Primary Care Physician Perspectives on the Influence of Patient Values, Health Priorities, and Preferences on Clinical Decision-Making for Complex Patients with Multimorbidity: A Qualitative Study.

Introduction: The prevalence of patients with multimorbidity (ie, multiple chronic conditions) is increasing. Clinical decision-making guided by patients' values, health priorities and goals, and treatment preferences is particularly important in the context of interacting diseases and psychosocial needs. Physicians face challenges incorporating patient perspectives into care plans. We examined primary care physician (PCP) views on the influence of patients' values, health priorities and goals, and preferences on clinical decisions for patients with multimorbidity and increased psychosocial complexity. Methods: We conducted semi-structured telephone interviews with 23 PCPs within patient-centered medical home teams in a nationally integrated health system in the United States between May and July 2020. Data were analyzed via thematic analysis with deductive and inductive coding. Results: Three major themes emerged: 1. Patient personal values were rarely explicitly discussed in routine clinical encounters but informed more commonly discussed concepts of patient priorities, goals, and preferences; 2. Patient values, health priorities and goals, and preferences were sources of divergent views about care plans between healthcare teams, patients, and families; 3. Physicians used explicit strategies to communicate and negotiate about patient values, health priorities and goals, and preferences when developing care plans, including trust-building; devoting extra effort to individualizing care; connecting patient values to healthcare recommendations; deliberate elicitation and acknowledgement of patient concerns; providing "space" for patient perspectives; incorporating family into care planning; pairing physician to patient priorities; and collaborative teamwork. Conclusion: Primary care physicians perceive patient values, health priorities and goals, and preferences as influential during clinical decision-making for complex patients with multimorbidity. Participants used concrete strategies to negotiate alignment of these aspects when physician-patient divergence occurred. While rarely discussed directly in clinical encounters, personal values affected patient health priorities, goals, and preferences during care planning, suggesting a clinical role for more deliberate elicitation and discussion of patient values for this population.

Associations Between Different Self-reported Social Risks and Neighborhood-level Resources in Medicaid Patients.

BACKGROUND: Adverse social conditions are a key contributor to health disparities. Improved understanding of how social risk factors interact with each other and with neighborhood characteristics may inform efforts to reduce health disparities. DATA: A questionnaire of 29,281 patients was collected through the enrollment of Medicaid beneficiaries in a large Northern California integrated health care delivery system between May 2016 and February 2020. EXPOSURES: Living in the least resourced quartile of neighborhoods as measured by a census-tract level Neighborhood Deprivation Index score. MAIN OUTCOMES: Five self-reported social risk factors: financial need, food insecurity, housing barriers, transportation barriers, and functional limitations. RESULTS: Nearly half (42.0%) of patients reported at least 1 social risk factor; 22.4% reported 2 or more. Mean correlation coefficient between social risk factors was ρ=0.30. Multivariable logistic models controlling for age, race/ethnicity, sex, count of chronic conditions, and insurance source estimated that living in the least resourced neighborhoods was associated with greater odds of food insecurity (adjusted odds ratio=1.07, 95% confidence interval: 1.00-1.13) and transportation barriers (adjusted odds ratio=1.20, 95% confidence interval: 1.11-1.30), but not financial stress, housing barriers, or functional limitations. CONCLUSIONS AND RELEVANCE: We found that among 5 commonly associated social risk factors, Medicaid patients in a large Northern California health system typically reported only a single factor and that these factors did not correlate strongly with each other. We found only modestly greater social risk reported by patients in the least resourced neighborhoods. These results suggest that individual-level interventions should be targeted to specific needs whereas community-level interventions may be similarly important across diverse neighborhoods.

Factors affecting primary care physician decision-making for patients with complex multimorbidity: a qualitative interview study.

