One size doesn’t fit all: Patient-centeredness leads to high-quality care

Personalizing care and using patient-centered performance measures are better suited to lead to high-benefit and appropriate care compared to one-size-fits-all guidelines, according to a viewpoint published July 10 in JAMA.

“A patient-centered performance management system would help clinicians and patients make individualized decisions about optimal care for common clinical situations, explicitly incorporate patient preferences, and reinforce such decisions through patient-centered performance measures,” wrote authors Eve A. Kerr, MD, MPH, and Rodney A. Hayward, MD, both of the VA Ann Arbor Healthcare System and the University of Michigan, Ann Arbor.

Typical guidelines, such as blood pressure targets, create an appropriateness threshold or a line between high-quality and inappropriate care, explained Kerr and Hayward. Often guidelines generally set such lines to minimize undertreatment at the cost of potentially promoting overtreatment.

In a hypothetical provided by the authors, a 48-year-old nonsmoker would like be directed to take medication if he presents with a blood pressure of 144/82 mm Hg since that doesn’t meet the guideline target of 140/90 mm Hg.

A patient-centered approach, however, would leverage the EHR to automatically calculate the patient’s 10-year risk of cardiovascular disease at 5 percent, as well as present information on benefits and adverse effects of medications. At this point, the patient and physician can decide together whether medication is the correct course of action.

“The EHR could help guide and support documentation of the patient’s goals and preferences,” wrote Kerr and Hayward. “In this way, the system not only could facilitate real-time optimal treatment but simultaneously collect performance data on the efficiency of care (frequency of provision of care with high net benefit minus care that is inappropriate or harmful) and patient-centeredness of care (documentation of patient preferences in care of modest net benefit).”

The authors outlined three broad steps necessary to distinguish high- and low-value care:

  1. Decision tools must be leveraged for common or costly scenarios.
  2. Tools must be integrated with the EHR to automatically fill-in patient-specific information.
  3. Information must be presented in a way that focuses on outcomes and facilitates improved decision making between the physician and patient.

“There are certainly challenges to achieving a patient-centered performance management system,” wrote the authors. “However, the benefits of this approach over current guideline and performance measurement approaches are great. The policy-making, health care delivery, research, and quality-improvement communities should dedicate themselves to making patient-centered performance management a reality in the foreseeable future.”