Expert panels write guidelines for single diseases. These panels rarely consider the problem of multiple diseases.
Any generalist will tell you that multiple conditions make guideline interpretation much more difficult. Dr. Cynthia Boyd and colleagues make this point in a classic JAMA article – Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid Diseases
This review suggests that adhering to current CPGs in caring for an older person with several comorbidities may have undesirable effects. Basing standards for quality of care and pay for performance on existing CPGs could lead to inappropriate judgment of the care provided to older individuals with complex comorbidities and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care. Developing measures of the quality of the care needed by older patients with complex comorbidities is critical to improving their care.
Part of reinventing the guideline movement includes an explicit consideration of multiple diagnoses. I suspect that we need suggestions on how to prioritize. I doubt that having a patient take 10 or more medications (all recommended by guidelines) is often a good idea. As we increase the number of medications, we increase the probability of drug interactions and medication side effects.
As currently constructed, guidelines assume standard management for each disease. Commonly patients have 4, 5 or more significant diseases. I believe that we should treat patients rather than diseases. Until we reinvent guidelines, generalists are too often criticized for their care of diseases rather than patients.
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2 Responses to Guidelines III
Dr. Smak
September 11th, 2007 at 7:52 pm
I’ve enjoyed this series.
The Pay For Performance push with tracking of compliance with guidelines is only slightly less troubling than the issues of patient safety that you outlined.
Pay for Performance and Covert Rationing (1) : The Covert Rationing Blog
January 23rd, 2009 at 12:22 pm
[...] as any objective observer can tell you, care guidelines themselves are inherently problematic. (DB’s Medical Rants has an enlightening series of posts describing how this is so.) The scientific evidence used to [...]