BACKGROUND: Patients with multiple chronic conditions (multimorbidity) and additional psychosocial complexity are at higher risk of adverse outcomes. Establishing treatment or care plans for these patients must account for their disease interactions, finite self-management abilities, and even conflicting treatment recommendations from clinical practice guidelines. Despite existing insight into how primary care physicians (PCPs) approach care decisions for their patients in general, less is known about how PCPs make care planning decisions for more complex populations particularly within a medical home setting. We therefore sought to describe factors affecting physician decision-making when care planning for complex patients with multimorbidity within the team-based, patient-centered medical home setting in the integrated healthcare system of the U.S. Department of Veterans Affairs, the Veterans Health Administration (VHA). METHODS: This was a qualitative study involving semi-structured telephone interviews with PCPs working > 40% time in VHA clinics. Interviews were conducted from April to July, 2020. Content was analyzed with deductive and inductive thematic analysis. RESULTS: 23 physicians participated in interviews; most were MDs (n = 21) and worked in hospital-affiliated clinics (n = 14) across all regions of the VHA's national clinic network. We found internal, external, and relationship-based factors, with developed subthemes describing factors affecting decision-making for complex patients with multimorbidity. Physicians described tailoring decisions to individual patients; making decisions in keeping with an underlying internal style or habit; working towards an overarching goal for care; considering impacts from patient access and resources on care plans; deciding within boundaries provided by organizational structures; collaborating on care plans with their care team; and impacts on decisions from their own emotions and relationship with patient. CONCLUSIONS: PCPs described internal, external, and relationship-based factors that affected their care planning for high-risk and complex patients with multimorbidity in the VHA. Findings offer useful strategies employed by physicians to effectively conduct care planning for complex patients in a medical home setting, such as delegation of follow-up within multidisciplinary care teams, optimizing visit time vs frequency, and deliberate investment in patient-centered relationship building to gain buy-in to care plans.

Aligning care with the personal values of patients with complex care needs.

OBJECTIVE: To identify opportunities to align care with the personal values of patients from three distinct groups with complex medical, behavioral, and social needs. DATA SOURCES/STUDY SETTING: Between June and August 2019, we conducted semi-structured interviews with individuals with complex care needs in two integrated health care delivery systems. STUDY DESIGN: Qualitative study using semi-structured interviews. DATA COLLECTION METHODS: We interviewed three groups of patients at Kaiser Permanente Washington and Kaiser Permanente Colorado representing three distinct profiles of complex care needs: Group A ("obesity, opioid prescription, and low-resourced neighborhood"), Group B ("older, high medical morbidity, emergency department, and hospital use"), and Group C ("older, mental and physical health concerns, and low-resourced neighborhood"). These profiles were identified based on prior work and prioritized by internal primary care stakeholders. Interview transcripts were analyzed using thematic analysis. PRINCIPAL FINDINGS: Twenty-four patients participated; eight from each complex needs profile. Mean age across groups was 71 (range 48-86) years. We identified five themes common across the three groups that captured patients' views regarding values-aligned care. These themes focused on the importance of care teams exploring and acknowledging a patient's values, providing access to nonphysician providers who have different perspectives on care delivery, offering values-aligned mental health care, ensuring connection to community-based resources that support values and address needs, and providing care that supports the patient plus their family and caregivers. CONCLUSIONS: Our results suggest several opportunities to improve how care is delivered to patients with different complex medical, behavioral, and social needs. Future research is needed to better understand how to incorporate these opportunities into health care.

Use of Latent Class Analysis and k-Means Clustering to Identify Complex Patient Profiles.

Importance: Medically complex patients are a heterogeneous group that contribute to a substantial proportion of health care costs. Coordinated efforts to improve care and reduce costs for this patient population have had limited success to date. Objective: To define distinct patient clinical profiles among the most medically complex patients through clinical interpretation of analytically derived patient clusters. Design, Setting, and Participants: This cohort study analyzed the most medically complex patients within Kaiser Permanente Northern California, a large integrated health care delivery system, based on comorbidity score, prior emergency department admissions, and predicted likelihood of hospitalization, from July 18, 2018, to July 15, 2019. From a starting point of over 5000 clinical variables, we used both clinical judgment and analytic methods to reduce to the 97 most informative covariates. Patients were then grouped using 2 methods (latent class analysis, generalized low-rank models, with k-means clustering). Results were interpreted by a panel of clinical stakeholders to define clinically meaningful patient profiles. Main Outcomes and Measures: Complex patient profiles, 1-year health care utilization, and mortality outcomes by profile. Results: The analysis included 104 869 individuals representing 3.3% of the adult population (mean [SD] age, 70.7 [14.5] years; 52.4% women; 39% non-White race/ethnicity). Latent class analysis resulted in a 7-class solution. Stakeholders defined the following complex patient profiles (prevalence): high acuity (9.4%), older patients with cardiovascular complications (15.9%), frail elderly (12.5%), pain management (12.3%), psychiatric illness (12.0%), cancer treatment (7.6%), and less engaged (27%). Patients in these groups had significantly different 1-year mortality rates (ranging from 3.0% for psychiatric illness profile to 23.4% for frail elderly profile; risk ratio, 7.9 [95% CI, 7.1-8.8], P < .001). Repeating the analysis using k-means clustering resulted in qualitatively similar groupings. Each clinical profile suggested a distinct collaborative care strategy to optimize management. Conclusions and Relevance: The findings suggest that highly medically complex patient populations may be categorized into distinct patient profiles that are amenable to varying strategies for resource allocation and coordinated care interventions.

