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Implications for Pay for Performance

Cynthia M. Boyd, MD, MPH; Jonathan Darer, MD, MPH; Chad Boult, MD, MPH, MBA; Linda P. Fried, MD, MPH; Lisa Boult, MD, MPH, MA; Albert W. Wu, MD, MPH

JAMA. 2005;294:716-724.

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 comorbidities 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 comorbidities 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.

Author Affiliations: Divisions of Geriatric Medicine and Gerontology (Drs Boyd, C. Boult, Fried, and L. Boult) and General Internal Medicine (Dr Wu), School of Medicine (Drs Boyd, C. Boult, Fried, L. Boult, and Wu), and Center on Aging and Health (Drs Boyd, C. Boult, and Fried), and Departments of Epidemiology (Dr Fried) and Health Policy and Management (Drs Boyd, C. Boult, and Wu), Bloomberg School of Public Health (Drs Boyd, C. Boult, Fried, and Wu), and Roger C. Lipitz Center for Integrated Health Care (Drs Boyd and C. Boult), Johns Hopkins University, Baltimore, Md; and Midatlantic Permanente Medical Group, Baltimore, Md (Dr Darer).

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