Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases - Implications for pay for performance
Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases - Implications for pay for performance
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DOI：
10.1001/jama.294.6.716
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发表时间：
2005-08-10
影响因子：
120.7
通讯作者：
Wu, AW
中科院分区：
文献类型：
--
作者：
Boyd, CM;Darer, J;Wu, AW
背景
临床实践指南（CPGs）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。
目的
评估CPGs对患有多种合并症的老年人护理的适用性。
数据来源
全国健康访谈调查以及具有全国代表性的医疗保险受益人样本（用于确定该人群中最常见的慢性病）；美国国家指南交换中心（用于查找每种慢性病的循证CPGs）。
研究选择
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医疗中进行管理，并为每种疾病选择了由国内和国际医学组织颁布的CPGs。
数据提取
两名研究者独立评估每个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、患者和照顾者的负担、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假设的79岁女性，我们汇总了相关CPGs的建议。
数据综合
大多数CPGs没有修改或讨论其建议对患有多种合并症的老年患者的适用性。大多数也没有对负担、短期和长期目标以及基础科学证据的质量发表评论，也没有为将患者偏好纳入治疗计划提供指导。如果遵循相关的CPGs，假设的患者将被开具12种药物（每月花费她406美元）以及一个复杂的非药物治疗方案。药物与疾病之间可能会产生不良相互作用。
结论
这项综述表明，在护理患有多种合并症的老年人时遵循当前的CPGs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CPGs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，并可能产生不良激励，强调对该人群护理的错误方面，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。
Context 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.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 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).Study Selection 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.Data Extraction 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.Data Synthesis 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 per month) and a complicated nonpharmacological 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 comorbiclities 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 comorbiclities 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.