CPGs may not be best for older patients
Comorbidities require more individualized care
Evidence-based medicine and clinical practice guidelines (CPGs) have become mantras of health care quality in the 21st century, but as a new study suggests, when it comes to older patients those guidelines should be used with extreme caution.
The report, published in the Aug. 10 issue of The Journal of the American Medical Association,1 says standard guidelines designed for conditions rarely account for older patients with several coexisting illnesses.
Data were drawn from The National Health Interview Survey and a nationally representative sample of Medicare beneficiaries (to identify the most prevalent chronic diseases in this population), as well as the National Guideline Clearinghouse (for locating evidence-based CPGs for each chronic disease).
"Most CPGs did not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities," write the researchers. "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."1
They go on to say that "basing standards for quality of care and pay for performance on existing CPGs could lead to inappropriate judgment of the care provided to older individuals with complex co-morbidities, and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care."1
"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 Cynthia M. Boyd, MD, MPH, assistant professor of geriatric medicine and gerontology at Johns Hopkins Bayview Medical Center in Baltimore and lead author of the study.
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 non-pharmacological 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.
Adhering to guidelines
The researchers further found that adhering to all five guidelines here could lead to interactions among medications for different diseases, or between food and medications.
The non-pharmacological recommendations also could contradict each other, such as recommending weight-bearing exercise for osteoporosis but recommending avoiding weight-bearing exercise for diabetics with severe diabetic nerve disease.
"The recommended regimens may present patients with an unsustainable treatment burden, making independent self-management and adherence difficult," Boyd 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.
A complex challenge
Trying to manage several chronic conditions at the same time is a complex challenge, Boyd concedes.
"The goal of practicing evidence-based medicine is growing, and appropriately so, but our project came from the realization that it is often unclear and difficult to take evidence-based practice guidelines and apply them to populations that don’t just have single diseases," she asserts. "And one-half of all adults over 65 have three or four chronic conditions."
Boyd says her team found that "the single-disease, evidence-based guideline may not apply well to older people with several diseases. It raises issues about how much you should focus on the patient population, how much the guidelines describe for older patients, and to what degree.
"We also found in the hypothetical patient that following practice guidelines for several of these individual diseases may lead to adverse conditions like being on multiple medications."
What this means, she continues, is that while these guidelines reflect the synthesis of best practices, they simply may not apply to older patients with several diseases "and may not be appropriate for developing a high quality of care for them." Clearly, she adds, this takes on greater significance as the population ages.
Developing protocols
The inference of the findings is that different protocols must be developed for elderly patients. "We talked about this a little in our paper," says Boyd.
"There is a good example of a guideline for adults with diabetes that provides recommendations on how to prioritize care," she adds.
This prioritization is critical, she says. "You must assess the risk and benefits and burdens of treatment — and these may vary depending on the person," she notes.
While future guidelines that address how to incorporate co-morbidities would be potentially more useful than those that currently exist, "we also need to train physicians to use clinical practice guidelines while incorporating these principles [of prioritization]," says Boyd.
"We may be able to address common patterns of co-morbidities, but the more obscure ones are harder, and many could be unwieldy and based on less evidence."
The best approach then, when dealing with multiple diseases, is to think about the individual circumstances of the patient, recommends Boyd.
"Engage in shared decision-making in language that patients can understand, in order to come to mutual agreement on the goals of treatment," she says.
"Learn what it is about their quality of life that is most important to them, and what risks, benefits, and burdens they are willing and able to tolerate. Then, come to a joint decision," she says.
Care coordination
Care coordination between multiple specialists also is critical, she adds.
There is an added danger, warns Boyd, that because standards for quality of care and reimbursements to physicians who perform medical tests for patients with chronic conditions often are based on clinical practice guidelines, this also can have unintended consequences with these older patients.
"Creating positive incentives is good, but we must avoid unintended perverse incentives for adults with multiple chronic diseases," she says. "We need to keep this in mind as we design changes to payment systems, or other methods of quality improvement."
Reference
- Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA 2005; 294:716-724.
Need More Information?
For more information, contact:
- Cynthia M. Boyd, MD, MPH, Assistant Professor of Geriatric Medicine and Gerontology, Johns Hopkins Bayview Medical Center, Mason F. Lord Building, 7th floor, Center Tower, 5200 Eastern Ave., Baltimore, MD 21224.
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