Potential pitfalls of disease-specific guidelines for patients with multiple conditions.

Quality-assurance initiatives encourage adherence to evidenced-based guidelines for the management of particular diseases and ensure that such adherence is monitored.1-3 The best of these guidelines, developed by national organizations, systematically collect the available evidence regarding a given disease and provide recommendations, including the use of multidrug regimens, for the treatment of patients with that disease.4-8 The goal is to maximize benefits to patients with specific diseases by encouraging standardization among providers of health care.1,2 The push for financial incentives linked to performance will probably accelerate the movement toward the guideline-driven prescribing of medications.1,2 The expected benefits, including the prevention of disease-specific outcomes, deaths, and hospitalizations, that are avoided because of adherence to disease-specific guidelines for the prescribing of medications have been well chronicled.2 No one doubts the benefit, for example, of beta-blockers in the prevention of recurrent myocardial infarctions7 or of angiotensin-converting–enzyme (ACE) inhibitors in retarding the loss of renal function.5 Some multidrug regimens clearly provide added disease-specific benefits for at least some subpopulations of patients, as compared with single-drug therapy.4,5,8 Less clear, however, are the long-term net benefits and harm associated with the combination of all medications that are taken in adherence to disease-specific guidelines for patients with several coexisting health conditions. Since 20 percent of Medicare beneficiaries have five or more chronic conditions9 and 50 percent are receiving five or more medications,10 this is not an inconsequential concern. Consider, for example, the case of a 70-year-old woman who has the common combination of hypertension, myocardial infarction, depression, diabetes mellitus, and osteoporosis. Adherence to disease guidelines might require this patient to take an aspirin, an ACE inhibitor, a betablocker, a bisphosphonate, calcium, a diuretic, a selective serotonin-reuptake inhibitor, a statin, a sulfonylurea drug, perhaps a thiazolidinedione, and vitamin D.4-8 These guideline-driven medications are taken in addition to prescription and over-thecounter drugs for conditions such as allergies, pain, dyspepsia, and insomnia. Viewing disease-specific medication guidelines from this perspective raises the question of whether what is good for the disease is always best for the patient. All medications have the potential for harm as well as benefit. Furthermore, evidence is emerging that patients, particularly elderly patients and those with multiple conditions, vary in regard to the amount of importance they place on health outcomes such as longer survival, the prevention of specific disease events, and physical and cognitive functioning, as well as in the amount of inconvenience and risk of adverse effects they are willing to tolerate.11-15 The developers of guidelines recognize that decisions about prescribing must be individualized, with patients’ overall health taken into account. Nevertheless, one of the hallmarks of qualityassurance programs is a reduction in the variation of practice patterns among providers.1-3 It is difficult to separate inappropriate variation due to neglect or ignorance on the part of providers from appropriate variation due to the total disease burden and the preferences of patients. A review of the evidence underlying disease-specific guidelines helps to explain the origin of the tension between the standardized treatment of diseases and the individualized care of patients with multiple conditions.