SPECIAL COMMUNICATION Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid Diseases Implications for Pay for Performance Cynthia M. Boyd, MD, MPH Jonathan Darer, MD, MPH Chad Boult, MD, MPH, MBA Linda P. Fried, MD, MPH Lisa Boult, MD, MPH, MA Albert W. Wu, MD, MPH Tlenges HE AGING OF THE POPULATION and the increasing prevalence of chronic diseases pose chal- to the development and application of clinical practice guide- lines (CPGs). In 1999, 48% of Medi- care beneficiaries aged 65 years or older had at least 3 chronic medical condi- tions and 21% had 5 or more.1 Health care costs for individuals with at least 3 chronic conditions accounted for 89% of Medicare���s annual budget.1 Comor- bidity is associated with poor quality of life, physical disability, high health care use, multiple medications, and in- creased risk for adverse drug events and mortality.2-4 Optimizing care for this population is a high priority.5 Clinical practice guidelines are based on clinical evidence and expert con- sensus to help decision making about treating specific diseases.6 Clinical prac- tice guidelines help to define stan- dards of care and focus efforts to im- prove quality.7,8 Most CPGs address single diseases in accordance with mod- ern medicine���s focus on disease and pathophysiology.9 However, physi- For editorial comment see p 741. Author Affiliations are listed at the end of this article. Corresponding Author: Cynthia M. Boyd, MD, MPH, Center on Aging and Health, 2024 E Monument St, Suite 2-700, Baltimore, MD 21205 (cyboyd@jhmi .edu). Context Clinical practice guidelines (CPGs) have been developed to improve the qual- ity of health care for many chronic conditions. Pay-for-performance initiatives assess physician adherence to interventions that may reflect CPG recommendations. Objective To evaluate the applicability of CPGs to the care of older individuals with several comorbid diseases. Data Sources The National Health Interview Survey and a nationally representa- tive 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). Study Selection Of the 15 most common chronic diseases, we selected hyperten- sion, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, dia- betes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporo- sis, which are usually managed in primary care, choosing CPGs promulgated by national and international medical organizations for each. Data Extraction Two investigators independently assessed whether each CPG ad- dressed older patients with multiple comorbid diseases, goals of treatment, interac- tions between recommendations, burden to patients and caregivers, patient prefer- ences, 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 recom- mendations from the relevant CPGs. Data Synthesis Most CPGs did not modify or discuss the applicability of their rec- ommendations for older patients with multiple comorbidities. Most also did not com- ment on burden, short- and long-term goals, and the quality of the underlying scien- tific evidence, nor give guidance for incorporating patient preferences into treatment plans. If the relevant CPGs were followed, the hypothetical patient would be pre- scribed 12 medications (costing her $406 per month) and a complicated nonpharma- cological regimen. Adverse interactions between drugs and diseases could result. Conclusions 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. JAMA. 2005 294:716-724 www.jama.com 716 JAMA, August 10, 2005���Vol 294, No. 6 (Reprinted) ��2005 American Medical Association. All rights reserved.

