The Call for Patient-Centered Care
Some wonderful concepts in patient-centered care were the topic of several pieces in this week’s New England Journal of Medicine (March 1, 2012). Overall, they discuss its critical role in the future of US health care reform. One key article was co-authored by two of the US’s most prominent geriatricians, Dr. David B. Reuben, Chief of Geriatrics at University of California, Los Angeles, and Dr. Mary E. Tinetti, Professor of Geriatrics at Yale University.
In this article, “Goal-Oriented Patient Care—An Alternative Health Outcomes Paradigm”, Drs. Reuben and Tinetti discuss the movement in US health care to make patients’ values guide clinical care in a more meaningful way. This is now an explicit aim of our ever-powerful Center for Medicare and Medicaid (see a prior post re Medicare, the US’s largest insurer). Yes, patients’ values should guide decision making, but they begin to answer why and how it can be achieved.
As someone training in geriatrics, it did not surprise me that geriatricians wrote this succinct and timely article. In our field, we frequently care for patients whose medical complexity makes it difficult to pursue the “standard of care” for many conditions. (Which looks bad on many traditional quality measures. For example, the measure of average blood sugar considered optimal for diabetics is not helpful for older adults in whom it is dangerous to keep at such low levels, but many quality measurements do not take this into account.)
One example might be a patient who is older, not very healthy, and who has a newly discovered kidney cancer that may take longer to grow and cause a problem than she is likely to live. Should she choose surgery to remove it when she may take months to recover and never get back to her prior state of health? The decision of what to do must be a carefully considered one between the patient and her doctors. The right answer lies in the complex mix of what the medical problem is, what is realistic, and what the patient wants based on understanding the medical options and her preferences. But how do you measure this? Should we even try?
Drs. Reuben and Tinetti suggest we should work with patients to understand their goals, and document this. We should then measure whether or not the patient’s goals were achieved with such techniques as “goal-attainment scaling,” or other measures of how well a patient’s goals were met. This should be part of how we look at quality in health care in a rigorous way.
The future is understanding that meeting patients’ goals are absolutely a critical part of how our health care system can be considered to be high quality. And the future is finding ways to measure how well we actually meet patient’s goals so we can value those physicians and systems of care that do it well. It will be very interesting to see how effective we are at doing this, and if indeed our paradigm shifts.
Reuben DB, Tinetti ME. Goal-Oriented Patient Care– An Alternative Health Outcomes Paradigm. N Engl J Med 2012; 366:777-779.