A problem with guideline based therapy and P4P

Guidelines May Fail to Meet Needs of Elderly Patients With Comorbidities

“Rewarding physicians based on what is good care for younger patients with single diseases is unrealistic,” the researcher added. “Performance incentives based on this model may penalize physicians caring thoughtfully for older patients and may impact the quality of care those patients receive.”

For their study, Dr. Boyd from Johns Hopkins University in Baltimore and her associates identified the most recently released evidence-based guidelines for hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes, osteoarthritis, chronic obstructive pulmonary disease (COPD), and osteoporosis.

They found that only guidelines for diabetes, chronic heart failure, angina, and hypercholesterolemia gave general guidance for patients with several comorbid conditions. None discussed the burden of comprehensive treatment on patients or caregivers, and only the guidelines for chronic heart failure explicitly discussed end-of-life treatment.

Dr. Boyd’s group used guidelines to develop a treatment plan for a hypothetical 79-year-old woman with osteoporosis, osteoarthritis, type 2 diabetes, hypertension, and COPD.

If all the recommendations were followed, the patient would require 12 separate medications taken as 19 doses at five times during a typical day. Without any insurance coverage for prescription drugs, that would amount to approximately $400 per month. If she were a typical Medicare patient, her costs with the new Medicare drug benefit would still add up to more than $3700 per year.

“We need to think less about individual disease and more about individual people who are living longer with multiple chronic conditions,” Dr. Boyd said. More research is needed, she added, to form “reasonable estimates of risks, benefits and burdens that are specific to them and their individual circumstances and preferences.”

Amen!

The problem with guidelines is understanding the constraints. I plan to blog more on this issue sometime this week.