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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    • "Few clinical guidelines even acknowledge the role that co-occurring conditions play in forming treatment recommendations possibly because methods have not been developed to assist in this critical area. In their investigation of the guidelines of national specialty organizations, Boyd and coworkers found few instances in which authors discussed how treatment of the index disease might be modified by the presence of co-existing diseases [1]. Given the ever expanding availability of treatments designed to treat persons with MCC, it is imperative that we have methods that allow us to understand how treating the disease of interest might be related to the presence of co-existing diseases. "

    Full-text · Article · Jan 2016
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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. "
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    ABSTRACT: The positive benefit–risk ratio of most drugs is decreasing in correlation to very old age, the extent of comorbidity, dementia, frailty and limited life expectancy (VOCODFLEX). First, we review the extent of inappropriate medication use and polypharmacy (IMUP) globally and highlight its negative medical, nursing, social and economic consequences. Second, we expose the main clinical/practical and perceptual obstacles that combine to create the negative vicious circle that eventually makes us feel frustrated and hopeless in treating VOCODFLEX in general, and in our ‘war against IMUP’ in particular. Third, we summarize the main international approaches/methods suggested and tried in different countries in an attempt to improve the ominous clinical and economic outcomes of IMUP; these include a variety of clinical, pharmacological, computer-assisted and educational programs. Lastly, we suggest a new comprehensive perception for providing good medical practice to VOCODFLEX in the 21st century. This includes new principles for research, education and clinical practice guidelines completely different from the ‘single disease model’ research and clinical rules we were raised upon and somehow ‘fanatically’ adopted in the 20th century. This new perception, based on palliative, geriatric and ethical principle, may provide fresh tools for treating VOCODFLEX in general and reducing IMUP in particular. Keywords: Inappropriate-Medication-Use, Polypharmacy, IGRIMUP, Comorbidity, Dementia, Frailty, Geriatric-Palliative, Limited Life-expectancy
    Full-text · Article · Dec 2015 · Therapeutic Advances in Drug Safety
    • "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.
    No preview · Article · Nov 2015 · European Journal of Internal Medicine
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