Complex health care decisions with older patients in general practice: patient-centeredness and prioritization in consultations following a geriatric assessment.

OBJECTIVE: To examine to what extent general practitioners in consultations after a geriatric assessment set shared health priorities with older patients experiencing multimorbidity and to what extent this was facilitated through patient-centered behavior. METHODS: Observation of consultations embedded in a cluster randomized controlled trial,(1) in which 317 patients from 41 general practices received the STEP assessment followed by a care planning consultation with their GPs. GPs in the intervention group used a structured procedure for setting health (care) priorities in contrast to control GPs. A sample of 43 consultations (24 intervention; 19 control) were recorded, transcribed and analyzed with regard to priority setting and patient-centeredness. RESULTS: Patient-centeredness was only moderately apparent in consultations dealing with complex care plans for older patients with multimorbidity. The shared determination of health priorities seemed unusual for both doctors and patients and was rarely practiced, albeit more frequently in intervention consultations. CONCLUSION: Setting health care priorities with patients experiencing multimorbidity is ethically desirable and medically appropriate. Yet a short structured guide for doctors cannot easily achieve this. PRACTICE IMPLICATIONS: More research is needed in regard to handling complex health needs of older patients. It requires a professional approach and training in patient-centered holistic care planning.

Impact of a priority-setting consultation on doctor-patient agreement after a geriatric assessment: cluster randomised controlled trial in German general practices.

BACKGROUND: General Practitioners (GPs) often have to simultaneously tackle multiple health problems of older patients. A patient-centred process that engages the patient in setting health priorities for treatment is needed. We investigated whether a structured priority-setting consultation reconciles the often-differing doctor-patient views on the importance of problems. DESIGN: Cluster randomised controlled trial with 40 GPs and their 317 consecutively recruited older patients. PROCEDURE: Following a geriatric assessment, patients and doctors independently rated the importance of each uncovered problem. GPs then selected priorities with their patients in a consultation. Trained intervention GPs held a structured consultation and utilised the list of uncovered patient problems with their importance ratings to agree priorities. Untrained control GPs only used the patient's problem list without importance ratings. MAIN OUTCOME: Doctor-patient agreement on independent importance ratings two weeks after the priority-setting consultation. ANALYSIS: Weighted kappa (κw) and multilevel logistic regression model. RESULTS: Intervention GPs and their patients determined mutual priorities for 20% of individual problems. In this process, GPs often succeeded in convincing their patients of the importance of vaccinations, lifestyle and cognitive issues. Likewise, patients convinced their GPs to prioritise their social and functional problems. Further treatment plans ensued in 84% of these priority areas. The regression model adjusting for clusters and baseline characteristics did not demonstrate significant differences in doctor-patient agreement on problems between groups a two weeks later. CONCLUSION: Differing views on the importance of health problems between GPs and older patients were not sustainably reconciled. The special consultation facilitated identification of priority problems for treatment despite differences in perceived importance of problems between patients and GPs. German clinical trials register drks 00000792.

What is important, what needs treating? How GPs perceive older patients' multiple health problems: a mixed method research study.

BACKGROUND: GPs increasingly deal with multiple health problems of their older patients. They have to apply a hierarchical management approach that considers priorities to balance competing needs for treatment. Yet, the practice of setting individual priorities in older patients is largely unexplored. This paper analyses the GPs' perceptions on important and unimportant health problems and how these affect their treatment. METHODS: GPs appraised the importance of health problems for a purposive sample of their older patients in semi-structured interviews. Prior to the interviews, the GPs had received a list of their patients' health problems resulting from a geriatric assessment and were asked to rate the importance of each identified problem. In the interviews the GPs subsequently explained why they considered certain health problems important or not and how this affected treatment. Data was analysed using qualitative content analysis and quantitative methods. RESULTS: The problems GPs perceive as important are those that are medical and require active treatment or monitoring, or that induce empathy or awareness but cannot be assisted further. Unimportant problems are those that are well managed problems and need no further attention as well as age-related conditions or functional disabilities that provoke fatalism, or those considered outside the GPs' responsibility. Statements of professional actions are closely linked to explanations of important problems and relate to physical problems rather than functional and social patient issues. CONCLUSIONS: GPs tend to prioritise treatable clinical conditions. Treatment approaches are, however, vague or missing for complex chronic illnesses and disabilities. Here, patient empowerment strategies are of value and need to be developed and implemented. The professional concepts of ageing and disability should not impede but rather foster treatment and care. To this end, GPs need to be able to delegate care to a functioning primary care team. TRIAL REGISTRATION: German Trial Register (DRKS): 00000792.

Priority setting in general practice: health priorities of older patients differ from treatment priorities of their physicians.

AIM: To ascertain health priorities of older patients and treatment priorities of their general practitioners (GP) on the basis of a geriatric assessment and to determine the agreement between these priorities. METHODS: The study included a sample of 9 general practitioners in Hannover, Germany, and a stratified sample of 35 patients (2-5 patients per practice, 18 female, average age 77.7 years). Patients were given a geriatric assessment using the Standardized Assessment for Elderly Patients in Primary Care (STEP) to gain an overview of their health and everyday problems. On the basis of these results, patients and their physicians independently rated the importance of each problem disclosed by the assessment. Whereas patients assessed the importance for their everyday lives, physicians assessed the importance for patients' medical care and patients' everyday lives. RESULTS: Each patient had a mean ± standard deviation of 18 ± 9.2 health problems. Thirty five patients disclosed a total of 634 problems; 537 (85%) were rated by patients and physicians. Of these 537 problems, 332 (62%) were rated by patients and 334 (62%) by physicians as important for patients' everyday lives. In addition, 294 (55%) were rated by physicians as important for patients' medical care. Although these proportions of important problems were similar between patients and physicians, there was little overlap in the specific problems that each group considered important. The chance-corrected agreement (Cohen κ) between patients and physicians on the importance of problems for patients' lives was low (κ=0.23). Likewise, patients and physicians disagreed on the problems that physicians considered important for patients' medical care (κ=0.18, P<0.001 for each). CONCLUSION: The low agreement on health and treatment priorities between patients and physicians necessitates better communication between the two parties to strengthen mutual understanding.