Clinical pathways should address all three aspects of the Triple Aim, but the aim of improving population health often is prioritized at the expense of improving the patient experience of care and reducing the cost of health care. The latter two aspects could be better achieved by providing care that is consistent with an individual patient’s health objectives. This includes engaging in shared decision-making with patients to determine whether to adopt treatment or testing recommendations and avoiding excessive or inappropriate care. Clinical pathways that allow for differences in patient goals and preferences will be better positioned to achieve the Triple Aim.
Clinical pathways should be utilized with the intention of addressing all three aspects of the Triple Aim: improving the patient experience of care, improving the health of populations, and reducing the cost of health care. While pathways developed by payers tend to focus costs, and those developed by health systems tend to focus on population health, the third aim—to improve the individual patient’s experience of care—is often lost.
Developing clinical pathways that are balanced to address all three aims requires a clear understanding of what individualized patient care means. Care providers have several opportunities throughout the patient care journey to ensure the delivery of individualized care that is consistent with a patient’s health objectives. This begins with a clear understanding of the patient’s health goals.
Referrals for Tests or Specialty Consultations
The decision to make a referral for a test or specialty consultation should be driven by the patient’s health objectives. Like in chess, providers need to consider the next few actions that will result from their first move. This means considering first what would be done with a test result or specialty consultation well before making that order.
As an example, consider a practice that has a standing order for a mammogram, based in part on achieving their quality measures. With this standing order, an older adult woman receiving palliative care for breast cancer automatically will be put through this procedure. If a suspicious lesion is found, the radiologist will recommend a needle biopsy. While these actions are consistent with standard of care on a population health basis, they may be far from what is in the best interest of this individual.
Instead, with a clear appreciation of this individual patient’s health objectives, appropriate testing and specialty referrals can be made with an understanding of how the results of these investigations will achieve the health objectives of that individual. And in cases where testing and referrals do not help to achieve those objectives, they can be avoided.
Specialty Recommendations and Shared Decision-Making
In addition to primary care providers, clinicians within the specialty network need to be educated to make care recommendations consistent with a patient’s health objectives. Once in the hands of a specialist, the shift from fee-for-service models and private practitioners to value-based health care should lead specialty providers to share a common focus with the referring organization. This can only occur through an investment of time in educating the specialist provider network on the health system practice philosophy for its patients. This education needs to be maintained as an ongoing process.
If this does not occur, then there is one final step that can assure a patient’s care is consistent with their health objective—this occurs via the health team working through a shared decision-making process with the patient to determine whether to accept or reject the specialist’s recommendations.
Even after a specialist recommendation has been made, it is important to remember this is only a recommendation until the health team, along with the patient, accepts that this action is in keeping with the patient’s health objectives, with the benefits exceeding the risks and/or costs. Patient preferences should be the major driver in the development of an individual’s course of treatment. Whether it is someone with cancer, heart disease, diabetes or depression, a patient faces choices not only among different drug therapies but also among different diagnostic and treatment modalities. Each patient weighs medication therapy, surgical intervention, end-of-life (EOL) care, or lifestyle changes through their own perspective. This approach can improve quality of life as well as be cost-effective.
Some examples of health care services for which shared decision-making processes can ensure more appropriate, individualized care include preventive screening, antibiotic use, “excessive” care, and EOL care.
