Anticipated Impact on Veterans Care: Current measures of chronic illness care do not account for patient preferences. Our study will provide novel information about how patient preferences can be incorporated into VA performance measures. Background: The Institute of Medicine established six principles to guide health care in the 21st century, stating that care should be: safe, effective, patient-centered, timely, efficient, and equitable. Clinical practice guidelines have been established to increase the effectiveness of the health care system by standardizing care for chronic conditions. However, most of these guidelines focus on care for individual conditions, thereby neglecting care required for medically complex patients, particularly those with multiple comorbidities. The provision of guideline concordant care in these patients would likely result in considerable additional medications, health care utilization, increased risk of adverse events, and thus, care that may not be patient-centered.Despite awareness of these potential adverse consequences, the relationship between quality of care and patient perceptions of their care is poorly understood. Recognizing the challenges of chronic illness management, the chronic care model (CCM) was developed, providing a widely accepted framework for delivering chronic illness care. The Patient Assessment of Chronic Illness Care (PACIC) survey was designed to measure aspects of care, consistent with the CCM, from the patient's perspective, including: (1)patient activation; (2)delivery system design/decision support; (3)goal setting; (4)problem solving/contextual counseling; and, (5)follow-up/coordination of care. The PACIC survey has previously been used to examine patient- centered outcomes and self-management behaviors in chronically ill patients. However, it has not been used to assess perceptions of care in chronically ill patients with multimorbidity or to examine the association between patient perceptions of care and the objective level of quality received. Thus, the goal of this study is to assess the relationship between guideline-recommended care and the degree to which patients perceive their care as being patient-centered in a cohort of Veterans with multimorbidity. Project Objectives: The objectives of the proposed pilot study are: 1) To measure patient perceptions of their chronic illness care using the adapted PACIC survey in a cohort of Veterans with multimorbidity. 2) To determine whether Veterans with multiple chronic medical conditions who receive guideline-recommended care perceive their care as patient-centered. Project Methods: Using VA administrative data, we will identify a cohort of patients receiving care at the Michael E. DeBakey VA Medical Center over a four-month period with the following chronic medical conditions: hypertension, ischemic heart disease, and diabetes mellitus. These conditions were selected because they commonly co-exist and because current VA performance indicators include measures to assess the quality of care for these conditions. After identifying a cohort of patients meeting our study criteria, we will determine the patient's next outpatient appointment in order to approach him/her for study participation. Primary data collection will include administration of the PACIC survey, a structured, validated instrument to measure chronically ill patients' experiences with the health care system. We will adapt the survey to better reflect the multimorbid cohort to whom it will be administered and calculate reliability statistics to compare to normative statistics from the validated survey. We will also perform a structured chart review using the VA's electronic medical record to examine the quality of care that participants received for each of the study conditions. Data abstracted from the medical record will include diagnoses, laboratory values, vital signs, medications, patient refusals and contraindications. We will run regression models to examine the association between the domains of chronic illness care assessed by the PACIC survey and the objective quality of chronic illness care. The information generated by this study will provide the foundation for future work to develop more patient-centered measures of chronic illness care in the VA.
Clinical practice guidelines have been developed to increase the effectiveness of the health care system by standardizing care for chronic conditions. However, their focus on individual conditions and failure to account for patient preferences does not fully reflect the complexities of care for patients with multimorbidity and thus, may inadvertently promote less patient-centered care. We propose to assess the relationship between guideline-recommended care and the degree to which patients perceive their care as being patient- centered in a cohort of Veterans with multimorbidity. This project will provide a critical foundation for submission of a VA Investigator Initiated Research (IIR) proposal that will enable us to perform our work on a larger scale throughout the VA and that will allow us to examine other aspects of chronic illness care and additional chronic conditions for Veterans with multimorbidity.
