A Novel Method for Measuring Goal-Concordant Care in Seriously Ill Older Adults with Multiple Chronic Conditions

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PROJECT SUMMARY / ABSTRACT Delivering goal-concordant care is considered a key component of high-value care for seriously ill older adults with multiple chronic conditions (MCC); however, no gold standard for measurement exists. The long- term goal of the proposed work is to advance the science of quality measurement among seriously ill older adults with palliative care needs. The overall objective in this application is to develop a psychometrically valid patient-reported experience measure (PREM) that measures goal-concordant care among seriously ill older adults with MCC. The rationale is that a validated PREM measuring goal-concordant care can provide real- time feedback necessary to deliver patient-centered care that meets the dynamic needs of this population, while simultaneously functioning as a quality indicator for palliative care delivery. The proposed work will complete the overall objective through three specific aims: 1) develop an item pool that measures goal- concordant care based on domains of health-related values among seriously ill older adults with MCC; 2) evaluate measurement properties of the item pool and resultant PREM by conducting Item Response Theory analysis and test-retest reliability of field test data; and 3) determine the acceptability, feasibility, and fidelity of PREM implementation in primary care. The first aim establishes the PREM’s content validity and is a multimethod qualitative study consisting of: 1) semi-structured interviews with seriously ill older adults with MCC and their PCPs and 2) content analysis of serious illness conversation documentation in the electronic health record identified using natural language processing. Themes that emerge from this qualitative process will inform item and scale generation and refine the hierarchy of health-related value domains relevant to goal- concordant care. Items will be further developed and refined via focus groups with patients and geriatric palliative care experts to identify relevant content not already covered; cognitive interviews with patients to format the items; and item review by the study team. The second aim will establish the PREM’s reliability and construct validity and consists of field tests of seriously ill older adults with MCC followed by psychometric analyses to develop and evaluate the items comprising the PREM. Under the third aim, 40 seriously ill older adults with MCC will complete the PREM in a primary care clinic over 48 weeks in a single-arm pilot study with a multistage, mixed methods design to evaluate the acceptability, feasibility, and fidelity of PREM implementation. This proposal is innovative because it will develop the first validated PREM that measures goal-concordant care among seriously ill older adults with MCC that can also be used to measure the effectiveness of advanced care planning. This work is highly significant because this PREM transforms goal- concordant care into a measurable and actionable construct by quantifying the patient’s experience of how effectively care processes support the patient’s ability to attain self-concordant goals. Ultimately, this PREM will help establish a quality standard for palliative care delivery for seriously ill older adults with MCC.