Clinical practice guidelines may not apply to older patients with several chronic illnesses

August 09, 2005

Results of a Johns Hopkins study suggests that doctors who follow current clinical practice guidelines when caring for an older person with multiple conditions may yield an overly complicated health regimen for the patient, or potentially harmful drug interactions.

The report, published in the Aug. 10 issue of The Journal of the American Medical Association, says standard guidelines designed for conditions rarely account for older patients with several coexisting illnesses.

"It is evident that these guidelines, designed largely by specialty-dominated committees for managing single diseases, provide clinicians little guidance about caring for older patients with multiple chronic diseases," says lead author Cynthia M. Boyd, M.D., M.P.H., an assistant professor of geriatric medicine and gerontology at Johns Hopkins Bayview Medical Center. "While some recommend interventions for specific pairs of diseases, they rarely give recommendations for treating patients with three or more chronic diseases --- a group that includes half of the population over age 65."

Clinical practice guidelines are systematically developed recommendations designed to assist practitioners in the prevention, diagnosis and management of specific illnesses. When handling patients with multiple conditions, physicians need to rely on their clinical judgment and create individual treatment plans that account for the individual circumstances and wishes of the patient and family members who contribute to the patient's care, says Boyd.

Moreover, because standards for quality of care and reimbursements to physicians who perform medical tests for patients with chronic conditions are often based on clinical practice guidelines, "these could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care," Boyd adds.

For the study, Boyd and colleagues determined the most prevalent diseases in older Americans by reviewing data from the National Health Interview Survey and a sample of national Medicare claim forms. They then evaluated clinical practice guidelines for nine of the 15 most common chronic diseases: hypertension, chronic heart failure, stable angina (chest pain), atrial fibrillation (irregular heartbeat), high cholesterol, diabetes, arthritis, chronic obstructive pulmonary disease and osteoporosis.

Next, they evaluated what would happen if they used clinical practice guidelines to treat a hypothetical 79-year-old woman with moderate severity osteoporosis, type 2 diabetes, arthritis, hypertension and chronic obstructive pulmonary disease. The researchers assembled a comprehensive treatment plan using explicit instructions from the assorted guidelines.

If all of the recommendations were followed, the patient would have to take 12 medications, at 19 doses per day, five times a day. The medications would cost more than $400 a month. The combined guidelines also recommended 14 nonpharmacological activities, such as dietary interventions, and one-time education and rehabilitation interventions, as well as monitoring of the assorted chronic diseases as often as daily or as infrequently as every two years.

Boyd and colleagues found that adhering to all five guidelines here could lead to interactions among medications for different diseases, or between food and medications. The nonpharmalogical recommendations also could contradict each other, such as recommending weight-bearing exercise for osteoporosis but recommending avoiding weight-bearing exercise for diabetes with severe diabetic nerve disease.

Boyd says that this degree of polypharmacy (multiple medications) increases risk of medication errors, adverse drug effects or potential hospitalization.

"The recommended regimens may present patients with an unsustainable treatment burden, making independent self-management and adherence difficult," she says.

Overall, seven of the nine guidelines under review discussed older adults or comorbid diseases, but only four guidelines (for diabetes, arthritis, atrial fibrillation and angina) specifically addressed older individuals with multiple illnesses.

Most guidelines did not comment on the time or financial burden of comprehensive treatment on patients or caregivers, discuss short- and long-term goals in disease management, or discuss the quality of underlying scientific evidence for patients with multiple comorbidities. They also did not give guidance for incorporating patient preferences into treatment plans.

The study was supported in part by the National Institute on Aging and the Health Resources and Services Administration and the Hartford/AFAR Academic Geriatrics Fellowship.

Coauthors were Jonathan Darer, M.D., M.P.H.; Chad Boult, M.D., M.P.H., M.B.A.; Linda P. Fried, M.D., M.P.H.; Lisa Boult, M.D., M.P.H., M.A.; and Albert W. Wu, M.D., M.P.H.
Boyd, Cynthia M. et al, "Clinical Practice Guidelines and Quality of Care for Older Patients with Multiple Comorbid Diseases: Implications for Pay for Performance," Journal of the American Medical Association, August 10, 2005, Vol. 294, No. 6, pages 716-724.

Johns Hopkins Medicine

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