Patients with tumors >/= 4 cm or at least four involved nodes experience LRR rates in excess of 20% and should be offered adjuvant irradiation. Additionally, patients with one to three involved nodes and large tumors, extranodal extension >/= 2 mm, or inadequate axillary dissections experience high rates of LRR and may benefit from postmastectomy irradiation.

Background The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project requires that residency program directors objectively document that their residents achieve competence in 6 general dimensions of practice.

Health care may be burdensome and of uncertain benefit for older adults with multiple chronic conditions (MCCs). Aligning health care with an individual's health priorities may improve outcomes and reduce burden.OBJECTIVE To evaluate whether patient priorities care (PPC) is associated with a perception of more goal-directed and less burdensome care compared with usual care (UC).DESIGN, SETTING, AND PARTICIPANTS Nonrandomized clinical trial with propensity adjustment conducted at 1 PPC and 1 UC site of a Connecticut multisite primary care practice that provides care to almost 15% of the state's residents. Participants included 163 adults aged 65 years or older who had 3 or more chronic conditions cared for by 10 primary care practitioners (PCPs) trained in PPC and 203 similar patients who received UC from 7 PCPs not trained in PPC. Participant enrollment occurred between February 1, 2017, and March 31, 2018; follow-up extended for up to 9 months (ended September 30, 2018).INTERVENTIONS Patient priorities care, an approach to decision-making that includes patients' identifying their health priorities (ie, specific health outcome goals and health care preferences) and clinicians aligning their decision-making to achieve these health priorities. MAIN OUTCOMES AND MEASURES Primary outcomes included change in patients' OlderPatient Assessment of Chronic Illness Care (O-PACIC), CollaboRATE, and Treatment Burden Questionnaire (TBQ) scores; electronic health record documentation of decision-making based on patients' health priorities; medications and self-management tasks added or stopped; and diagnostic tests, referrals, and procedures ordered or avoided. RESULTSOf the 366 patients, 235 (64.2%) were female and 350 (95.6%) were white. Compared with the UC group, the PPC group was older (mean [SD] age, 74.7 [6.6] vs 77.6 [7.6] years) and had lower physical and mental health scores. At follow-up, PPC participants reported a 5-point greater decrease in TBQ score than those who received UC (ß [SE], -5.0 [2.04]; P = .01) using a weighted regression model with inverse probability of PCP assignment weights; no differences were seen in O-PACIC or CollaboRATE scores. Health priorities-based decisions were mentioned in clinical visit notes for 108 of 163 (66.3%) PPC vs 0 of 203 (0%) UC participants. Compared with UC patients, PPC patients were more likely to have medications stopped (weighted comparison, 52.0% vs 33.8%; adjusted odds ratio [AOR], 2.05; 95% CI, 1.43-2.95) and less likely to have self-management tasks (57.5% vs 62.1%; AOR, 0.59; 95% CI, 0.41-0.84) and diagnostic tests (80.8% vs 86.4%; AOR, 0.22; 95% CI, 0.12-0.40) ordered.CONCLUSIONS AND RELEVANCE This study's findings suggest that patient priorities care may be associated with reduced treatment burden and unwanted health care. Care aligned with patients' priorities may be feasible and effective for older adults with MCCs.TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03600389

Caring for older adults with multiple chronic conditions (MCCs) is challenging. The American Geriatrics Society (AGS) previously developed The AGS Guiding Principles for the Care of Older Adults With Multimorbidity using a systematic review of the literature and consensus. The objective of the current work was to translate these principles into a framework of Actions and accompanying Action Steps for decision making for clinicians who provide both primary and specialty care to older people with MCCs. A work group of geriatricians, cardiologists, and generalists: (1) articulated the core MCC Actions and the Action Steps needed to carry out the Actions; (2) provided decisional tips and communication scripts for implementing the Actions and Action Steps, using commonly encountered situations: (3) performed a scoping review to identify evidence‐based, validated tools for carrying out the MCC Actions and Action Steps; and (4) identified potential barriers to, and mitigating factors for, implementing the MCC Actions. The recommended MCC Actions include: (1) identify and communicate patients' health priorities and health trajectory; (2) stop, start, or continue care based on health priorities, potential benefit vs harm and burden, and health trajectory; and (3) align decisions and care among patients, caregivers, and other clinicians with patients' health priorities and health trajectory. The tips and scripts for carrying out these Actions are included in the full MCC Action Framework available in the supplement (http://www.geriatricscareonline.org). J Am Geriatr Soc 67:665–673, 2019.

