We strongly agree that creating a decision support tool is important to help physicians prioritize interventions when caring for patients with multiple chronic conditions. Indeed, we have a parallel stream of ongoing work directly aligned with this goal.1 We view prioritization as complementary to the payoff time framework, however, rather than as a substitute for assessing individual guidelines. Many guidelines, particularly involving cancer screening, involve downstream benefits but up-front harms (eg, from the tests themselves, and from the management of false-positive results), yet the guidelines are frequently applied to patients with substantial comorbidity. The payoff time approach can be used to deemphasize these recommendations, when appropriate, and the remaining guidelines could be prioritized using a systematic approach based on magnitude of benefit.
Braithwaite B, Chang CC, Roberts MS. The Next Frontier: Quantifying Risks for Interventions With No End in Sight—Reply. Arch Intern Med. 2008;168(11):1230-1231. doi:10.1001/archinte.168.11.1231