Using single, disease-specific clinical practice guidelines for older patients with multiple chronic conditions can have dangerous consequences, according to a report in the Aug. 10 issue of the Journal of the American Medical Association.
Forty-eight percent of Medicare beneficiaries over 65 have at least three chronic medical conditions, and about one-fifth of those patients have five or more conditions. But most guidelines address only one condition.
Johns Hopkins University researchers created a hypothetical 79-year-old woman suffering from five common conditions -- diabetes, hypertension, obstructive pulmonary disease, osteoarthritis and osteoporosis -- and then developed a treatment regimen using federal guidelines.
The result: 12 medications costing about $400 per month and the potential for adverse interactions. The conflicts occurred with drugs and other treatment recommendations, such as weight-bearing exercise for treating osteoporosis but not for diabetes.
As some guidelines run hundreds of pages, it's difficult for doctors confronted with multiple conditions to sort out the best treatment options for their patients, said study co-author Cynthia Boyd, an assistant professor of medicine at Johns Hopkins. (See Modern Healthcare's special report on disease management, Aug. 8, p. 26.)
"It is very challenging to synthesize all these guidelines into one regimen, and what you get is a regimen that's very complex," Boyd said. "I hope this draws attention to a patient population that, while very prevalent, is under-recognized in terms of their healthcare needs. I think that we need more research to do optimal quality of care for this population.
"You want to see the whole patient," she said. "They may have several different diseases, but they are one patient."
The authors warned against using disease-specific guidelines as a measure of quality in pay-for-performance programs, partly because the guidelines alone are inadequate for determining treatment of the large population of patients with multiple conditions.
Paul Keckley, executive director at the Center for Evidence-based Medicine at Vanderbilt University, said Medicare pay-for-performance programs focus on fairly simple conditions, such as hip replacements and community-acquired pneumonia, where there is strong evidence about the best care3/4for example, giving a patient an antibiotic within four hours of hospitalization for pneumonia.
"There's a heck of a lot of data that suggests this is the right thing to do," Keckley said.
Yank Coble Jr., president of the World Medical Association and past president of the AMA, noted that guidelines reflect accumulated helpful knowledge. "The guidelines are never perfect, but it's constantly emphasized that guidelines are tools, not rules," Coble said, adding that the researchers' report "demonstrates the importance of knowing your patients well."
