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Author Archives: Cynthia Boyd

Improving Guidelines for Multimorbid Patients



By Cynthia M. Boyd and David M. Kent

With rare exceptions, guidelines focus on the management of a single disease, or a single disease-problem, and do not address how to optimally integrate care for individuals whose multiple problems may make guideline-recommended management of any single disease impractical, irrelevant or even harmful.  Current standards of guideline development or appraisal do not prompt guideline developers to routinely address the issue that not all patients with the same condition benefit similarly from similar therapy, nor do they provide tools for adapting the recommendations to the patient with many diseases or for prioritizing the most important recommendations within a single disease, let alone between diseases. The root of this problem, however, is not narrowly confined to guideline development and implementation. At each phase of the translational path including trial and study design and analysis, the synthesis of trial and observational study results in meta-analyses and systematic reviews, and the guideline development process, the very information necessary to support evidence-based care of the person with multimorbidity is excluded.  Needed, then, is a comprehensive approach built on a firm understanding of each of these phases of evidence generation, synthesis and integration, and guideline development. 

To address these issues, we assembled a collaborative team with complementary expertise spanning the various phases of evidence development and translation to develop a comprehensive description of the problem and provisional recommendations.  These were refined through an iterative process of feedback from researchers (from medicine, public health, biostatistics), guideline developers, and stakeholders from government, other payers and industry, which culminated at a conference on Improving Guidelines for Multimorbid Patients (Baltimore, Maryland October 2010). The results of this project are presented in 4 papers [1-4] in a symposium in the Journal of General Internal Medicine, focused on the following 3 areas: 1) evidence generation (clinical trial and observational study design and analysis), 2) evidence synthesis (systematic review, meta-analyses) and 3) guideline development.

 References

1. Boyd CM and Kent DM. Evidence-Based Medicine and the Hard Problem of Multimorbidity. JGIM 2014 Jan 18. [Epub ahead of print].
2. Weiss CO, Varadhan R, Puhan M, Vickers A, Bandeen-Roche K, Boyd CM, Kent  DM. Multimorbidity and Evidence Generation, JGIM 2014 Jan 18. [Epub ahead of print].
3. Trikalinos T, Segal J, Boyd CM. Addressing Multimorbidity in Evidence Synthesis and Integration., JGIM 2014 Jan 18. [Epub ahead of print].
4. Uhlig K, Leff B, Kent DM, Dy S, Brunnhuber K, Burgers J, Greenfield S, Guyatt G, High K, Leipzig R, Mulrow C, Schmader K, Schunemann H, Walter L, Woodcock J, and Boyd CM. A framework for crafting clinical practice guidelines that are relevant to the care and management of people with multimorbidity. JGIM 2014 Jan 18. [Epub ahead of print].

Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society

By Cynthia Boyd

A new report issued by the American Geriatrics Society (AGS) outlines how clinicians can tailor care to better meet the unique needs older adults with multimorbidity.  More than half of adults 65 and older have at least three chronic conditions, such as heart disease, diabetes, and arthritis.

Entitled Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society, the new report was published in today’s early, online edition of the Journal of the American Geriatrics Society (JAGS) and is available at www.americangeriatrics.org, in conjunction with a longer version of the documents with more complete references.  A wealth of related information, tips, and tools for both clinicians and the public are also available on the AGS website.

To help both clinicians and patients make complex treatment decisions, the expert panel that developed the report has outlined five essential elements, or guiding principles, for quality care for older adults with multimorbidity: 

  • Preferences: Elicit and incorporate patient preferences* into medical decision-making for older adults with multimorbidity.

By using the term “patient” preferences, we aim to keep the patient central to the decision-making process while recognizing that family and social supports play a vital role in management and decision-making whether or not cognitive impairment is present.

  • Interpreting the evidence: Recognizing the limitations of the evidence base, interpret and apply the medical literature specifically to older adults with multimorbidity.
  • Prognosis: Frame clinical management decisions within the context of risks, burdens, benefits, and prognosis (e.g. remaining life expectancy, functional status, quality of life) for older adults with multimorbidity.
    • Clinical Feasibility: Consider treatment complexity and feasibility when making clinical management decisions for older adults with multimorbidity.
    • Optimizing Therapies and Care Plans: Utilize strategies for choosing therapies that optimize benefit, minimize harm, and enhance quality of life for older adults with multimorbidity.

    The report also describes the urgent need for research to develop and implement evidence-based practices for each of these areas.

    Cynthia Boyd, MD MPH
    Associate Professor of Medicine
    Division of Geriatric Medicine and Gerontology
    Johns Hopkins University School of Medicine