Understanding What Is Most Important to Individuals with Multiple Chronic Conditions: A Qualitative Study of Patients' Perspectives.

BACKGROUND: To improve care for individuals living with multiple chronic conditions, patients and providers must align care planning with what is most important to patients in their daily lives. We have a limited understanding of how to effectively encourage communication about patients' personal values during clinical care. OBJECTIVE: To identify what patients with multiple chronic conditions describe as most important to their well-being and health. DESIGN: We interviewed individuals with multiple chronic conditions in their homes and analyzed results qualitatively, guided by grounded theory. PARTICIPANTS: A total of 31 patients (mean age 68.7 years) participated in the study, 19 of which included the participation of family members. Participants were from Kaiser Permanente Washington, an integrated health care system in Washington state. APPROACH: Qualitative analysis of home visits, which consisted of semi-structured interviews aided by photo elicitation. KEY RESULTS: Analysis revealed six domains of what patients described as most important for their well-being and health: principles, relationships, emotions, activities, abilities, and possessions. Personal values were interrelated and rarely expressed as individual values in isolation. CONCLUSIONS: The domains describe the range and types of personal values multimorbid older adults deem important to well-being and health. Understanding patients' personal values across these domains may be useful for providers when developing, sharing, and following up on care plans.

Development and Validation of a Tool to Identify Patients With Type 2 Diabetes at High Risk of Hypoglycemia-Related Emergency Department or Hospital Use.

Importance: Hypoglycemia-related emergency department (ED) or hospital use among patients with type 2 diabetes (T2D) is clinically significant and possibly preventable. Objective: To develop and validate a tool to categorize risk of hypoglycemic-related utilization in patients with T2D. Design, Setting, and Participants: Using recursive partitioning with a split-sample design, we created a classification tree based on potential predictors of hypoglycemia-related ED or hospital use. The resulting model was transcribed into a tool for practical application and tested in 1 internal and 2 fully independent, external samples. Development and internal testing was conducted in a split sample of 206 435 patients with T2D from Kaiser Permanente Northern California (KPNC), an integrated health care system. The tool was externally tested in 1 335 966 Veterans Health Administration and 14 972 Group Health Cooperative patients with T2D. Exposures: Based on a literature review, we identified 156 candidate predictor variables (prebaseline exposures) using data collected from electronic medical records. Main Outcomes and Measures: Hypoglycemia-related ED or hospital use during 12 months of follow-up. Results: The derivation sample (n = 165 148) had a mean (SD) age of 63.9 (13.0) years and included 78 576 (47.6%) women. The crude annual rate of at least 1 hypoglycemia-related ED or hospital encounter in the KPNC derivation sample was 0.49%. The resulting hypoglycemia risk stratification tool required 6 patient-specific inputs: number of prior episodes of hypoglycemia-related utilization, insulin use, sulfonylurea use, prior year ED use, chronic kidney disease stage, and age. We categorized the predicted 12-month risk of any hypoglycemia-related utilization as high (>5%), intermediate (1%-5%), or low (<1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% were categorized as high, intermediate, and low risk, respectively, with observed 12-month hypoglycemia-related utilization rates of 6.7%, 1.4%, and 0.2%, respectively. There was good discrimination in the internal validation KPNC sample (C statistic = 0.83) and both external validation samples (Veterans Health Administration: C statistic = 0.81; Group Health Cooperative: C statistic = 0.79). Conclusions and Relevance: This hypoglycemia risk stratification tool categorizes the 12-month risk of hypoglycemia-related utilization in patients with T2D using only 6 inputs. This tool could facilitate targeted population management interventions, potentially reducing hypoglycemia risk and improving patient safety and quality of life.

