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Clinical practice guidelines increase treatment burden for older adults with multimorbidity

Stephen Padilla
17 Sep 2019

Current single-disease clinical practice guidelines (CPGs) poorly address the patient-centred care approach for older adults with multimorbidity and, when applied cumulatively, create a treatment burden that is time-consuming, costly and disruptive, according to a Singapore study.

“Patients’ goals and preferences must guide prioritization of care such that treatment burden remains minimally disruptive to their lives,” the researchers said. “Developing future CPGs to deliver patient-centred rather than disease-focused care will be crucial to the management of multimorbidity.”

This study developed a treatment plan for a hypothetical 72-year-old woman with asthma, depression, diabetes mellitus, dyslipidaemia, hypertension and osteoarthritis according to the latest CPG recommendations.

The researchers assessed treatment burden in terms of time spent, cost, and the number of appointments and medications. Each of the six CPGs applied was appraised vis-à-vis the care of older adults, patients with multimorbidity and patient-centred care.

Strict application of the CPGs resulted in an average of about 2 hours spent daily taking 14 different medications and following 21 nonpharmacological recommendations. The hypothetical patient’s out-of-pocket payment totaled SGD 104.42 monthly despite a subsidy on healthcare bills of approximately 90 percent. [Singapore Med J 2019;doi:10.11622/smedj.2019109]

In general, all six CPGs that were cumulatively followed inadequately addressed patient-centred care of older adults with multimorbidity.

“Our results highlight the various shortcomings of single-disease CPGs when managing patients with multimorbidity in Singapore, a finding that is consistent with previous studies from other countries,” the researchers said. [JAMA 2005;294:716-724; Age Ageing 2013;42:62-69; Can Fam Physician 2011;57:e253-e262]

The hypothetical patient in this study was prescribed 14 medications for her six conditions, as compared with a 2015 study wherein up to 18 different medications were prescribed in patients with six conditions. This variation was driven by the differences in the selection of conditions and disease severity defined. [BMJ Open 2016;6:e010119; Age Ageing 2013;42:62-69]

Furthermore, the treatment burden was exacerbated by the cumbersome pharmacological regimen that involved a high pill burden and the complexity of preparing several medications daily. As a result, polypharmacy tended to increase medication errors, adverse drug events, drug interactions and hospital admission. [Expert Opin Drug Saf 2014;13:57-65]

“Chronic conditions represent a lifetime burden that impact not only health services, but also patients and their caregivers who work to incorporate the increasingly complex treatment regimens into their daily lives,” according to the researchers. [BMJ 2009;339:b2803]

“Patients are significantly affected when they have to constantly juggle the demands of managing chronic conditions with other family, social and personal demands,” they added. [Aust J Prim Health 2010;16:66-74]

As the healthcare workload is balanced against the patient’s capacity to manage their own health, patients are sometimes weighed down by both the illness and treatment burden when such workload exceeds their capacity, the researchers said. [J Clin Epidemiol 2012;65:1041-1051]

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