Baltimore, MD - Clinical practice guidelines (CPGs) for some of the most common chronic diseases do not, for the most part, include information on the applicability of the guidelines to older adults with multiple diseases, a new analysis shows [1]. The findings carry important implications for pay-for-performance initiatives in which physicians are rewarded for adhering closely to the CPGs for one disease state, ignoring the effects of this treatment strategy on other illnesses older patients may have, researchers say.

"Much of medicine currently reflects a single-disease focus, and I think that our evidence base, and therefore our clinical practice guidelines, are drawn from that," lead author Dr Cynthia M Boyd (Johns Hopkins University, Baltimore, MD) explained to heartwire.

The study by Boyd and colleagues appears in the August 10, 2005 issue of the Journal of the American Medical Association.

The authors point out that some of the most recent statistics about Medicare beneficiaries aged 65 and older indicate that almost half have three or more chronic medical conditions, and 21% have five or more. To assess whether CPGs include recommendations for older individuals with multiple diseases, the authors reviewed the CPGs for nine of the 15 most common chronic diseases of the elderly. They found that of the nine CPGs reviewed, only four—for diabetes mellitus, osteoarthritis, atrial fibrillation, and angina—included recommendations for modifying the CPGs for older patients with and without multiple comorbidities. Seven of the nine included information about treating older patients, but not those with other major chronic diseases.

"It is evident that CPGs, designed largely by specialty-dominated committees for managing single diseases, provide clinicians little guidance about caring for older patients with multiple chronic diseases," the authors conclude. Since pay-for-performance programs are typically based on physicians meeting quality-of-care standards, which are largely based on the recommendations of CPGs, physicians aiming to provide the most compassionate care for their elderly patients may not meet the standards set by pay-for-performance initiatives, the authors note.

"Rewarding physicians based on what is good care for younger patients with single diseases is unrealistic," Boyd commented to heartwire. "I think pay-for-performance is kind of based on this model. It may have unintended consequences by not rewarding and perhaps penalizing thoughtful physicians who are caring for older patients who have several diseases, and we need to keep this in mind because design payment changes go into effect as early as 2006."

Boyd acknowledges that adding information on multiple comorbidities to each set of CPGs would be a "cumbersome" process, particularly given the sheer number of different diseases that would need to be considered in elderly patients. A better approach, she says, might be to make sure quality-of-life and risk/benefit elements are emphasized within CPGs and to stress to physicians that the guidelines are not rules, but something to be used to complement clinical judgment.

"I don't think there's a simple solution in terms of how CPGs could be changed to fix these inherent problems," Boyd acknowledged. "I think its more [an issue] that, generally in medicine, in CPGs, in the way we do research, and in the way we try to improve quality of care, we need to think less about individual diseases and more about individual people who are living longer with multiple chronic diseases."

Generally in medicine, in CPGs, in the way we do research, and in the way we try to improve quality of care, we need to think less about individual diseases and more about individual people who are living longer with multiple chronic diseases.

In an editorial accompanying Boyd et al's paper [2], Dr Patrick J O'Connor (HealthPartners Research Foundation, Minneapolis, MN) points out that despite their shortcomings, CPGs "remain an important and necessary tool." He advocates improvements to CPGs, such as recommendations that incorporate the level of evidence for particular patient groups and that take into account the economic and personal burden on the patient and caregiver. In the future, writes O'Connor, CPGs could include information on the "number needed to treat to obtain a specified benefit" and consider factors such as age, life expectancy, and comorbidities when calculating the anticipated benefits of treatment strategies.

"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," O'Connor concludes. "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."