Using Electronic Health Record Data to Measure Care Quality for Individuals with Multiple Chronic Medical Conditions.

OBJECTIVES: To inform the development of a data-driven measure of quality care for individuals with multiple chronic conditions (MCCs) derived from an electronic health record (EHR). DESIGN: Qualitative study using focus groups, interactive webinars, and a modified Delphi process. SETTING: Research department within an integrated delivery system. PARTICIPANTS: The webinars and Delphi process included 17 experts in clinical geriatrics and primary care, health policy, quality assessment, health technology, and health system operations. The focus group included 10 individuals aged 70-87 with three to six chronic conditions selected from a random sample of individuals aged 65 and older with three or more chronic medical conditions. MEASUREMENTS: Through webinars and the focus group, input was solicited on constructs representing high-quality care for individuals with MCCs. A working list was created of potential measures representing these constructs. Using a modified Delphi process, experts rated the importance of each possible measure and the feasibility of implementing each measure using EHR data. RESULTS: High-priority constructs reflected processes rather than outcomes of care. High-priority constructs that were potentially feasible to measure included assessing physical function, depression screening, medication reconciliation, annual influenza vaccination, outreach after hospital admission, and documented advance directives. High-priority constructs that were less feasible to measure included goal setting and shared decision-making, identifying drug-drug interactions, assessing social support, timely communication with patients, and other aspects of good customer service. Lower-priority domains included pain assessment, continuity of care, and overuse of screening or laboratory testing. CONCLUSION: High-quality MCC care should be measured using meaningful process measures rather than outcomes. Although some care processes are currently extractable from electronic data, capturing others will require adapting and applying technology to encourage holistic, person-centered care.

Do Patients Who Access Clinical Information on Patient Internet Portals Have More Primary Care Visits?

BACKGROUND: As health care costs alarm the nation and the debate increases about the impact of health information technologies, patients are reviewing their medical records increasingly through secure Internet portals. Important questions remain about the impact of portal use on office visits. OBJECTIVE: To evaluate whether use of patient Internet portals to access records is associated with increased primary care utilization. RESEARCH DESIGN: A prospective cohort study. SUBJECTS: Primary care patients registered on patient Internet portals, within an integrated health system serving rural Pennsylvania and an academic medical center in Boston. MEASURES: Frequency of "clinical portal use" (days/2 mo intervals over 2 y) included secure messaging about clinical issues and viewing laboratory and radiology findings. In year 2, a subset of patients also gained access to their primary care doctor's visit notes. The main outcome was number of primary care office visits. RESULTS: In the first 2 months of the 2-year period, 14% of 44,951 primary care patients engaged in clinical portal use 2 or more days per month, 31% did so 1 day per month, and the remainder had no clinical portal use. Overall, adjusted for age, sex, and chronic conditions, clinical portal use was not associated with subsequent office visits. Fewer than 0.1% of patients engaged in high levels of clinical portal use (31 or more login days in 2 mo) that were associated with 1 or more additional visits in the subsequent 2 months (months 3 and 4). However, the reverse was true: office visits led to subsequent clinical portal use. Similar trends were observed among patients with or without access to visit notes. CONCLUSIONS: Patients turn to their portals following visits, but clinical portal use does not contribute to an increase in primary care visits.

Antiretroviral Therapy Adherence and Use of an Electronic Shared Medical Record Among People Living with HIV.

Electronic shared medical records (SMR) are emerging healthcare technologies that allow patients to engage in their healthcare by communicating with providers, refilling prescriptions, scheduling appointments, and viewing portions of medical records. We conducted a pre-post cohort study of HIV-positive adults who used and did not use SMR in two integrated healthcare systems. We compared the difference in antiretroviral refill adherence between SMR users and age- and sex-frequency matched non-users from the 12-month period prior to SMR useto the 12-month period starting 6 months after initiation of SMR use. High adherence was maintained among SMR users (change = -0.11 %) but declined among non-users (change = -2.05 %; p = 0.003). Among SMR users, there was a steady improvement in adherence as monthly frequency of SMR use increased (p = 0.009). SMR use, particularly more frequent use, is associated with maintaining high adherence and non-use is associated with declines in adherence over time among patients with access to these online services.