Preventive screening presents an example of the conflict between population health aims and the aims of individualized care and cost reduction.1 Screening recommendations differ depending on age and life expectancy to account for patients for whom the benefits of screening may not be realized. For example, some women aged 75 years and older who are in good health and have excellent functional status may benefit from mammography screening, whereas others who are in poor health and have short life expectancies probably would not. The most significant risk of screening the oldest-old women is the detection of tumors that may not become clinically important during a patient’s lifetime. The American Geriatrics Society encourages screening mammography for women younger than 85 years who have at least 5 years’ life expectancy and for healthy women 85 years and older who have excellent functional status or who feel strongly about the benefits of screening. When a provider discusses whether to stop screening with older women who have shorter life expectancies, it is important to address issues that may make women want to continue screening, including habit and the need for reassurance.2
The American Cancer Society recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information. The discussion about screening should take place at age 50 years for men who are at average risk of prostate cancer and are expected to live at least 10 more years.3 To begin to answer this question, urologists Schaeffer and Carter worked with investigators from the Baltimore Longitudinal Study of Aging. They studied the prostate-specific antigen (PSA) measurements of more than 800 men as they aged, and found that, among men over 75 years with PSA < 3 ng/ml, none died of prostate cancer and only one developed aggressive, high-risk prostate cancer. Based on these findings, Schaeffer has stated that men over age 75 years of age with a PSA < 3 ng/mL may choose, after consultation with their urologist, to discontinue PSA testing and be followed with exams and clinical histories. Further, this study suggests that men aged 75 to 80 years who have a PSA level < 3 ng/mL are unlikely to be diagnosed with a high-risk prostate cancer.4
The inappropriate use of antibiotics, especially overly broad spectrum antibiotics, is another area of medicine in which just saying no is a benefit to both patients and society. Two treatment areas in which this is especially problematic is urinary tract infections (UTI) and viral infections.
With regard to UTIs, unless the patient has symptoms of a bacterial UTI that would be treated, the clinician should consider not ordering tests—in this case, a urinalysis and culture. All too often, a urinalysis is done as a screen with results noting a colonization or contamination that a provider than feels obligated to treat. Instead, it would be more appropriate not to test unless true signs and symptoms of a bacterial infection exist, including having more than one or two isolated symptoms. For example, the McGeer criteria define UTIs as having at least three symptoms, including fever, burning pain on urination, flank or suprapubic pain, change in character of the urine, or worsening mental or functional status, in patients who do not have chronic indwelling catheters.5
Also of concern is the treatment of viral infections with an antibiotic because it is requested by the patient. Prescribing antibiotics for symptoms such as runny or stuffy nose, sneezing, sore throat, hoarseness, difficulty swallowing, dry cough, or swollen or tender glands, should be avoided. Patient reassurance and recommendation of supportive measures should take the place of prescribers feeling the pressure to prescribe antibiotics in these situations.
“Excessive” Care and EOL Care Discussions
Excessive care is defined not only in terms of financial excess, which can be substantial with the rise in patient out-of-pocket costs, but also in terms of excessive toxicity, which can take a toll on health outcomes as well as quality of life. Two types of therapies, antiviral therapy for hepatitis C virus (HCV) and chemotherapy for cancer, provide examples of why excessive therapy is at odds with achievement of the Triple Aim.
HCV treatment can cost over $100,000. Although newer antiviral treatments have significantly fewer side effects than traditional regimens that include interferon, they are not without their expense. Clinical practice guidelines6 strongly recommend treating all patients with chronic HCV infections except those with short life expectancies (< 12 months) that cannot be altered by treating HCV, by liver transplantation, or by other directed therapy. This would include patients whose life expectancy is shortened by other comorbid conditions such as heart failure, end-stage chronic obstructive pulmonary disease, or advanced dementia. The goal of treatment should be to reduce all-cause mortality in patients who are subject to such conditions as end-stage liver disease and hepatocellular carcinoma.
Regarding chemotherapy, when disease is diagnosed at an advanced stage, patients are less likely to benefit from aggressive care. It has been recognized that better tools are needed to identify which patients are at higher risk of early death following initiation of chemotherapy.7 This information can be used to direct appropriate discontinuation.
