My previous post highlighted a JAMA article concerning clinical practice guidelines when older patients have mulitple diseases. The authors have this ending paragraph:
For the present, widely used CPGs offer little guidance to clinicians caring for older patients with several chronic diseases. The use of CPGs as the basis for pay-for-performance initiatives that focus on specific treatments for single diseases may be particularly unsuited to the care of older individuals with multiple chronic diseases. Quality improvement and pay-for-performance initiatives within the Medicare system should be designed to improve the quality of care for older patients with multiple chronic diseases; a critical first step is research to define measures of the quality of care needed by this population, including care coordination, education, empowerment for self-management, and shared decision making based on the individual circumstances of older patients.
The guideline movement is important. Careful evaluation of evidence provides good summaries of how we should care for individual patients with individual diseases. However, too many patients have multiple problems. Guidelines cannot take multiple diseases into consideration, because the data use for guideline development generally comes from studies done on single disease patients.
Until we develop a reimbursement system which takes the complexity of care into true consideration, we will be cursed with polypharmacy and poor quality indicator scores. Please reread the HL Mencken quote on the left. P4P will happen. It makes for good politics. On the surface it sounds proper. We want to encourage best practices. However, the problem is in defining best practices. This article does the best job of framing the problem that I have seen.
Bravo!
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1 Response to More on the complex patient
matt
August 11th, 2005 at 8:54 pm
Today on Nat’l public radio I heard a peice about the american Bar assoc. meeting in Chicago. 10,000 attendies.
one keynote speaker was arguing for very narrow rules to replace guidelines that federal judges should use…as current guidelines for sentencing are “too variable” To often,the keynote speaker remarked, outcomes of sentences are not uniform and too many local variations including social economic class, geography, and mitigating circumstances make guidelines unequal among judges.
Of course, there was strong opposition to removing latitude for judges.
Hmmmm…. if guidelines seem to be unequally applied for well trained judges….maybe guidelines for medical doc’s will also be unequally applied.