Patient-centered cardiovascular care enhances outcomes

Adult cardiovascular care centered on the patient can improve individuals' experiences and their medical outcomes, according to a new American Heart Association Scientific Statement published today in Circulation.

Patient-centered care means seeing the patient as a person and being respectful of their beliefs, preferences and values. Patient-centered care combines the health care professional's expertise with consideration of the patient's health priorities. It involves empowering patients to make informed decisions by providing information and developing an active partnership among the patient, family and the health care team. Patient-centered care does not mean that patients can choose what they want, when they want."

Michael J. Goldfarb, M.D., M.Sc., chair of the scientific statement writing committee and associate professor of cardiology at the Jewish General Hospital and McGill University in Montreal, Quebec, Canada

"There is a need for health care professionals managing adults with heart disease to receive guidance and practical tools on how to incorporate a person-centered care approach into routine clinical practice," said Goldfarb.

 The new scientific statement describes several elements that are essential to patient-centered care, including shared decision-making, medication management and patient-oriented outcomes.

Shared decision-making is a collaborative partnership among patients, family and health care professionals based on trust, mutual respect and open and honest communication. Health professionals need to consider their patient's level of health literacy and provide clear, jargon-free and relevant information about risk factors, current health conditions and the realities, risks and benefits of possible screening and treatment options. Patients must have the opportunity to ask questions, express their values, preferences and goals, and work together with the medical team to agree on a plan for managing their heart disease.

Although the benefits of using medication to prevent and treat heart disease are well known, for a myriad of reasons, more than half of patients with cardiovascular disease do not always take their medications as prescribed. Conditions such as high blood pressure and high cholesterol raise the risk of heart attack and stroke, but undertreatment of these silent conditions is common.

Patient-centered discussions of current and proposed medications may also help to improve adherence to needed medications and minimize drug costs and side effects. In some cases, a combination pill may reduce the number of tablets that must be taken each day, or a less expensive but equally effective medication may be substituted for a more expensive option. An open, honest discussion about medication may also lead to the decision to eliminate a longstanding medication that may no longer be needed.

"Prior to starting, adjusting or stopping cardiovascular medications, there is a need to establish and take into account patient preferences and goals," said Goldfarb.

While physical examinations and lab tests provide important data about how a patient with heart disease is doing, patient-centered care incorporates people's own reports of their physical functioning, symptom burden, emotional well-being, social functioning and quality of life. Collecting this information gives health care professionals a more complete picture of how a patient is doing so they may detect subtle changes in the progression of heart disease and assess the impact (negative or positive) of current or proposed treatments.

"While some care outcomes are important for health care professionals and health systems, these may not always reflect what is important to the patient. For example, while the length of a hospital stay is often recorded as a marker of care quality, the patient may prioritize their physical functioning and quality of life after a heart attack," said Goldfarb.

Ensuring patient-centered care for all

The statement gives special consideration to overcoming barriers to patient-centered care and in applying patient-centered care to the people who carry an outsized burden of cardiovascular disease. For example:

• People from underrepresented and historically underserved races and ethnicities have the highest rates of cardiovascular disease and death and are often affected by adverse social determinants of health (SDOH, including measures such as economic stability, education, neighborhood safety and access to quality health care ). Effective patient-centered care may involve the use of tools to assess SDOH, followed by care provided by culturally and linguistically competent multidisciplinary teams that include social workers, interpreters and patient navigators.
• Older adults often face other complex aging-related health issues in addition to heart disease. Patient-centered care needs to consider age-associated risks (such as multiple medications, frailty, dementia, falls, social isolation) when evaluating the pros and cons of various medications and interventions.
• Women can benefit from patient-centered cardiovascular care throughout adulthood, including care to prevent and treat pregnancy-related heart issues, and care at time of menopause.
• Individuals with behavioral and mental health disorders may face psychological challenges that often impact heart health. Patient-centered care for these individuals should include behavioral health services in addition to specialized cardiovascular care.
• Adults with congenital heart disease are an increasing group of patients who, throughout their lifetimes, benefit from a patient-centered approach as they transition from pediatric into adult care and face decisions about high-level medical and surgical treatment.
• People with physical disabilities often have reduced access to health services and report worse overall health than adults without disabilities. According to the statement, the health care system should address inadequate access to preventive care and the treatment of heart disease and other chronic conditions for individuals with disabilities.

Barriers to patient-centered care

There are many barriers to incorporating patient-centered care, including those arising from patients, clinicians and health systems.

• Patients, who may distrust or lack access to the health system, have limited health literacy, limited English proficiency or cultural barriers to communicating with health care professionals, be more concerned about their caregivers and family than themselves, or hold medical beliefs and preferences that conflict with best health practices.
• Clinicians, who operate under time pressures and increasing demands for documentation, may have different incentives than patients and may also work in settings where the workforce lacks the diversity of the patients served.
• Health systems may be fragmented, provide limited access to specialty care, have limited space or inadequate systems to share information and/or lack team-based care.

"Patient-centered care is possible-;and already occurs to a certain extent-;in today's care delivery systems. Further development and inclusion of patient-centered outcomes measures will be important for optimizing care for patients, their families and caregivers," said Goldfarb.

This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association's Council of Clinical Cardiology; the Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; the Council on Lifestyle and Cardiometabolic Health; the Council on Peripheral Vascular Disease; and the Council on Quality of Care and Outcomes Research. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association's official clinical practice recommendations.