Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid Diseases

Division of Geriatric Medicine, School of Medicine, Johns Hopkins University, Baltimore, Md, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 09/2005; 294(6):716-24. DOI: 10.1001/jama.294.6.716
Source: PubMed


Clinical practice guidelines (CPGs) have been developed to improve the quality of health care for many chronic conditions. Pay-for-performance initiatives assess physician adherence to interventions that may reflect CPG recommendations.
To evaluate the applicability of CPGs to the care of older individuals with several comorbid diseases.
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 (for locating evidence-based CPGs for each chronic disease).
Of the 15 most common chronic diseases, we selected hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis, which are usually managed in primary care, choosing CPGs promulgated by national and international medical organizations for each.
Two investigators independently assessed whether each CPG addressed older patients with multiple comorbid diseases, goals of treatment, interactions between recommendations, burden to patients and caregivers, patient preferences, life expectancy, and quality of life. Differences were resolved by consensus. For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated the recommendations from the relevant CPGs.
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 dollars per month) and a complicated nonpharmacological regimen. Adverse interactions between drugs and diseases could result.
This review suggests that adhering to current CPGs in caring for an older person with several comorbidities may have undesirable effects. 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 comorbidities and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care. Developing measures of the quality of the care needed by older patients with complex comorbidities is critical to improving their care.

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Available from: Linda P Fried, Mar 08, 2015
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    • "Eventually, the higher the number of diseases (and specialists), the higher the complexity of guidelines recommended by health authorities. Boyd and colleagues have warned that 'adhering to current clinical practice guidelines in elders with several co-morbidities may have undesirable effects … lead to inappropriate judgment of the care provided, create perverse incentives … and diminish the quality of their care' [Boyd et al. 2005]. Obviously, the negative economic outcomes of IMUP are huge. "

    Therapeutic Advances in Drug Safety 11/2015; DOI:10.1177/2042098615613984
    • "c o m / l o c a t e / e j i m Please cite this article as: Ena J, et al, Management of patients with type 2 diabetes and multiple chronic conditions: A Delphi consensus of the Spanish Society of Internal..., Eur J Intern Med (2015), Clinical practice guidelines are usually focused on a single condition although some of them can provide recommendations for diabetes care in specific populations [7] [8]. Nevertheless, most clinical practice guidelines do not consider the underlying scientific evidence, the patient goals at short-and long-term, or the applicability of the recommendations for patients with multiple chronic conditions [9]. "
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    ABSTRACT: Aims: To develop consensus-based recommendations for the management of chronic complex patients with type 2 diabetes mellitus using a two round Delphi technique. Methods: Experts from the Diabetes and Obesity Working Group (DOWG) of the Spanish Society of Internal Medicine (SEMI) reviewed MEDLINE, PubMed, SCOPUS and Cochrane Library databases up to September 2014 to gather information on organization and health care management, stratification of therapeutic targets and therapeutic approach for glucose control in chronic complex patients with type 2 diabetes mellitus. A list of 6 recommendations was created and rated by a panel of 75 experts from the DOWG by email (first round) and by open discussion (second round). A written document was produced and sent back to DOWG experts for clarification purposes. Results: A high degree of consensus was achieved for all recommendations summarized as 1) there is a need to redesign and test new health care programs for chronic complex patients with type 2 diabetes mellitus; 2) therapeutic targets in patients with short life expectancy should be individualized in accordance to their personal, clinical and social characteristics; 3) patients with chronic complex conditions and type 2 diabetes mellitus should be stratified by hypoglycemia risk; 4) age and specific comorbidities should guide the objectives for glucose control; 5) the risk of hypoglycemia should be a key factor when choosing a treatment; and 6) basal insulin analogs compared to human insulin are cost-effective options. Conclusion: The assessment and recommendations provided herein represent our best professional judgment based on current data and clinical experience.
    European Journal of Internal Medicine 11/2015; DOI:10.1016/j.ejim.2015.10.015 · 2.89 Impact Factor
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    • "barrier to guideline implementation, arguing that the guidelines are simply not relevant or applicable to their typical patients, who have multiple chronic diseases [9]. If each of the guidelines was used for each of the health problems present in a patient with multimorbidity, the patient would be unable to comply with the treatment recommendations, and interactions among medications for multiple diseases might occur [10]. Therefore, the disorders that are not designated as the ''primary'' condition are often undertreated [11]. "

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