A 42-year-old man comes to the primary care office to establish care. The patient has asthma but has not seen a physician in several years because he did not have insurance. He now has a high-deductible insurance plan offered by his new employer. The patient has been experiencing increasing shortness of breath and is using a friend's spare albuterol inhaler at least twice a day, which improves his symptoms. He has smoked 2 or 3 cigarettes several days a week for 15 years and currently is not interested in quitting. Blood pressure is 135/89 mm Hg and pulse is 77/min. Oxygen saturation is 98% on room air. BMI is 34 kg/m2. Physical examination reveals mild expiratory wheezing but is otherwise normal. The physician considers initiating various interventions to improve control of asthma. Which of the following best represents a patient-centered approach to manage this patient's asthma?
Patient-centered care | |
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Examples |
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Patient-centered care (PCC) improves outcomes by considering factors (eg, costs, beliefs) valued by patients, including factors outside the immediate clinical setting. For example, patient adherence to treatment is frequently affected by medication affordability. PCC can guide management of conditions (eg, asthma) for which available treatment options have widely divergent out-of-pocket costs by emphasizing shared decision-making, in which physicians discuss relative benefits of acceptable treatments and elicit patients' preferences in selecting therapy.
Insurance plans often require patient out-of-pocket spending (eg, co-payments, or patient's share of the cost) for prescription medications; such spending can vary significantly among various therapies (eg, generic versus brand-name drug). This patient has an insurance plan with a high deductible (ie, amount of patient spending required before insurance coverage starts), typically entailing higher patient spending on health care services. Therefore, considering out-of-pocket costs in selecting treatment is likely to reduce barriers to care, improve treatment adherence, and optimize long-term outcomes.
(Choice A) Biweekly clinic follow-up is excessive and likely to be burdensome for this patient (eg, requiring work absences, additional visit co-pays). If frequent clinical contact is desired, alternate communication modalities (eg, electronic portal, telephone follow-up) may be equally effective and more acceptable to the patient.
(Choice C) Nicotine replacement therapy is most effective when patients are motivated and interested in quitting smoking (ie, contemplative or action stage). This patient is not interested in quitting (ie, precontemplative stage); therefore, nicotine replacement is premature, does not reflect his preferences, and risks alienating him.
(Choice D) Obesity can aggravate asthma, and weight loss can facilitate better long-term control. However, this patient has increasing symptoms and his medication regimen should be optimized first.
(Choice E) Validated clinical guidelines are useful for optimizing patient management. However, many chronic conditions, including asthma, have multiple acceptable treatment strategies. In such cases, PCC emphasizes tailoring care to the specific patient situation. Medication affordability may necessitate substituting first-line treatment with an acceptable, evidence-supported alternate (eg, second-line generic medication) to optimize adherence.
Educational objective:
Patient-centered care (PCC) improves outcomes by considering factors valued by patients. Treatment adherence is frequently affected by medication affordability; PCC emphasizes shared decision-making, in which physicians consider treatment costs, discuss relative benefits of acceptable options, and elicit patients' preferences in selecting therapy.