Much of the guidance surrounding appropriate discontinuation of chemotherapy in patients with cancer simply recommend earlier EOL care discussions. A population- and health systems–based prospective study revealed that timing of EOL care discussions strongly affects the intensity of care that patients with advanced cancer receive near the end of their lives.8 Specifically, patients who had EOL care conversations with their doctors before the last 30 days of life were much more likely to receive hospice care and less likely to undergo “aggressive” medical care compared with those that had EOL conversations later.8
The American Society of Clinical Oncology (ASCO) makes a clear distinction between patient and disease outcomes. Patient outcomes refer to the likelihood of post-treatment survival and the subsequent quality of life; disease outcomes refer to the typical treatment response rate and response duration. ASCO recommendations often falls in line with patient outcomes; if a treatment does not ultimately increase patient lifespan or quality of life, then it is not justified.9 In a study of patients with end-stage cancer, it was shown that high-functioning patients receiving chemotherapy toward the EOL demonstrated a significantly and meaningfully lower quality of life than those who did not.10 Evaluating the risks and benefits specific to each patient can determine the appropriate time to say no to therapy and, thus, can result in better outcomes.
A patient’s health objectives should drive any individualized approach to care. Consideration of these individual preferences make a difference in the quest for achieving good clinical outcomes. Patient engagement strategies can improve financial outcomes as well. The ability to adapt to new technologies—such as virtual visits or tablet technology—can affect adherence to specific care plans. In addition, literacy issues and cultural preferences may require that care models be altered to better fit the needs of individual patients. The one-size-fits-all model is not appropriate for every patient scenario. Thus, the desire for a standardized approach must be tempered by consideration of personal preferences for the benefit of the other two aspects of the Triple Aim: individualized care and cost-effectiveness.
Providers’ knowledge can be used to assess, on an individual patient basis, the benefits against the burdens to decide whether it would be better to just say no to a particular intervention, whether it be a test, a referral, or a treatment. This assistance in the saying of “no” can be of tremendous comfort to patients.
Unfortunately, clinical pathways are often solely focused on initiating and continuing therapy, typically based on population health guidelines rather than focusing on the other aspects of the Triple Aim. Balancing the Triple Aim in clinical pathways requires careful considerations of the goals and objectives of individual patients such that all three aims can be successfully achieved.
1. Stefanacci RG, Riddle A. Knowing when to just say no because we should know better. Geriatric Nursing. In Press.
2. Schonberg M. Breast cancer screening: at what age to stop? Consultant. 2010;50(5):196-205.
3. American Cancer Society. American Cancer Society recommendations for prostate cancer early detection. ACS website. http://www.cancer.org/cancer/prostatecancer/moreinformation/prostatecancerearlydetection/prostate-cancer-early-detection-acs-recommendations. Revised April 14, 2016. Accessed January 31, 2017.
4. The James Buchanan Brady Urological Institute at Johns Hopkins. When can you stop checking your PSA? Prostate Cancer Discovery. 2010;7.
5. Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: revising the McGeer Criteria. Infect Control Hosp Epidemiol. 2012;33(10): 965-977.
6. AASLD-IDSA. Recommendations for testing, managing, and treating hepatitis C. http://www.hcvguidelines.org. Updated September 16, 2016. Accessed March 1, 2017.
7. Thomas SP, Rice MA, Ho TA, et al. Evaluation of chemotherapy within last two weeks of life: patterns of care. J Clin Oncol. 2013;31(suppl):e17590.
8. For patients with advanced cancer, earlier discussion of end-of-life care options may lead to greater use of hospice and less aggressive care in the final days of life. Cancer.net. http://www.cancer.net/patients-advanced-cancer-earlier-discussion-end-life-care-options-may-lead-greater-use-hospice-and. Published November 13, 2012. Accessed January 31, 2017.
9. American Society of Clinical Oncology. Outcomes of cancer treatment for technology assessment and cancer treatment guidelines. American Society of Clinical Oncology. J Clin Oncol. 1996;14(2):671-679.
10. Prigerson HG, Bao Y, Shah MA, et al. Chemotherapy use, performance status, and quality of life at the end of life. JAMA Oncol. 2015;1(6):778-784.