that discussed the concept of goal-oriented patient care.

While major efforts have been launched to make care more patient-centered, defined as “respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions,”  assessments of quality of care and health outcomes have not yet incorporated patient-centeredness.

Reimbursement will increasingly be tied to the achievement of patient outcomes such as quality and outcomes measurement.  Quality measurements have addressed preventive and disease-specific care processes (e.g., smoking-cessation counseling and initiation of appropriate medications after myocardial infarction). Similarly, outcomes measurement has focused on condition-specific indicators, both short-term (e.g., glycated hemoglobin levels and hypertension control) and longer-term (e.g., disease-free survival), as well as overall mortality.

While these process and outcome measures work well for relatively healthy patients with single diseases, they may be inappropriate for patients with multiple conditions, severe disability, or short life expectancy.  For these patients, the overall quality of care depends on more than just disease-specific care processes. Furthermore, disease-specific outcomes may not adequately reflect their treatment goals.

For example, one outcomes measurement for patients with cardiovascular pulmonary disease is an inventory of symptoms such as edema, dyspnea, etc.   Clinicians are reimbursed as patients reach a general goal related to these metrics.  However, a patient with cardiovascular and pulmonary disease may have a different, specific goal in mind.  Perhaps he wants to have just enough control of his symptoms to play golf for an hour.   Or perhaps a patient with advancing Parkinson’s disease wishes to remain mobile despite the side effects associated with increasing doses of his medication.

However, until the health system ties reimbursement to quality metrics that capture individual goal elicitation and attainment, we’ll be unable to move toward goal-directed, patient-centered decision making in any meaningful way.


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