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January 4, 2006

Clinical Practice Guidelines for Older Patients With Comorbid Diseases

JAMA. 2006;295(1):33-35. doi:10.1001/jama.295.1.33-b

To the Editor: Dr Boyd and colleagues1 point to the dangers of slavishly following CPGs in patients with multiple comorbid diseases. They express particular concern that pay-for-performance schemes may lead to inappropriate clinical practice.

These problems are not insuperable. A major pay-for-performance scheme currently makes up 25% of the pay of primary care physicians in the United Kingdom.2 However, when it comes to the clinical performance indicators, physicians can choose to exclude patients from any of the clinical indicators when calculating their performance. This can be done for a range of reasons such as a patient has another condition that makes treatment inappropriate, a patient does not wish to have his or her condition treated, or a patient has not responded to written requests to have his or her condition reviewed. In this way, the indicators are designed to distort clinical practice as little as possible because the physician can effectively say that a particular indicator does not apply to his or her patient. This is the type of flexible implementation of CPGs that Dr O’Connor calls for in his accompanying editorial.3 As a check, in the UK system, a physician's practice is subject to an annual inspection, and those physicians who exclude large numbers of patients are open to having their judgments questioned.

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