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Older adults with multiple chronic conditions (MCCs) receive care that is fragmented and burdensome, lacks evidence, and most importantly is not focused on what matters most to them. An implementation feasibility study of Patient Priorities Care (PPC), a new approach to care that is based on health outcome goals and healthcare preferences, was conducted. This study took place at 1 primary care and 1 cardiology practice in Connecticut and involved 9 primary care providers (PCPs), 5 cardiologists, and 119 older adults with MCCs. PPC was implemented using methods based on a practice change framework and continuous plan‐do‐study‐act (PDSA) cycles. Core elements included leadership support, clinical champions, priorities facilitators, training, electronic health record (EHR) support, workflow development and continuous modification, and collaborative learning. PPC processes for clinic workflow and decision‐making were developed, and clinicians were trained. After 10 months, 119 older adults enrolled and had priorities identified; 92 (77%) returned to their PCP after priorities identification. In 56 (46%) of these visits, clinicians documented patient priorities discussions. Workflow challenges identified and solved included patient enrollment lags, EHR documentation of priorities discussions, and interprofessional communication. Time for clinicians to provide PPC remains a challenge, as does decision‐making, including clinicians' perceptions that they are already doing so; clinicians' concerns about guidelines, metrics, and unrealistic priorities; and differences between PCPs and patients and between PCPs and cardiologists about treatment decisions. PDSA cycles and continuing collaborative learning with national experts and peers are taking place to address workflow and clinical decision‐making challenges. Translating disease‐based to priorities‐aligned decision‐making appears challenging but feasible to implement in a clinical setting.

Recommendation 3.1: Population-based payment models should use outcomebased population health measures and risk adjustment systems that are designed to support population-specific and community-specific priorities for prevention and health promotion.Recommendation 3.2: If a payment model is based on measures of value that use annual measures of spending, high-value preventive services with multi-year benefits should be paid for through a separate payment mechanism or budget in order to facilitate patient access to the services, to protect against underuse of services, and to enable flexibility in the way preventive services are delivered. 7 Recommendation 6.1: A clinician or other healthcare provider who is taking accountability under an alternative payment model for improving the quality of care for a patient and for controlling the cost of the patient's care should have the flexibility to design or redesign cost-sharing requirements for the patient where necessary to enable and encourage the patient to adhere to a care plan developed through a shared decision-making process.Recommendation 6.2: Providers should be transparent about the quality of care they deliver so that patients can be assured that they are receiving high-quality care under value-based payment systems and benefit designs. Data and Analyses Needed to Develop and Implement Successful Payment ModelsRecommendation 7.1: Data on all of the important clinical and non-clinical factors that can have a significant impact on patient needs and outcomes must be accessible in order to support development and use of valid and reliable risk stratification methodologies in performance measures and alternative payment models.Recommendation 7.2: Linkages must be developed between the information in claims data, the information in electronic health records and registries, and information on patient-reported outcomes in order to provide the analyses needed to improve care and measure performance. Funding should be provided to enable Qualified Entities (which have multi-payer claims data), Qualified Clinical Data Registries (which collect clinical information relating to patient care), and Patient-8 Reported Outcome databases to link their data for specific uses that will benefit patients, payers, and providers and that incorporate appropriate protections to ensure responsible use.Recommendation 7.3: All Electronic Health Record systems should be required to support (a) the creation of custom fields and (b) data retrieval and analysis. Incentives should be created to encourage the development of infrastructure for linking data and there should be penalties for vendors that block data.Recommendation 7.4: Payers and provider organizations should be required to give clinicians access to information on the amounts payers and patients pay for services. Facilitating the Transition to Improved Payment SystemsRecommendation 8.1: Alternative payment models should be implemented using multi-year contracts and/or multi-year performance measures that allow for a shortterm peri...

The overuse of medical services is an increasingly recognized driver of poor quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. Other drivers of utilization influence this interaction and include health care system factors, the practice environment, the culture of professional medicine, the culture of health care consumption, and individual patient and clinician factors. The variable strength of evidence in support of these domains highlights important areas for further investigation.