Results of a Johns Hopkins study suggest that doctors
who follow current clinical practice guidelines when caring
for an older person with multiple conditions may yield an
overly complicated health regimen for the patient, or
potentially harmful drug interactions.
The report, published in the Aug. 10 issue of the
Journal of the American Medical Association, says
that standard guidelines designed for conditions rarely
account for older patients with several coexisting
illnesses.
"It is evident that these guidelines, designed largely
by specialty-dominated committees for managing single
diseases, provide clinicians little guidance about caring
for older patients with multiple chronic diseases," said
lead author Cynthia M. Boyd, an assistant professor of
geriatric medicine and gerontology at
Johns Hopkins Bayview
Medical Center. "While some recommend interventions for
specific pairs of diseases, they rarely give
recommendations for treating patients with three or more
chronic diseases — a group that includes half of the
population over age 65."
Clinical practice guidelines are systematically
developed recommendations designed to assist practitioners
in the prevention, diagnosis and management of specific
illnesses. When handling patients with multiple conditions,
Boyd said, physicians need to rely on their clinical
judgment and create individual treatment plans that account
for the individual circumstances and wishes of the patient
and family members who contribute to the patient's care.
Moreover, because standards for quality of care and
reimbursements to physicians who perform medical tests for
patients with chronic conditions are often based on
clinical practice guidelines, "these could create perverse
incentives that emphasize the wrong aspects of care for
this population and diminish the quality of their care,"
she said.
For the study, Boyd and colleagues determined the most
prevalent diseases in older Americans by reviewing data
from the National Health Interview Survey and a sample of
national Medicare claim forms. They then evaluated clinical
practice guidelines for nine of the 15 most common chronic
diseases: hypertension, chronic heart failure, stable
angina (chest pain), atrial fibrillation (irregular
heartbeat), high cholesterol, diabetes, arthritis, chronic
obstructive pulmonary disease and osteoporosis.
Next, they evaluated what would happen if they used
clinical practice guidelines to treat a hypothetical
79-year-old woman with moderate severity osteoporosis, type
2 diabetes, arthritis, hypertension and chronic obstructive
pulmonary disease. The researchers assembled a
comprehensive treatment plan using explicit instructions
from the assorted guidelines.
If all the recommendations were followed, the patient
would have to take 12 medications, at 19 doses per day,
five times a day. The medications would cost more than $400
a month. The combined guidelines also recommended 14
nonpharmacological activities, such as dietary
interventions, and onetime education and rehabilitation
interventions, as well as monitoring of the assorted
chronic diseases as often as daily or as infrequently as
every two years.
Boyd and colleagues found that adhering to all five
guidelines here could lead to interactions among
medications for different diseases, or between food and
medications. The nonpharmalogical recommendations also
could contradict each other, such as recommending
weight-bearing exercise for osteoporosis but recommending
avoiding weight-bearing exercise for diabetes with severe
diabetic nerve disease.
Boyd said that this degree of polypharmacy (multiple
medications) increases risk of medication errors, adverse
drug effects or potential hospitalization.
"The recommended regimens may present patients with an
unsustainable treatment burden, making independent
self-management and adherence difficult," she said.
Overall, seven of the nine guidelines under review
discussed older adults or comorbid diseases, but only four
guidelines (for diabetes, arthritis, atrial fibrillation
and angina) specifically addressed older individuals with
multiple illnesses.
Most guidelines did not comment on the time or
financial burden of comprehensive treatment on patients or
caregivers, discuss short- and long-term goals in disease
management or discuss the quality of underlying scientific
evidence for patients with multiple comorbidities. They
also did not give guidance for incorporating patient
preferences into treatment plans.
The study was supported in part by the National
Institute on Aging, Health Resources and Services
Administration and Hartford/AFAR Academic Geriatrics
Fellowship.
Co-authors were Jonathan Darer, Chad Boult, Linda P.
Fried, Lisa Boult and Albert W. Wu.
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