Randomized trial of depression follow-up care by online messaging.

BACKGROUND: Quality of antidepressant treatment remains disturbingly poor. Rates of medication adherence and follow-up contact are especially low in primary care, where most depression treatment begins. Telephone care management programs can address these gaps, but reliance on live contact makes such programs less available, less timely, and more expensive. OBJECTIVE: Evaluate the feasibility, acceptability, and effectiveness of a depression care management program delivered by online messaging through an electronic medical record. DESIGN: Randomized controlled trial comparing usual primary care treatment to primary care supported by online care management SETTING: Nine primary care clinics of an integrated health system in Washington state PARTICIPANTS: Two hundred and eight patients starting antidepressant treatment for depression. INTERVENTION: Three online care management contacts with a trained psychiatric nurse. Each contact included a structured assessment (severity of depression, medication adherence, side effects), algorithm-based feedback to the patient and treating physician, and as-needed facilitation of follow-up care. All communication occurred through secure, asynchronous messages within an electronic medical record. MAIN MEASURES: An online survey approximately five months after randomization assessed the primary outcome (depression severity according to the Symptom Checklist scale) and satisfaction with care, a secondary outcome. Additional secondary outcomes (antidepressant adherence and use of health services) were assessed using computerized medical records. KEY RESULTS: Patients offered the program had higher rates of antidepressant adherence (81% continued treatment more than 3 months vs. 61%, p = 0.001), lower Symptom Checklist depression scores after 5 months (0.95 vs. 1.17, p = 0.043), and greater satisfaction with depression treatment (53% "very satisfied" vs. 33%, p = 0.004). LIMITATIONS: The trial was conducted in one integrated health care system with a single care management nurse. Results apply only to patients using online messaging. CONCLUSIONS: Our findings suggest that organized follow-up care for depression can be delivered effectively and efficiently through online messaging.

Participatory (re)design of a sociotechnical healthcare delivery system: the Group Health Patient-Centered Medical Home.

This paper describes one organization's interpretation of the Patient-Centered Medical Home concept and the healthcare delivery system that has emerged from their participatory redesign initiative. Group Health, a large integrated healthcare system based in Seattle, Washington, USA initiated a Patient-Centered Medical Home care delivery system transformation in January 2007. Current theories and evidence about the Patient-Centered Medical Home (PCMH), the Chronic Care Model, and effective primary care were interpreted via a facilitated group process and translated into a core set of 5 system design principles. These design principles guided all subsequent system transformation activities. The central organizing principle is supporting and sustaining the patient-primary care physician relationship. The emergent PCMH healthcare delivery system comprises both opportunistic point-of-care and outreach components, many of which leverage and enhance the organization's health information and communication technologies.

Patient experience should be part of meaningful-use criteria.

The proposed federal "meaningful use" criteria for electronic health records include the direct engagement of patients in their care. In this study, we sought to describe the adoption and use of online services linked to the electronic health record at Group Health Cooperative. By August 2009, six years after the introduction of these services, 30 percent of outpatient "encounters" were actually conducted through secure electronic messaging. Meanwhile, 10 percent of enrollees reviewed medical test results online, while 10 percent went online to request medication refills. These results highlight the need to measure the patient experience as part of meaningful use and to enact policies supporting online and phone communication by patients and providers.

Patient use of secure electronic messaging within a shared medical record: a cross-sectional study.

BACKGROUND: Most patients would like to be able to exchange electronic messages with personal physicians. Few patients and providers are exchanging electronic communications. OBJECTIVE: To evaluate patient characteristics associated with the use of secure electronic messaging between patients and health care providers. DESIGN, SETTING, AND PATIENTS: Cross-sectional cohort study of enrollees over 18 years of age who were enrolled in an integrated delivery system in 2005. MEASUREMENTS AND MAIN RESULTS: Among eligible enrollees, 14% (25,075) exchanged one or more secure messages with a primary or specialty care provider between January 1, 2004 and March 31, 2005. Higher secure messaging use by enrollees was associated with female gender (OR, 1.15; 95% CI, 1.10-1.19), greater overall morbidity (OR, 5.64; 95% CI, 5.07-6.28, comparing high or very high to very low overall morbidity), and the primary care provider's use of secure messaging with other patients (OR, 1.94; 95% CI, 1.67-2.26, comparing 20-50% vs.

