How can clinical plans be improved to reduce morbidity and mortality?

Improving Clinical Plans to Reduce Morbidity and Mortality

Implement collaborative care planning with structured action plans and team-based care models, as these interventions have demonstrated reduced mortality and hospitalizations in patients with chronic conditions.

Core Framework: Collaborative Care Planning

Collaborative care planning—where health professionals, patients, caregivers, and families jointly develop management strategies—should be the foundation of clinical plans. 1 This approach moves beyond simple shared decision-making to create ongoing partnerships that empower patients to manage chronic disease. 1

Structured Action Plans Reduce Mortality

• Written action plans provided after visits or upon discharge improve recognition of disease exacerbations, initiate appropriate therapy, and reduce combined mortality or hospitalizations. 1 This has been specifically demonstrated in heart failure populations. 1

• Action plans must include specific instructions for patients to follow, not vague recommendations. 1

• Goals-of-care documentation should occur within 48 hours of admission using structured note templates, as this approach has shown 97% completion rates and facilitates real-time medical decisions aligned with patient values. 2

Team-Based Care Models That Reduce Mortality

The American College of Cardiology identifies three evidence-based approaches that reduce all-cause mortality: 1

1. Multidisciplinary interventions bridging hospital admission to discharge (to home or transitional care) - demonstrated reduced heart failure admissions in randomized controlled trials 1

2. Case management with telephone follow-up and home visitations after discharge - tends to reduce all-cause mortality and heart failure admissions 1

3. Specialty clinic follow-up - though evidence for this approach alone is limited 1

Interprofessional collaboration improves healthcare processes and outcomes, though benefits are promising but not yet definitively proven. 1

Mutual Goal-Setting: Essential for Adherence

Long-term management of chronic conditions requires mutual goal-setting between clinicians and patients, as recommendations incongruent with patients' values, goals, and culture will not be followed. 1

• Collaborative goal-setting interventions increase self-care behaviors and reduce distress among persons with cardiovascular conditions. 1

• The CHANGE intervention demonstrated that patients in usual care were 76% more likely to stop exercising compared to those receiving collaborative goal-setting (hazard ratio 1.76; 95% CI 1.08-2.86, p=0.02). 1

• Patients with chronic conditions set ambitious goals when given structured support: mean goal weight loss of -16.8 lbs, HbA1C reduction of -1.3%, and blood pressure reduction of -9.8 mmHg. 3

Addressing Therapeutic Inertia

Therapeutic inertia—the failure to initiate or intensify therapy when treatment goals are not met—is a major barrier to reducing mortality. 1

Evidence of the Problem

• Antihypertensive therapy is intensified at only 13% of visits with uncontrolled blood pressure. 1

• Patients with the lowest rates of therapeutic inertia are 33 times more likely to achieve blood pressure control compared to those with highest inertia rates. 1

• One-third of patients with established atherosclerotic cardiovascular disease are not receiving statin therapy at 14-month follow-up. 1

Solutions to Therapeutic Inertia

The American College of Cardiology recommends three strategies: 1

1. Clinician and patient education - including clinician-patient discussion of net clinical benefit, decision support at point-of-care, and guideline-based algorithmic approaches to treatment 1

2. Team-based care - placing the patient at the center of the care team and empowering patients through shared decision-making 1

3. Systems approaches - real-time audit and feedback, system-wide quality improvement, and use of implementation science principles 1

Guideline Adherence Directly Correlates with Mortality

Every 10% increment in clinical practice guideline adherence is associated with a 10% reduction in hospital mortality. 1 This relationship has been demonstrated across acute coronary syndrome populations. 1

• Evidence-based therapies initiated before hospital discharge are associated with incremental survival advantage in follow-up. 1

• Combination evidence-based therapies reduce mortality to 1 year following myocardial infarction independent of renal function. 1

Quality Improvement Infrastructure

The American Diabetes Association recommends health systems: 1

• Facilitate team-based care including those knowledgeable in disease management 1

• Utilize patient registries, decision support tools, and proactive care planning 1

• Adopt a culture of quality improvement, implement benchmarking programs, and engage interprofessional teams to support sustainable process changes 1

• Assess management using reliable data metrics to improve processes of care and health outcomes, with attention to care costs, individual preferences, and treatment burden 1

Self-Management Systems

Easy-to-use and inexpensive self-management systems must be readily available to patients, with reporting mechanisms to provide patient-collected data back to clinicians. 1 This enables the healthcare team, including the patient, to conduct appropriate collaborative care planning and goal-setting. 1

Managing Non-Compliance in High-Risk Patients

When patients are non-compliant and at high mortality risk: 4

• Document all instances of non-compliance in the medical record, including specific discussions about mortality risks 4

• Implement a non-judgmental approach rather than confrontational methods 4

• Consider having the patient sign an "informed refusal" document acknowledging understanding of risks 4

• Provide continuous education about disease, treatment goals, and consequences of non-adherence 4

• Simplify treatment regimens when possible to improve adherence 4

• Consider directly observed therapy for high-risk patients when feasible 4

Critical Pitfalls to Avoid

• Do not assume treatment ineffectiveness when the real issue may be non-compliance. 4 Physicians frequently overestimate patient compliance and misinterpret treatment failures. 4

• Do not rely solely on patient self-reporting of compliance, as this is often inaccurate. 4

• Avoid confrontational approaches, which damage the doctor-patient relationship and further reduce compliance. 4

• Do not delay goals-of-care conversations until late in illness, as this reduces their impact on care processes. 5 Early discussions are associated with better quality of life, reduced use of nonbeneficial care, and reduced costs. 5