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

Abstract

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.

Introduction

One of the current challenges in primary care in Germany is the treatment of older patients who consult their general practitioners (GPs) with multiple health and associated everyday problems [1], [2], [3], [4]. GPs can generally only respond to one or two patient problems due to short patient contact times in the current structure of consultations [5]. The use of disease-oriented guidelines and disease management programs reinforce this focus on single issues and lead to the fragmentation of what should be a holistic approach to the patient [2], [6]. Furthermore, treatment of multiple health problems in accordance with guidelines often leads to a disproportionately large number of recommendations and to an unimplementable number of codes of conduct that are frequently contradictory [2], [7], [8]. A holistic approach therefore needs to assess all individual health problems and select only a few for treatment. An ethically desirable process of reducing individual health problems for treatment is by a priority setting process involving the mutual agreement of the doctor and the patient. The question of how this individual prioritization [see 9] can be integrated into the consultation currently remains largely unanswered. However, ascertaining the patient's view on health priorities in relation to his other problems seems inevitable.

Setting priorities has been defined as part of a patient-centered approach in the European definition of general practice [10]. The basis of this process is the creation of a trusting relationship in which the older patient and the doctor can both participate in the shared decision-making process of priority setting [see 11]. Whereas at a health policy level much thought has already been given to the process of prioritization, only little is known about individual priority setting in patients with multimorbidity.

Achieving agreement in priority setting between the doctor and the patient is essential. Agreement not only strengthens the doctor–patient relationship, but also promotes adherence and can lead to improved health outcomes [12]. Agreement itself is an inevitable prerequisite of shared decision making (SDM), and it requires a patient-centered approach.

Patient centeredness contributes to better patient knowledge and more realistic patient expectations about the course of the disease, more active patient participation in the treatment process and fewer decisional conflicts [13]. For the doctor, including the patient perspective in the consultation demonstrably leads to less medication being prescribed for certain conditions [14]. However patient-centered care has been studied more often in doctors caring for healthier patients [15] in contrast to our multimorbid target group. Furthermore the specific evidence for improved outcomes of patient-centeredness in consultations is mixed and limited [16], [17].

This study has two objectives:

• Doctor–patient care planning consultations following geriatric assessments are examined as to whether individual prioritization actually takes place and to what extent patient-centered elements are applied.

• The GPs in the intervention group, who have received a short training on prioritization and patient-centeredness, are compared with the GPs in the control group, who have received no specific training, in order to investigate whether such training has an effect on the extent of patient-centered conversation and shared priorities.