Objective To examine the applicability of 10 common clinical practice guidelines (CPGs) to elderly patients with multiple comorbidities.
Design Content analysis of published Canadian CPGs for the following chronic diseases: diabetes, dyslipidemia, dementia, congestive heart failure, depression, osteoporosis, hypertension, gastroesophageal reflux disease, chronic obstructive pulmonary disease, and osteoarthritis.
Main outcome measures Presence or absence of 4 key indicators of applicability of CPGs to elderly patients with multiple comorbidities. These indicators include any mention of older adults or people with comorbidities, time needed to treat to benefit in the context of life expectancy, and barriers to implementation of the CPG.
Results Out of the 10 CPGs reviewed, 7 mentioned treatment of the elderly, 8 mentioned people with comorbidities, 4 indicated the time needed to treat to benefit in the context of life expectancy, 5 discussed barriers to implementation, and 7 discussed the quality of evidence.
Conclusion This study shows that although most CPGs discuss the elderly population, only a handful of them adequately address issues related to elderly patients with comorbidities. In order to make CPGs more patient centred rather than disease driven, guideline developers should include information on elderly patients with comorbidities.
Clinical practice guidelines (CPGs) are defined as “systematically developed statements to assist practitioners’ and patients’ decisions about appropriate health care for specific clinical circumstances.”1 Clinical practice guidelines are developed to assist clinicians in providing the best care using the most recent evidence. There have been debates among physicians about the usefulness of CPGs in improving the quality of care of patients.2–7 Proponents of CPGs encourage the use of CPGs in order to reduce variation and arbitrariness in practice, as well as to improve the quality of care.4,5 Opponents of CPGs cite a lack of improvement in the quality of care despite wide dissemination of guidelines; potential conflict of interest, especially in CPGs sponsored by industries; a lack of comprehensiveness of CPGs to all domains of medicine; and contradictory recommendations among multiple CPGs within the same disease category.2,3,6,8 Recent studies have focused on various aspects of CPGs, such as incorporation of patients’ values and treatment preferences in therapeutic decision making9 and adherence to established methodologic standards.10
Clinical practice guidelines have been criticized as being “disease driven rather than patient driven.”11,12 Disease-specific CPGs are particularly challenging to apply to elderly patients with multiple comorbidities. Studies done in the United States13 and Australia14 have shown that about half of the reviewed CPGs addressed this population.
The Canadian population is aging. Between 1981 and 2005, the number of seniors (≥ 65 years of age) in Canada increased from 2.4 to 4.2 million. It is projected that by 2036 seniors will account for more than a quarter of the Canadian population.15 Up to 81% of seniors living in the community have at least 1 chronic condition, and 33% have 3 or more chronic conditions.16 Primary care physicians, the primary users of CPGs, are increasingly providing care to elderly patients with multiple comorbidities. These providers require improved CPGs with specific recommendations targeting elderly patients with multiple comorbidities. To the best of our knowledge, no Canadian studies have examined the applicability of CPGs to elderly patients with multiple comorbidities. Therefore, the purpose of this study was to examine the applicability of common CPGs to elderly patients with multiple comorbidities.
We conducted a content analysis of the most recently published Canadian CPGs. Two independent reviewers (D.R.M. and H.G.) conducted the analysis separately and then compared the results. Consensus was reached at the end of the review to finalize the results. Clinical practice guidelines were selected on 2 rationales: 1) most prevalent chronic conditions17 in the elderly population, and 2) most common medications prescribed to the elderly population in Ontario during a 10-year period (1997 to 2006).18 We mapped the top 10 prescription claims with the top 10 common chronic diseases managed by primary care physicians (Table 117,18). Most CPGs were identified from the Canadian Medical Association Infobase website19 and a few were obtained by using the Google search engine. We selected 10 CPGs that were most relevant to and most likely to be used by family physicians.
Definitions of main outcome measures
The main outcome measures (ie, mention of older adults or people with comorbidities, time needed to treat in the context of life expectancy, and barriers to implementation) were selected from previous studies that examined applicability of CPGs to elderly patients.13,14
We defined elderly as people older than 65 years of age. When no specific age was indicated, we looked for words that signified older age in the CPGs (eg, senior, older adults, frail elderly).
The applicability of CPGs to people with comorbidities was determined by scanning CPG documents for any mention of people with 1 or more chronic conditions in addition to the primary disease that would affect treatment choices.
The outcome of time needed to treat in the context of life expectancy has also been used in previous literature.13,14 It refers to specific recommendations on how to modify treatment for the elderly in the context of life expectancy. The recommendations must balance the risks and benefits to the patient; specifically, the guidelines should address the treatment within the context of life expectancy, prognosis, quality of life, or end-of-life care.
Finally, the outcome measure of barriers to implementation includes explicit statements that help clinicians to understand the limitations that might pose difficulty in executing the recommendations.
