Background/Objectives Older adults commonly face difficult decisions regarding invasive medical treatments near the end of life, including surgical procedures. There is a need for interventions that help physicians, patients and caregivers deliberate about these difficult decisions and make informed choices that reflect patients’ values and goals. Design We designed a communication tool called “Best Case/Worst Case” (BC/WC) based on an established conceptual model of shared decision making. We evaluated the tool with focus groups of seniors (4 groups) and surgeons (2 groups) using modified questions from the Decision Aid Acceptability Scale and the Decisional Conflict Scale. Setting and Participants We recruited 37 adults over age 60 from senior centers and 17 surgeons from academic and private practices in Wisconsin to participate in the study. Measurements We used qualitative content analysis to explore themes and concepts identified by focus group respondents. Results Seniors and surgeons praised the tool for the unambiguous illustration of multiple treatment options, and the clarity gained from presentation of an array of treatment outcomes. Participants noted that the tool provides both an opportunity for in-the-moment, preference-based deliberation about options and a platform for further discussion with other clinicians and loved ones. Seniors worried that the format of the tool was not universally accessible for patients with different educational backgrounds, while surgeons had concerns that the tool was vulnerable to physicians’ subjective biases. Conclusion The BC/WC tool is a novel decision support intervention that may help facilitate difficult decision making for older adults and their physicians when considering invasive, acute medical treatments such as surgery.

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Objective To explore high-stakes surgical decision making from the perspective of seniors and surgeons. Background A majority of older chronically ill patients would decline a low-risk procedure if the outcome was severe functional impairment. However, 25 percent of Medicare beneficiaries have surgery in their last three months of life, which may be inconsistent with their preferences. How patients make decisions to have surgery may contribute to this problem of unwanted care. Methods We convened four focus groups at senior centers and two groups of surgeons in Madison and Milwaukee, Wisconsin, where we showed a video about a decision regarding a choice between surgery and palliative care. We used qualitative content analysis to identify themes about communication and explanatory models for end-of-life treatment decisions. Results Seniors(N = 37) and surgeons (N = 17) agreed that maximizing quality of life should guide treatment decisions for older patients. However, when faced with an acute choice between surgery and palliative care, seniors viewed this either as a choice between life and death or a decision about how to die. Although surgeons agreed that very frail patients should not have surgery they held conflicting views about presenting treatment options. Conclusions Seniors and surgeons highly value quality of life but this notion is difficult to incorporate in acute surgical decisions. Some seniors use values to consider a choice between surgery and palliative care, while others view this as a simple choice between life and death. Surgeons acknowledge challenges framing decisions and describe a clinical momentum that promotes surgical intervention.

IMPORTANCE Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost.OBJECTIVES To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation's health and fiscal integrity.EVIDENCE REVIEW Qualitative synthesis of 19 National Academy of Medicine-commissioned white papers, with supplemental review and analysis of publicly available data and published research findings. FINDINGSThe US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation's health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities-pay for value, empower people, activate communities, and connect care-recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient-and community-focused health system. The essential infrastructure needs-measure what matters most, modernize skills, accelerate real-world evidence, and advance science-were the most commonly cited foundational elements to ensure progress. CONCLUSIONS AND RELEVANCEThe action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress.

Purpose-The purpose of this paper is to present a statement about the involvement of patients in the education of health and social care professionals developed at an international conference in November 2015. It aims to describe the current state and identify action items for the next five years. Design/methodology/approach-The paper describes how patient involvement in education has developed as a logical consequence of patient and public participation in health care and health research. It summarizes the current state of patient involvement across the continuum of education and training, including the benefits and barriers. It describes how the conference statement was developed and the outcome. Findings-The conference statement identifies nine priorities for action in the areas of policy, recognition and support, innovation, research and evaluation, and dissemination and knowledge exchange. Originality/value-The conference statement represents the first time that an international and multidisciplinary group has worked together to assemble in a single document specific priorities for action to embed the patient's voice in health professional education.