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Clinicians should seek individualized treatment plans for geriatric patients with multiple comorbidities, according to experts

Wednesday, May 09 2007 | Comments
Evidence Grade 0 What's This?
The geriatric population consists of such great variability in terms of disease and health status that clinicians should attempt to treat patients according to their individual needs rather than by general guidelines, a panel of experts recommended.

Approximately 80% of adults aged 65 years or older have >=1 chronic condition, and 50% have >=3 chronic conditions, according to Dr. Samuel Durso, an associate professor of medicine at Johns Hopkins University. He added that there is a large discrepancy between the life expectancies of the sickest and the healthiest elderly patients.

Because of these discrepancies, treatment guidelines may not provide more than very general direction in creating effective treatment plans for elderly patients who have multiple comorbidities.

"We all know as clinicians that there is often not enough time to do everything that's recommended for either prevention or management of chronic diseases," said Dr. Cynthia Boyd, also of Johns Hopkins University. "I think that clearly doing everything is potentially not always wanted by patients or [is] not always possible, either because of patient factors or because of interaction between diseases."

In addition, doing everything that is recommended may be downright wasteful for clinicians and organizations, noted Dr. Louise Walter, a staff physician at the San Francisco Veterans Affairs Medical Center (SFVAMC).

While discussing a study she and colleagues conducted at the SFVAMC, Dr. Walter explained that one performance measure at the SFVAMC was based on an external review of SFVAMC patients' colorectal cancer screening records. In 2002, after auditors had declared the SFVAMC deficient in delivering these screenings, Dr. Walter and colleagues completed "an audit of the auditors' audit."

They found that, of the 229 patients at the SFVAMC in the given time period who met requirements for mandatory screenings, 81 were not tested. However, 25 patients were found to have been too sick to benefit from the screenings, 38 had refused testing, and 10 had been instructed to receive screening yet had failed to do so. The SFVAMC had no valid explanation regarding the lack of screening in the remaining 8 patients.

Dr. Walter pointed out that, as these study results suggest, a high screening rate should not be used as a valid indicator of good care, as it does not support the individualized treatment of patients. "[T]he one-size-fits-all approach to medical care really doesn't work in the very diverse elderly population," she said.

Moreover, she added that "there are downsides [and] harms when you don't individualize decisions," noting that there should be more research regarding the benefits and harms of certain interventions.

Dr. Kenneth Covinsky of the University of California San Francisco argued that, although steps clinicians take to meet guidelines are not harmful to patients per se, general guidelines do "divert attention from what's most important and what's more effective" in terms of treatment. He added that there are not enough "clinically friendly measures" to help clinicians assess disease prognosis in a real-world setting.

According to Dr. Covinsky, clinicians are not great at assessing disease prognosis anyway--much less in such a varied and multimorbid population--which is why prognostic assessment tools provide them with such help. These tools can also aid the cause of individualized treatment, as they typically use a point system to determine a patient's prognosis based on a combination of factors such as comorbidities, functional status, and demographics.

In addition to prognostic tools, clinicians can use prioritization of care to help individualize treatment, Dr. Boyd said. This approach will ideally lead to a care plan, which involves setting goals related to management of conditions, screening strategies, and nondisease interventions such as preventing falls.

Dr. Boyd added that taking into account a patient's personal goals, observing a patient's treatment burden, and making decisions alongside the patient may help clinicians to prioritize treatment.

Dr. Walter agreed. "Good medical care really involves decision making where ... patient preferences are considered," she reiterated. "We need to evolve from the disease-driven guidelines and quality indicators to more of a patient-driven focus. It's pretty clear that what's best for the disease is not always what's best for the patient."

Dr. Boyd added that it is also important for clinicians to examine clinical evidence, watching carefully for studies that are applicable to their patients' situations. She suggested that clinicians carefully observe a study's average patient age and primary outcome, as well as absolute risk reduction--and whether it is calculable for their patient population--to determine possible routes to individualized care.

By Lindsay Harrel

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