Data collection and analysis
Relevant data were extracted using a data collection sheet. The data collection sheet was constructed from existing validated instruments, including the Appraisal of Guidelines for Research and Evaluation instrument20,21 and a checklist for reporting CPGs developed by the Conference on Guideline Standardization,22 and other published studies that focused on applicability of CPGs to elderly patients with multiple comorbidities.13,14 The final data collection sheet included 4 key indicators: any mention of older adults, mention of people with comorbidities, time needed to treat to benefit in the context of life expectancy, and barriers to implementation of the CPG. Data were collected, summarized, and tabulated in an Excel spreadsheet.
Table 223–38 is an overview of CPGs we reviewed. The CPGs were published between 2005 and 2009. With the exception of the osteoarthritis CPG (developed by British Columbia’s Ministry of Health Services),23 the CPGs were developed by various Canadian national organizations or societies. At the time of data collection, there were no CPGs for managing thyroid diseases.
Table 323–28,30–38 shows tabulation of each applicability indicator included in the CPGs. Out of 10 CPGs reviewed, 7 mentioned treatment of the elderly, 8 mentioned people with comorbidities, 4 indicated the time needed to treat to benefit in the context of life expectancy, 5 discussed barriers to implementation, and 7 discussed the quality of evidence.
Recommendations specific to the elderly
Table 424–28,31–38 shows examples of statements and recommendations about issues related to the elderly in CPGs. With the exception of the dementia32–38 and congestive heart failure28 (CHF) CPGs, the rest of the CPGs specified the applicable age in their recommendations. Two CPGs (diabetes26 and CHF28) used words such as elderly or frail elderly. The diabetes26 and depression31 CPGs provided evidence that treatment response was similar in older people and in the younger population. Three CPGs (diabetes,26 hypertension,27 and depression31) provided a list of suitable and unsuitable pharmacotherapy and nonpharmacologic therapies to be used in elderly patients.
Recommendations for people with comorbidities
Table 523,25–28,30–38 provides a summary of CPGs that mentioned or addressed people with comorbidities. Two CPGs (CHF28 and depression31) recommend multidisciplinary and interdisciplinary care of patients with multiple comorbidities. In addition, the diabetes26 CPG recommends a multidisciplinary and interdisciplinary approach to all diabetes patients, regardless of age. The depression31 CPG provides a list of medications with low potential for drug-drug interactions. On the other hand, the osteoarthritis23 CPG leaves it to a physician’s discretion for how to handle comorbidities. The chronic obstructive pulmonary disease30 (COPD) CPG provides different treatment regimens for those with and those without comorbidities. Finally, the diabetes26 CPG recommends modification of glycemic targets among elderly patients with comorbidities. In addition, some CPGs provide recommendations on modification of treatment targets (diabetes26 CPG), comorbidites that warrant screening for lipid profiles (dyslipidemia25 CPG) or comorbidity-specific treatment recommendations (hypertension27 CPG).
Time to benefit in the context of life expectancy
Table 626,28,30,31 shows how several CPGs addressed issues related to treatment in the context of life expectancy. Four CPGs (CHF,28 COPD,30 diabetes,26 and depression31) discuss issues related to end-of-life care. The CHF,28 COPD,30 and diabetes26 CPGs recommend modification of treatment goals in accordance with prognosis and patient choice. The depression31 CPG recommends indefinite treatment of elderly patients with partial resolution of symptoms.
Barriers to implementation
Table 726–28,31–38 provides a summary of CPGs that list or discuss barriers to implementation. Most of the listed CPGs acknowledge gaps and a lack of good evidence for recommendations pertaining to the elderly population with or without comorbidities. Barriers to implementation are discussed in terms of adherence, polypharmacy, and difficulty in achieving treatment targets.
Evidence levels of recommendations
Recommendations in each guideline were generated by using different evidence grading systems. We list the available evidence level of the recommendations targeting elderly with comorbidities in Tables 323–28,30–38 to 7.26–28,31–38 The recommendations varied from grade A to grade D.
Elderly with or without comorbidities
We reviewed CPGs for 10 common chronic conditions managed by primary care physicians in elderly patients. This study has shown that most of these CPGs do mention the elderly population (7 out of the 10 CPGs, which is comparable to US13 and Australian14 studies). However, while most of the CPGs mention elderly patients, few of them adequately discuss issues related to elderly patients with comorbidities. Only 3 CPGs (CHF,28 diabetes,26 and depression31) have dedicated sections addressing elderly patients with comorbidities. The osteoarthritis23 and osteoporosis24 CPGs provide recommendations specific to elderly patients, but the recommendations are broad and nonspecific. The osteoarthritis23 and dementia32–38 CPGs have minimal discussions on issues pertaining to elderly patients with comorbidities. The dementia32–38 CPGs recommend that physicians stop medication if there is high risk of drug-to-drug interaction, although they did not specify common comorbidities that providers should be aware of.
