Author Affiliations: Divisions of Geriatric
Medicine and Gerontology (Drs Boyd, C. Boult, Fried, and L. Boult) and General
Internal Medicine (Dr Wu), School of Medicine (Drs Boyd, C. Boult, Fried,
L. Boult, and Wu), and Center on Aging and Health (Drs Boyd, C. Boult, and
Fried), and Departments of Epidemiology (Dr Fried) and Health Policy and Management
(Drs Boyd, C. Boult, and Wu), Bloomberg School of Public Health (Drs Boyd,
C. Boult, Fried, and Wu), and Roger C. Lipitz Center for Integrated Health
Care (Drs Boyd and C. Boult), Johns Hopkins University, Baltimore, Md; and
Midatlantic Permanente Medical Group, Baltimore, Md (Dr Darer).
Context 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.
Objective To evaluate the applicability of CPGs to the care of older individuals
with several comorbid diseases.
Data Sources 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).
Study Selection 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.
Data Extraction 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.
Data Synthesis 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 per month) and a complicated
nonpharmacological regimen. Adverse interactions between drugs and diseases
Conclusions 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.
Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical Practice Guidelines and Quality of Care for Older Patients
With Multiple Comorbid DiseasesImplications for Pay for Performance. JAMA. 2005;294(6):716-724. doi:10.1001/jama.294.6.716