Benefits of Guideline Standards to Older Americans: a patient perspective

1. Benefits of Guideline Standards to Older Americans: a patient perspective IOM Committee on Standards for Developing Trustworthy Clinical Practice Guidelines Joyce Dubow, AARP January 11, 2010

2. Critical need to improve care • Quality problems are widely recognized, well-documented • Older people are high users of health care • Top ¼ of beneficiaries account for 85 percent of Medicare spending (2005) • Those age 65+ made up 13 percent of the U.S. population in 2002, but consumed 36 percent of total U.S. personal health care expenses • Patients would directly benefit from more effective, efficient, and safer care • Poor quality is costly

3. Value to older patients • Patients benefit when their clinicians adhere to evidence-based guidelines • Need to incent provider adherence to guidelines • Financial reward • Recognition • Guidelines need to be presented in formats that will facilitate adherence: brief, clear, credible

4. Benefits to Patients • Patients and their caregivers benefit when they are informed and knowledgeable about their conditions and recommended interventions—better outcomes, often reduced costs • Need to provide patients with tools to care for themselves • Decision support- help with uncertainty; risk/benefit assessment; understand what is possible, realistic • Self-management- active engagement in their own (loved one’s) care to improve: symptom management, communication with clinicians, hospital utilization (<), self-reported health status • Self-efficacy or confidence is associated with health outcomes

5. Chronic disease self-management: lessons learned David Sobel, Kaiser Permanente Adherence to guidelines would improve outcomes. Patients need help to make healthy choices and decisions. Support includes: • Timely, accurate, understandable information • Involvement in collaborative decision making • Goal setting and problem-solving • Help managing psychosocial issues

6. Guidelines for Patient Guidelines • Brief • Clear • Trustworthy • Accessible • Understandable • Meaningful (reflects patient preferences) • Consistent with other guidelines • Evidence-based (preference-related evidence for health outcomes, financial considerations, esp. when there are tradeoffs) How communicated and by whom

7. Barriers and Challenges • Numeracy • Relationship of numeracy to risk perception (A. Fagerlin) • Poor numeracy skills related to difficulty in calculating benefit of a procedure • Poor numeracy skills affect health outcomes

8. Barriers and Challenges • Characteristics of older adults can affect adherence to guidelines: • Health literacy/numeracy deficits • Decision making skills • Cognitive impairment • Personal preferences • Physician-centric practices • Physicians discuss risks and benefits only 9% of the time and assess understanding only 2% of the time Braddock, J Gen Intern Med. 1997;12: 339–345

9. Barriers and Challenges • Insufficient evidence to manage many conditions affecting older persons (Reuben, 12/2009) • Evidence for decisions may not fit the combination of a patient’s unique clinical and social situations • Non-adherence to guidelines by clinicians and patients even when evidence exists • Incorporating patient preference throughout the guideline development/implementation process remains elusive • “Productive communication” not widespread (lack of empathy, desire to control…)