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Seniors With Multiple Illnesses Endangered by Lack
of Clinical Guidelines
Aug. 10, 2005 – The lack of clinical practice
guidelines written for the treatment of the growing population of senior
citizens with multiple illnesses can lead to excessive medications and
adverse interactions between drugs and diseases. This is the opinion
reported in the Journal of the American Medical Association today. 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. Yet,
CPGs are written only for single illness treatment.
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.
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.
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.
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.
“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.
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