NEJM: Goal Directed Care, an alternative?

I have a feeling that if you end any argument with these eight words, "according to the New England Journal of Medicine," you've probably won half the battle. Spice it up with a little JAMA, you're literally there. And, oh man, mention your point of view was championed in the Lancet, set it and forget it - it's in the bag.

The Perspectives section of these week's NEJM features a number of views on the relationship between clinician and patient. One article in particular, caught my attention, "Goal-Oriented Patient Care — An Alternative Health Outcomes Paradigm." The argument is that the current model of health-care views success as achieving a number of objective parameters, such as decreased blood pressure, HbA1c within acceptable ranges, overall survival. While this may be an acceptable standard to apply to relatively uncomplicated patients, it is not suitable for patients with multiple comorbidities for whom achieving such measures may come at the cost of quality of life. Rather, they contend that outcomes should be more individually tailored and should instead be measured according to individual patient's goals - such  as, in the example they provide, a man with COPD, who simply wants to walk his granddaughter down the wedding aisle. In the table below, culled from the article (I hope I am not infringing on copyright, but I thought the following basically sums up the paper), the authors provide differences between traditional disease-specific outcomes and so-called goal-oriented outcomes.

From a personal standpoint - I am all for quality of life over quantity and I am sure there are many with multiple co-morbidities who would also agree. I also loathe the idea of cookie-cutter treatment approaches hastily applied to any one patient with a particular condition or specific set of lab results. An indispensable asset of a family physician - well, any physician - is the ability to engage in shared-decision making with patients, which requires and understanding of patients' goals.* I understand that at times, such goals may conflict with evidence-based treatment algorithms constructed for Patient X with condition Y.

However, the multiple co-morbidities crowd is not a monolith and some patients - and their clinician as well - may still prefer to evaluate clinical success by traditional measures such as mortality or encouraging trends in their lipid panel.  Also one must admit that even within individual specialties, care is being taken to adjust recommended outcomes according to functional status, age, co-morbidity, etc. For example, HbA1c ranges are generally adjusted for elderly patients, owing to increased risk of hypoglycemic spells - perhaps, not anyone's goal. Another example - invasive screening recommendations are relaxed for patients with limited life expectancies (think prostate biospsies in a 96-year-old). In addition, I think medical training today emphasizes the need the approach each patient as an individual with a unique set of needs and goals. Perhaps, I am a bit sheltered, but I see goal-directed patient care as a given at my institution.

I believe that over time, the "traditional model" has made attempts, perhaps, indirectly, to account for tough quality of life issues patients may face. Again, I cannot dismiss this "Perspective," and I believe that it provides the beginnings of an interesting conversation on how we measure outcomes as we go forward in this rapidly changing health care environment. However, I am not yet convinced that goal-directed outcomes is necessarily an alternative paradigm. Also, I was unclear as to whether the writers seek to create a sort of two-tier system, in which healthy patients are evaluated by evidence-based measures, and other, more complex patients, are not provided with such an option. I think there is a place for adapting the traditional outcomes model even further to include elements of goal directed care. For example, we can include, in evaluation measures patient's perception of quality of life, patient satisfaction with health care received, etc.

*3/17/12 Addendum: Going back to the comments on the actual article, many commented that goal-directed health-care, was, in essence, the family medicine paradigm. Perhaps I have been so immersed in the Family Medicine culture, so early in my training, that I assumed that most other physicians thought similarly.

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