A Hexagonal Aim as a Driver of Change for Health Care and Health Insurance Systems.

Policy Points Improving health systems requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers - Quadruple Aim -. Reinforcing the recently defined Fifth Aim as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. Adding a Sixth Aim to take into account the increased health risks due to climate change. CONTEXT: Improving health systems, such as the U.S. or French, requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers, including clinicians and staff - Quadruple Aim -. While these aims are already ambitious, they may be insufficient when considering the economic, social and environmental challenges to the health of our communities in the near and long term. METHODS: A conceptual framework to provide additional ethical guardrails for health systems. RESULTS: Recently, authors have articulated a Fifth Aim and we propose to add a Sixth Aim to the Quadruple Aim model. These additional aims are meant to account for our growing knowledge around the determinants of health and the challenging processes and structures of governance across a wide range of sectors in society including healthcare. We are strengthening the Fifth Aim defined as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. The Sixth Aim is to account for the increase in risk to population health due to climate change as well as the impact our health systems have on the environment. CONCLUSIONS: As social tension and environmental changes seem to continue to impact the structure of our society this "Hexagonal Aim" taken together might provide additional ethical guiderails as we set our healthcare goals.

Randomized evaluation of decision support interventions for atrial fibrillation: Rationale and design of the RED-AF study.

BACKGROUND: Shared decision making (SDM) improves the likelihood that patients will receive care in a manner consistent with their priorities. To facilitate SDM, decision aids (DA) are commonly used, both to prepare a patient before their clinician visit, as well as to facilitate discussion during the visit. However, the relative efficacy of patient-focused or encounter-based DAs on SDM and patient outcomes remains largely unknown. We aim to directly estimate the comparative effectiveness of two DA's on SDM observed in encounters to discuss stroke prevention strategies in patients with atrial fibrillation (AF). METHODS: The study aims to recruit 1200 adult patients with non-valvular AF who qualify for anticoagulation therapy, and their clinicians who manage stroke prevention strategies, in a 2x2 cluster randomized multi-center trial at six sites. Two DA's were developed as interactive, online, non-linear tools: a patient decision aid (PDA) to be used by patients before the encounter, and an encounter decision aid (EDA) to be used by clinicians with their patients during the encounter. Patients will be randomized to PDA or usual care; clinicians will be randomized to EDA or usual care. RESULTS: Primary outcomes are quality of SDM, patient decision making, and patient knowledge. Secondary outcomes include anticoagulation choice, adherence, and clinical events. CONCLUSION: This trial is the first randomized, head-to-head comparison of the effects of an EDA versus a PDA on SDM. Our results will help to inform future SDM interventions to improve patients' AF outcomes and experiences with stroke prevention strategies.