Time needed to treat in the context of life expectancy
Only the CPGs for CHF,28 diabetes,26 and COPD30 specifically recommend modification of treatment in the context of life expectancy and patients’ preferences and prognoses. The other CPGs do not address issues related to time needed to treat to benefit in the context of life expectancy. This finding might be partly explained by the fact that primary studies often focus on evaluation of benefits rather than harms, which requires much more expensive longitudinal studies.39 Recently, one study focused on developing a payoff time framework, which might identify patients for whom particular clinical guidelines are unlikely to confer benefit; however, this framework has not been validated in a clinical setting.40
Barriers to implementation
Only half of the reviewed CPGs provide explicit statements on when or under what circumstances CPGs might be difficult to implement. Such statements address issues like treatment targets in the elderly, warnings about polypharmacy or drug-drug interactions, and the lack of evidence for some recommendations. Acknowledgment of barriers to implementation is an important component of continuous quality improvement of CPGs. By identifying and explicitly stating areas where it might be difficult to implement CPGs, strategies can then be developed to address the shortcomings and therefore improve the quality of CPGs or develop strategies to overcome the barriers.
Evidence level of recommendations
We found that very few recommendations for elderly with comorbidities were based on clinical trials (ie, grade A recommendations). This is not surprising, as most randomized trials exclude the elderly, especially those of advanced age or with comorbidities.39 It is estimated that only 5% of trials are designed specifically for elderly patients 65 years of age and older, and 15% of trials exclude elderly participants without any justification.41
This is the first Canadian study that has attempted to study applicability of CPGs to elderly patients with comorbidities. Our study has several limitations. This study evaluated only 10 CPGs. The conditions discussed are the most common chronic conditions seen in the elderly and are managed largely by primary care physicians. Other diseases such as cancer and thyroid problems were not included but would likely be in the realm of both specialist and primary care providers. Second, there is no validated instrument to evaluate applicability of CPGs to elderly patients with comorbidities. We constructed our data collection sheet from different sources. We covered only 4 items that we believed were specific to the elderly and those with comorbidities. It is likely that there are other important domains that were not evaluated in this study. Future studies should develop and validate an instrument for assessing applicability of CPGs to elderly patients with comorbidities.
This study shows that only a handful of CPGs adequately address important issues common in the care of elderly patients. Given the demographic transition occurring in Canada, this is of urgent importance. Clearly, there is considerable room for improvement in these CPGs. There is a pressing need to improve the evidence base that undergirds the care of people of advanced age and with multiple concurrent chronic diseases.42 Guideline developers should include much more detailed information on management of elderly patients, with a particular emphasis on eliciting patient and caregiver concerns, setting clinical priorities, managing expectations (particularly around prognosis), and fostering optimum communication. This will aid in making CPGs more patient centred rather than disease driven. Based on this research, we propose that an ideal guideline should consider an open discussion about patients’ preferences, benefits of intervention in advanced age, time to benefit from treatment, trade-offs for function over disease control, as well as acknowledgment of uncertainty.
Dr Upshur is supported by the Canada Research Chair in Primary Care Research.
EDITOR’S KEY POINTS
Family physicians, who are the primary users of clinical practice guidelines (CPGs), are increasingly providing care to elderly patients with multiple comorbidities.
This article examines the applicability of common CPGs to elderly patients with comorbidities.
This study shows that only a handful of CPGs adequately address important issues common in the care of the elderly. Guideline developers should include much more detailed information on management of elderly patients, with a particular emphasis on eliciting patient and caregiver concerns, setting clinical priorities, managing expectations (particularly around prognosis), and fostering optimum communication. This will aid in making CPGs more patient centred rather than disease driven.
POINTS DE REPÈRE DU RÉDACTEUR
Les médecins de famille, qui sont les principaux utilisateurs des directives de pratique clinique (DPC), soignent de plus en plus de patients âgés présentant plusieurs affections.
Cet article cherche à savoir si les DPC générales s’appliquent aux patients âgés qui présentent des affections multiples.
Cette étude montre que très peu de DPC correspondent adéquatement aux importants problèmes fréquemment rencontrés chez les personnes âgées. Les concepteurs des directives devraient inclure des informations beaucoup plus détaillées sur le traitement des personnes âgées, en insistant particulièrement sur la nécessité de s’enquérir des préoccupations des patients et des intervenants, d’établir les priorités cliniques, de gérer les attentes (notamment au sujet du pronostic) et d’améliorer les communications. De cette façon, les DPC devraient être davantage centrées sur les patients plutôt que sur les maladies.
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
All authors contributed to the concept, analysis, drafting, and critical review of the article, and all approved the final version for submission.
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