Clinical practice guidelines for adults with several illnesses could have undesirable effects

August 09, 2005

Current clinical practice guidelines are not written with older adults with multiple illnesses in mind, according to a study in the August 10 issue of JAMA.

The aging of the population and the increasing prevalence of chronic diseases pose challenges to the development and application of clinical practice guidelines (CPGs), according to background information in the article. In 1999, 48 percent of Medicare beneficiaries aged 65 years or older had at least 3 chronic medical conditions and 21 percent had 5 or more.

Clinical practice guidelines are based on clinical evidence and expert consensus to help decision making about treating specific diseases. Most CPGs address single diseases in accordance with modern medicine's focus on disease and pathophysiology. However, physicians who care for older adults with multiple diseases must strike a balance between following CPGs and adjusting recommendations for individual patients' circumstances. Difficulties escalate with the number of diseases the patient has. The limitations of current single-disease CPGs may be highlighted by the growth of pay-for-performance initiatives, which reward practitioners for providing specific elements of care. Because the specific elements of care may be based on single-disease CPGs, pay-for-performance may create incentives for ignoring the complexity of multiple comorbid (co-existing illnesses) chronic diseases and dissuade clinicians from providing optimal care for individuals with multiple comorbid diseases.

Cynthia M. Boyd, M.D., M.P.H., from the Center on Aging and Health, Johns Hopkins University, Baltimore, and colleagues examined how CPGs address comorbidity in older patients and explored what happens when multiple single-disease CPGs are applied to a hypothetical 79-year-old woman with 5 common chronic diseases. Selection of these diseases were based on data from the National Health Interview Survey and a nationally representative sample of Medicare beneficiaries (to identify the most prevalent chronic diseases in this population). The National Guideline Clearinghouse was used to locate evidence-based CPGs for each chronic disease. Of the 15 most common chronic diseases, the researchers focused on CPGs for hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis.

Two investigators independently assessed whether each CPG addressed older patients with comorbidities, goals of treatment, interactions between recommendations, burden to patients and caregivers, patient preferences, life expectancy, and quality of life. For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, the authors aggregated the recommendations from the relevant CPGs.

The researchers found that most CPGs did not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities. Most also did not comment on burden, short- and long-term goals, and the quality of the underlying scientific evidence, nor give guidance for incorporating patient preferences into treatment plans. If the relevant CPGs were followed, the hypothetical patient would be prescribed 12 medications (costing her $406 per month) and a complicated nonpharmacological regimen. Adverse interactions between drugs and diseases could result.

"For the present, widely used CPGs offer little guidance to clinicians caring for older patients with several chronic diseases. The use of CPGs as the basis for pay-for-performance initiatives that focus on specific treatments for single diseases may be particularly unsuited to the care of older individuals with multiple chronic diseases. Quality improvement and pay-for-performance initiatives within the Medicare system should be designed to improve the quality of care for older patients with multiple chronic diseases; a critical first step is research to define measures of the quality of care needed by this population, including care coordination, education, empowerment for self-management, and shared decision making based on the individual circumstances of older patients," the authors conclude.
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(JAMA. 2005; 294:716-724. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: For funding/support information, please see the JAMA article.

Editorial: Adding Value to Evidence-Based Clinical Guidelines

In an accompanying editorial, Patrick J. O'Connor, M.D., M.P.H., of the HealthPartners Research Foundation, Minneapolis, comments on the study by Boyd et al.

"Despite their limitations, evidence-based CPGs remain an important and necessary tool in the effort to improve health care quality. Strategies to address the limitations of current CPGs need to be developed and implemented, including providing recommendations based on level of evidence for particular patient groups and considering the potential economic and personal burden on the patient and caregiver as well as potential interactions with comorbid conditions. Future CPGs could be improved by including explicit information such as the number needed to treat to obtain a specified benefit, and should also be crafted more systematically to consider the influence of patient-specific factors such as age, life expectancy, and comorbidity on anticipated benefits of interventions. In addition, CPGs could include information on cost of various potential therapies, which may influence patient preferences and patient adherence to therapeutic regimens. Such modifications will increase the value of CPGs to clinicians and patients at the point of care, especially when physicians have too much to do [in a given office visit]."

"Encouraging customization of care in complex clinical scenarios respects the individuality of patients and the professional judgment of highly skilled physicians and minimizes the problem of overtreating patients most susceptible to drug interactions, drug adverse effects, and medical error. Boyd and colleagues have presented these important 'in the trenches' issues in a clear and compelling way. Physicians and designers of CPGs owe it to themselves and their patients to consider these issues carefully and to craft CPGs and pay-for-performance accountability measures that will reinforce excellent clinical care while being mindful of resource use and being respectful of patient preferences and priorities," Dr. O'Connor concludes.

(JAMA. 2005; 294:741-743. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: For funding/support information, please see the JAMA editorial.
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