Boyd Cynthia M, Darer Jonathan, Boult Chad, Fried Linda P, Boult Lisa, Wu Albert W
Division of Geriatric Medicine, School of Medicine, Johns Hopkins University, Baltimore, Md, USA.
JAMA. 2005 Aug 10;294(6):716-24. doi: 10.1001/jama.294.6.716.
Clinical practice guidelines (CPGs) have been developed to improve the quality of health care for many chronic conditions. Pay-for-performance initiatives assess physician adherence to interventions that may reflect CPG recommendations.
To evaluate the applicability of CPGs to the care of older individuals with several comorbid diseases.
The National Health Interview Survey and a nationally representative sample of Medicare beneficiaries (to identify the most prevalent chronic diseases in this population); the National Guideline Clearinghouse (for locating evidence-based CPGs for each chronic disease).
Of the 15 most common chronic diseases, we selected hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis, which are usually managed in primary care, choosing CPGs promulgated by national and international medical organizations for each.
Two investigators independently assessed whether each CPG addressed older patients with multiple comorbid diseases, goals of treatment, interactions between recommendations, burden to patients and caregivers, patient preferences, life expectancy, and quality of life. Differences were resolved by consensus. For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated the recommendations from the relevant CPGs.
Most CPGs did not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities. Most also did not comment on burden, short- and long-term goals, and the quality of the underlying scientific evidence, nor give guidance for incorporating patient preferences into treatment plans. If the relevant CPGs were followed, the hypothetical patient would be prescribed 12 medications (costing her 406 dollars per month) and a complicated nonpharmacological regimen. Adverse interactions between drugs and diseases could result.
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.
临床实践指南（CPG）已被制定用于提高许多慢性病的医疗质量。按绩效付费举措评估医生对可能反映CPG建议的干预措施的依从性。
评估CPG对患有多种合并症的老年人护理的适用性。
国家健康访谈调查以及医疗保险受益人的全国代表性样本（以确定该人群中最常见的慢性病）；国家指南交换中心（用于查找每种慢性病基于证据的CPG）。
在15种最常见的慢性病中，我们选择了高血压、慢性心力衰竭、稳定型心绞痛、心房颤动、高胆固醇血症、糖尿病、骨关节炎、慢性阻塞性肺疾病和骨质疏松症，这些疾病通常在初级保健中进行管理，并为每种疾病选择了由国家和国际医学组织发布的CPG。
两名研究人员独立评估每个CPG是否涉及患有多种合并症的老年患者、治疗目标、建议之间的相互作用、对患者和护理人员的负担、患者偏好、预期寿命和生活质量。分歧通过协商解决。对于一名假设的患有慢性阻塞性肺疾病、2型糖尿病、骨质疏松症、高血压和骨关节炎的79岁女性，我们汇总了相关CPG的建议。
大多数CPG没有修改或讨论其对患有多种合并症的老年患者建议的适用性。大多数也没有评论负担、短期和长期目标以及基础科学证据的质量，也没有给出将患者偏好纳入治疗计划的指导。如果遵循相关的CPG，该假设患者将被开12种药物（每月花费406美元）和一个复杂的非药物治疗方案。药物与疾病之间可能产生不良相互作用。
本综述表明，在护理患有多种合并症的老年人时遵循当前的CPG可能会产生不良影响。将医疗质量标准和按绩效付费基于现有的CPG可能会导致对为患有复杂合并症的老年人提供的护理做出不恰当的判断，并可能产生错误的激励措施，强调对该人群护理的错误方面并降低他们的护理质量。制定针对患有复杂合并症的老年患者所需护理质量的衡量标准对于改善他们的护理至关重要。