Evaluation of the group health cooperative access initiative: study design challenges in estimating the impact of a large-scale organizational transformation.

The Institute of Medicine argues that poorly designed delivery systems are a major cause of low-quality care in the United States but does not present methods for evaluating whether its recommendations, when implemented by a health care organization, actually improve quality of care. We describe how time-series study designs using individual-level longitudinal data can be applied to address methodological challenges in our evaluation of the impact of the Group Health Cooperative "Access Initiative," an integrated set of 7 "patient-centered" reforms in its integrated delivery system that are consistent with the Institute of Medicine's recommendations. The methods may be generalizable to evaluating similar reforms in other integrated delivery systems with representative patient and physician data sources.

Providers' experience with an organizational redesign initiative to promote patient-centered access: a qualitative study.

BACKGROUND: Patient-centered access is a philosophy and a method that supports efforts to redesign health-care delivery systems to deliver higher quality care and to better meet the needs and preferences of patients. Since mid-2000, Group Health Cooperative has pursued an ensemble of strategic initiatives aimed at promoting patient-centered access, referred to as the Access Initiative. In support of this strategy, Group Health has also engaged in enterprise implementation of an electronic medical record and clinical information system that is integrated with their patient Web site, MyGroupHealth. OBJECTIVE: To elicit, describe, and characterize providers' perceptions of the effects of the Access Initiative, an information technology-enabled organizational redesign initiative intended to promote patient-centered access. DESIGN: Thematic analysis of semi-structured in-depth interviews. PARTICIPANTS: Twenty-two care providers representing 14 primary care, medical, and surgical specialties at Group Health Cooperative, an integrated health-care system based in Seattle, Washington. FINDINGS: Analyses of the interview transcripts revealed nine emergent themes, five of which have particular relevance for health-care organizations pursuing patient-centered access: the Access Initiative improved patient satisfaction, improved the quality of encounter-based care, compromised providers' focus on population health, created additional work for providers, and decreased job satisfaction for primary care providers and some medical specialists. CONCLUSIONS: Providers like that the Access Initiative is mostly good for their patients, but dislike the negative effects on their own quality of life - especially in primary care. These reforms may not be sustainable under current models of organization and financing.

Patient web services integrated with a shared medical record: patient use and satisfaction.

OBJECTIVES: This study sought to describe the evolution, use, and user satisfaction of a patient Web site providing a shared medical record between patients and health professionals at Group Health Cooperative, a mixed-model health care financing and delivery organization based in Seattle, Washington. DESIGN: This study used a retrospective, serial, cross-sectional study from September 2002 through December 2005 and a mailed satisfaction survey of a random sampling of 2,002 patients. MEASUREMENTS: This study measured the adoption and use of a patient Web site (MyGroupHealth) from September 2002 through December 2005. RESULTS: As of December 2005, 25% (105,047) of all Group Health members had registered and completed an identification verification process enabling them to use all of the available services on MyGroupHealth. Identification verification was more common among patients receiving care in the Integrated Delivery System (33%) compared with patients receiving care in the network (7%). As of December 2005, unique monthly user rates per 1,000 adult members were the highest for review of medical test results (54 of 1,000), medication refills (44 of 1,000), after-visit-summaries (32 of 1,000), and patient-provider clinical messaging (31 of 1,000). The response rate for the patient satisfaction survey was 46% (n = 921); 94% of survey respondents were satisfied or very satisfied with MyGroupHealth overall. Patients reported highest satisfaction (satisfied or very satisfied) for medication refills (96%), patient-provider messaging (93%), and medical test results (86%). CONCLUSION: Use and satisfaction with MyGroupHealth were greatest for accessing services and information involving ongoing, active care and patient-provider communication. Tight integration of Web services with clinical information systems and patient-provider relationships may be important in meeting the needs of patients.