For Doctors in a Hurry
- Clinicians often struggle to ensure that medical care aligns with the specific goals of patients with serious cardiopulmonary disease.
- The researchers conducted a randomized clinical trial involving 306 participants to evaluate a nurse and social worker palliative telecare intervention.
- The intervention showed no significant difference in goal concordance compared to usual care, with an adjusted difference of 4.2%, p=0.67.
- The authors concluded that this specific telecare model did not improve goal concordance or reduce uncertainty regarding care focus.
- Future efforts should explore alternative strategies to better align clinical care with the stated preferences of high-risk patients.
The Challenge of Aligning Care with Patient Goals in Chronic Disease
Managing advanced cardiopulmonary disease requires balancing life-prolonging interventions with symptom-focused palliative care to maintain patient quality of life [1, 2]. While telemedicine and mobile health platforms have improved psychological symptoms and functional capacity, their ability to facilitate complex shared decision-making remains less certain [3, 4]. Ensuring goal-concordant care, a clinical state where the medical treatment provided aligns with the patient’s stated priorities, is a central objective of modern palliative medicine [5, 6]. However, clinicians frequently encounter barriers such as patient uncertainty and fragmented communication that complicate the delivery of integrated care [7, 8]. The Advancing Symptom Alleviation with Palliative Treatment (ADAPT) trial evaluated a nurse and social worker telecare team among 306 predominantly male veterans (mean age 68.9 years) with heart failure or chronic obstructive pulmonary disease [5]. Although the intervention improved quality of life and reduced depression, it did not significantly influence goal concordance (p = 0.67) or the proportion of participants unsure of their care focus (p = 0.42) [5, 2].
The ADAPT Telecare Intervention Model
The Advancing Symptom Alleviation with Palliative Treatment (ADAPT) trial was a randomized clinical trial designed to determine if a structured telecare team could bridge the gap between patient preferences and clinical reality. The study enrolled 306 participants from two Veterans Affairs (VA) health systems, specifically targeting individuals with cardiopulmonary disease who reported a poor quality of life. This cohort was predominantly male (90.2%) and white (80.1%), with a mean age of 68.9 years (standard deviation: 7.7 years). These demographics reflect a high-risk population of older veterans managing chronic, life-limiting respiratory and cardiac conditions, where the transition from curative to palliative intent is often medically complex. The intervention utilized a study nurse and a social worker to conduct serious illness conversations via telephone, a delivery method intended to overcome the geographical and mobility barriers that frequently prevent this patient population from accessing specialty palliative services.
By facilitating these discussions remotely, the researchers aimed to improve goal concordance, which is the clinical state where a patient’s treatment preferences align with the actual focus of their medical care. For a practicing physician, achieving goal concordance is the gold standard for ethical and effective chronic disease management, as it ensures that aggressive interventions are not forced upon patients who prioritize comfort. The trial also sought to reduce the proportion of patients who were unsure of their care focus. This ambiguity is a common challenge in advanced cardiopulmonary disease, where the clinical trajectory is often unpredictable, and patients may not fully grasp whether their current regimen is intended to extend life or simply alleviate symptoms.
Quantifying Goal Concordance and Patient Uncertainty
To evaluate the efficacy of the ADAPT intervention, the researchers utilized a standardized assessment of treatment alignment based on two questions modified from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) study. This landmark investigation provides the framework for understanding how clinical decisions are made in the face of life-limiting illness. Patients were asked to quantify their treatment preferences on a Likert scale (a psychometric tool used to measure the intensity of a respondent's feelings or attitudes) ranging from 0 to 10. On this specific scale, a score of 0 indicated a preference for medical care focused on extending life, while a score of 10 represented a preference for care focused on relieving pain and discomfort. This numerical approach allows clinicians to move beyond vague qualitative statements and pinpoint a patient's exact position on the spectrum of care.
The study's primary endpoint relied on the internal consistency of patient responses regarding their desires and their perceptions of current treatment. Goal concordance was defined as participants reporting the same preference and perceived focus of care, indicating that the patient believed their clinical management was actively reflecting their personal priorities. Furthermore, the researchers accounted for cognitive or communicative barriers in care planning by allowing a specific response for ambiguity. Participants could choose 'I am unsure' when asked about the focus of their current medical care, a metric designed to capture the prevalence of patient uncertainty regarding the trajectory of their cardiopulmonary treatment. For the clinician, this 'unsure' metric is a vital indicator of a breakdown in communication or a lack of health literacy regarding the patient's own prognosis.
Statistical Outcomes and Clinical Implications
To evaluate the longitudinal impact of the ADAPT intervention, the researchers utilized linear mixed modeling (a statistical method used to analyze data collected over time while accounting for both fixed effects, like the intervention itself, and random effects, such as individual patient variability). This analysis examined changes in the proportions of concordant and unsure participants from baseline to the six month follow up. Despite the structured nature of the nurse and social worker led phone calls, the study found that the intervention did not significantly improve the alignment between patient preferences and their perceived care. Specifically, there was no difference in the change in proportions of concordant participants in the intervention group compared to usual care, with an adjusted difference in the change of proportions of only 4.2% (p = 0.67).
The study also assessed whether these telecare conversations could reduce patient ambiguity regarding their medical management. The results indicated that the intervention was similarly ineffective in reducing patient confusion. There was no difference in the change in proportions of unsure participants between the study arms, showing an adjusted difference in the change of proportions of 6.2% (p = 0.42). These data lead to the conclusion that the intervention did not influence goal concordance or the proportion of participants unsure of care focus. For clinicians managing high risk cardiopulmonary disease, these findings suggest that telephone based palliative conversations, as structured in this trial, may not be sufficient to shift treatment focus or clarify care goals. This indicates that more intensive, perhaps in-person or multi-modal interventions, may be required to truly align clinical care with the complex values of patients facing chronic organ failure.
References
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2. Sali SR, Ampeti S, Srivastava M, Sheikh RB, Kirankumar PN. Telemedicine in Chronic Cardiopulmonary and Cardiovascular Diseases: A Comprehensive Review. 2025. doi:10.63096/medtigo30922310
3. Ajmera P, Miraj M, Kalra S, et al. Impact of telehealth interventions on physiological and psychological outcomes in breast cancer survivors: A meta-analysis of randomised controlled trials. Frontiers in Oncology. 2023. doi:10.3389/fonc.2022.1017343
4. Zhang Y, Leuk JS, Teo W. Domains, Feasibility, Effectiveness, Cost, and Acceptability of Telehealth in Aging Care: Scoping Review of Systematic Reviews. JMIR Aging. 2023. doi:10.2196/40460
5. Lange AV, Hess E, Barón AE, et al. Goal Concordance in the Advancing Symptom Alleviation with Palliative Treatment Clinical Trial of a Nurse and Social Worker Palliative Telecare Team Intervention.. Journal of palliative medicine. 2026. doi:10.1177/10966218261444977
6. Bauer EH, Schultz ANØ, Brandt F, Smith AC, Bollig G, Dieperink KB. Patient and families’ perspectives on telepalliative care: A systematic integrative review. Palliative Medicine. 2023. doi:10.1177/02692163231217146
7. Lindberg B, Nilsson C, Zotterman D, Söderberg S, Skär L. Using Information and Communication Technology in Home Care for Communication between Patients, Family Members, and Healthcare Professionals: A Systematic Review. International Journal of Telemedicine and Applications. 2013. doi:10.1155/2013/461829
8. Volpato E, Farver-Vestergaard I, Brighton LJ, et al. Nonpharmacological management of psychological distress in people with COPD. European Respiratory Review. 2023. doi:10.1183/16000617.0170-2022