cians who care for older adults with multiple diseases must strike a bal- ance between following CPGs and adjusting recommendations for indi- vidual patients��� circumstances. Diffi- culties escalate with the number of dis- eases the patient has.10 The limitations of current single- disease CPGs may be highlighted by the growth of pay-for-performance initia- tives,whichrewardpractitionersforpro- viding specific elements of care.8 Be- cause the specific elements of care are based on single-disease CPGs, pay-for- performance may create incentives for ignoring the complexity of multiple co- morbid chronic diseases and dissuade clinicians from caring for individuals with multiple comorbid diseases. Qual- ity-of-care standards based on these CPGs also may lead to unfair and inac- curate judgments of physicians��� care for this population. We examined how CPGs address co- morbidity in older patients and ex- plored what happens when multiple single-disease CPGs are applied to a hy- pothetical 79-year-old woman with 5 common chronic diseases. We discuss the results in the context of incentives that are created by pay for performance and related health care initiatives. METHODS CPGs Included in the Review To identify the diseases most prevalent in older individuals in the United States, we reviewed data from the National Health Interview Survey and a nation- ally representative sample of Medicare beneficiaries (5% of the Standard Ana- lytic File).1,11 We defined a chronic dis- ease as being present when a patient had 2 outpatient claims or 1 inpatient claim for the disease during 1999. From the 15 most common chronic diseases, we selected 9 that are usually managed in primary care: hyperten- sion, chronic heart failure, stable an- gina, atrial fibrillation, hypercholester- olemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary dis- ease, and osteoporosis. We excluded de- pression and dementia to focus on pa- tients who would be most likely to adhere to recommendations and under- standhealthinformation.12,13 Amongthe 5% sample in 2001, half of the benefi- ciaries had at least 2 of these 9 chronic diseases and 80% had at least 1 other condition.1 We identified the most re- centlyreleased(asofMarch1,2005)evi- dence-basedCPGspromulgatedforeach chronic disease by national and inter- nationalmedicalorganizationsusingthe National Guideline Clearinghouse.14-42 Data Abstraction Our review was based on standards for developing and rating the quality of CPGs.43-48 Indications of high quality in- cluded describing the target popula- tion,gradingthequalityofevidencesup- porting recommendations, discussing therapeutic goals, addressing quality of life, and incorporating patient prefer- ences. We examined the concepts of competing risks and burden of treat- ment for patients and caregivers be- cause these issues are central in the care ofolderadultswithmultiplediseases.49,50 Two investigators (C.M.B. and J.D.) independentlyabstracteddatafromeach CPG about applicability to individuals aged 65 years or older with multiple co- morbid diseases and the quality of evi- denceforthispopulation indicationsfor treatment, feasibility of treatment, or modifiedgoalsfortreatingtheindexdis- ease in the setting of comorbid dis- eases and duration of therapy neces- sary to achieve benefit in the context of life expectancy. We reviewed CPGs for discussion of patient-centered aspects of medical decision making including ef- fects on quality of life defined as ex- plicit discussion of quality of life, physi- cal function, or symptoms such as pain and dyspnea differentiation between short- and long-term effects, goals of treatment (eg, cure, arresting progres- sion of disease, preventing complica- tions, or managing symptoms) incor- porationofpatientpreferencesorshared decision making and burden of follow- ing recommendations on patients and their unpaid caregivers defined as ex- plicit discussion of burden, or of the ag- gregate weight or intensity of therapy to either patients or caregivers. Of 117 ab- straction decisions, investigators dis- agreed on 22. All were resolved by con- sensus after discussion between reviewers. Most disagreements in- volved statements that appeared am- biguous to the reviewers some expla- nation is provided in the tables and additional details are available on re- quest from the authors. Hypothetical Patient We examined the feasibility of combin- ing the treatment recommendations from relevant CPGs for a hypothetical 79-year-old woman with osteoporosis, osteoarthritis, type 2 diabetes mellitus, hypertension, and chronic obstructive pulmonary disease, all of moderate se- verity. We abstracted the recommenda- tions (medications, self-monitoring, tests, environmental change, diet, exer- cise,involvementofspecialistsandother clinicians, and frequency of follow-up) from the relevant CPGs and assembled a comprehensive treatment plan using explicit instructions from CPGs when- ever possible.19-40 We attempted to de- velop a treatment plan as simple and in- expensive as possible. When several options existed, we selected generic medicationswiththeleastfrequentdaily dosing and least potential for adverse ef- fects. To reduce complexity of treat- ment, when possible we chose medica- tions recommended for more than 1 condition and combined self-care ac- tivities whenever possible. We identi- fied conflicts that emerged when rel- evant CPGs were applied (eg, potential adverse effects on other diseases when treating the target disease, interactions between recommended medications, and interactions between food and medications). We tabulated the number of medi- cations and medication doses per day. We quantified the complexity of the medication regimen by summing the number of different dosage schedules, weighted for dosing frequency (eg, once per day=1 3 times per day=3).51 A regi- men with 7 different medications con- sisting of 4 drugs taken once per day and 3 drugs taken twice per day gen- erates a complexity score of 3 (1 2). CPGS FOR OLDER PATIENTS WITH MULTIPLE COMORBID DISEASES ��2005 American Medical Association. All rights reserved. (Reprinted) JAMA, August 10, 2005���Vol 294, No. 6 717