Moving From Disease-Centered to Patient Goals–Directed Care for Patients With Multiple Chronic Conditions

Decision making in cardiology concentrates on diseasespecific outcomes following practice guidelines for specific conditions.Quality metrics implemented for valuebased purchasing and public reporting also largely focus on individual diseases.Disease-centered approaches are appropriate when individuals have a single predominant disease and everyone with the disease desires the same outcome, such as prolonged survival or stroke prevention. 1 This disease-centered framework is illsuited, however, for persons with multiple chronic conditions, including most older adults with cardiovascular conditions and the majority of adult health care users of all ages. 2 Disease-centered decision making for this population results in treatment burden when patients must adhere to multiple guidelines and harm when guideline recommendations conflict. 3Furthermore, disease-centered recommendations may not address what matters most to these patients who vary in their health priorities. 4o consider an alternative to disease-centered decision making that better aligns care with what matters most to patients and reduces treatment burden, it is helpful to think of health care decisions as value propositions in which value = health outcome / cost.From the population perspective, health care value is defined as survival or disease benefit (output) per dollar spent (input).From patients' perspective, however, the personal health outcomes that they hope to achieve are more appropriate outputs. 4The appropriate inputs may include financial costs, but often more relevant are costs in terms of the time, discomfort, harms, and workload required to achieve their health outcomes. 3When defined as what patients are willing and able to do for their health, these broader costs inform care preferences.An alternative approach to decision making, therefore, is predicated on achieving patients' specific health outcome goals within the context of their acceptable workload.High-value care is defined as achievement of each patient's highest-level health outcome goals given the workload each is willing and able to perform.This is not as daunting a task as it may seem; patients implicitly consider trade-offs between outcome and workload even if it is not explicitly discussed. 3Examples of health outcome goals and patient workload are shown in the Box.This approach represents a shift from diseasecentered to patient goals-directed care.The idea that health care decisions should include patients' health VIEWPOINT