Some Elderly Not Helped by Guidelines

Generally accepted clinical practice guidelines (CPGs) offer little help to physicians who are treating elderly patients with multiple chronic conditions, according to a recent study in the Journal of the American Medical Association.

In terms of medication dosage, for instance, following the CPGs for a hypothetical 79-year-old woman with nine chronic diseases could get downright confusing.

The patient would have to take 12 separate medications. "This regimen requires 19 doses per day, taken at five times during a typical day...."

An editorial in the same issue of JAMA (Aug. 10) says that, "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."

The study — "Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid Diseases" — looks at how following the CPGs for nine conditions would, in the case of that hypothetical 79-year-old woman, play out.

The "patient" has hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis.

"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 study says. About half of people over 65 have three or more chronic diseases.

The JAMA editorial states that CPGs should take into account individual factors such as age.

"This is especially important for frail elderly patients with multiple chronic conditions, who may be unable or unwilling to tolerate, afford, or adhere to a large number of pharmacological and lifestyle interventions over long periods," the editorial says.

One problem doctors face is the proliferation of CPGs over the years.

"The National Guideline Clearinghouse ... listed about 650 CPGs in 1999 and more than 1,650 active CPGs in July 2005," the JAMA editorial notes.

The inability of CPGs to help manage elderly patients with multiple chronic conditions may be exacerbated by pay-for-performance initiatives.

The study states, "Because the specific elements of care are based on single-disease CPGs, pay-for-performance may create incentives for ignoring the complexity of multiple comorbid chronic diseases and dissuade clinicians from caring for individuals with multiple comorbid diseases."

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