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Editor's Correspondence
June 9, 2008

The Next Frontier: Quantifying Risks for Interventions With No End in Sight

Arch Intern Med. 2008;168(11):1230-1231. doi:10.1001/archinte.168.11.1230-b

As a framework, Braithwaite et al1 offer a useful tool for quantifying risk and harm for a particular type of clinical guideline—one in which the benefit occurs subsequent to the harm. They cite colonoscopy as an example. Furthermore, they state that this condition (ie, benefit following harm) occurs often in clinical practice guidelines. This may be overstating the case. While the tool is conceptually useful (and I will use it), this type of practice recommendation probably represents a small fraction of the relevant clinical practice guideline recommendations that physicians must consider when caring for older adults with multiple chronic illnesses. For example, in the study by Boyd et al,2 a significant proportion of the recommendations for 10 of the most prevalent diseases in older adults (eg, hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis) involved long-term medication use and long-term behavioral changes.2 For these interventions, harms or burdens are continuous and may be cumulative. A knottier challenge remains: creating a decision support tool that helps physicians caring for patients with multiple chronic conditions prioritize interventions that are most beneficial and relevant within the context of these patients' lives.

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