Evidence based goal-setting for patients with multiple chronic conditions

The Patient Matrix supports the implementation of evidence-based clinical guidelines for MACS patients.The database allows clinicians to record patient comorbidities, medications and other relevant information, and facilitates the generation of clinic letters and health goals.

Evidence-based goals

For each of the most common chronic conditions seen in the MACS population, relevant Australian clinical guidelines were sourced via the NHMRC guidelines portal. These were used to generate a set of clinically relevant core goals for the MACS clinic, to form the minimum standard of treatment for the management of each condition. These included recommended goals for: 

  • diet
  • lifestyle
  • self-monitoring
  • exercise 
  • medications
  • diagnostic tests
  • devices and other areas. 

The number of core goals varied depending on the chronic condition.

Goal reconciliation for multiple chronic conditions

Where different conditions had different recommendations about the same goal area, guidelines were compared and reconciled. In many cases the recommendations were similar but phrased differently, and in others there were different levels of intensity for different conditions, such as a recommendation to increase regular exercise in ischemic stroke, to undertake regular walking in peripheral vascular disease, and referral to a dedicated exercise program in chronic heart failure. 

Where the recommendations were contradictory, such as increased protein intake for patients with chronic obstructive airways disease, but decreased protein intake in patients with chronic renal failure, these required reconciliation by an expert clinician. The specialists working in the clinic agreed to the reconciled recommendations, for which a computerised algorithm was written for the database.

Goals in the patient matrix

The clinic database generates core goals using the following algorithm: where no conflicts in recommendations exist between conditions, it presents all of the recommendations for all conditions. If an ordinal level of intensity for a particular domain exists across conditions, the most intensive recommendation is presented. Where recommendations conflict, the system highlights the conflict and clarifies the disagreement.

Goal modification

The algorithm sets default targets for each goal, but these targets can be modified according to individual patient needs. The algorithm also assigns default responsibility for each goal to a clinician, such that specific members of the multidisciplinary team action different goals (eg nursing staff for heart failure education, doctors for medication titration, pharmacists for medication review). The goals are reviewed by the patient and physician together, and tailored to meet individual needs. Where appropriate, the physician will assign specific goals to other members of the multidisciplinary team or to the patient’s General Practitioner (GP).

The database also supports consultation with the patient’s GP about the appropriateness of goals, and the role they want to take in achieving them, to make the process of role delineation transparent. The database enables the tracking of goal progress, to evaluate how effectively the clinical guidelines are being addressed for each patient.

Goal resources

Resources are presented for each goal where possible, to reduce barriers for the implementation of the recommendation. 

For example, for the recommendation to increase walking where the patient has ischemic heart disease, the resource presented is a link to the Heart Foundation Walking resources. If the patient has chronic heart failure, the resource is the referral form for exercise physiology (supporting referral to an exercise program).