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Patient Preferences in Clinical Practice Guidelines
JAMA has published an online first Viewpoint article by Montori and colleagues that highlights the importance, and challenge for clinicians and creators of clinical guidelines, of balancing patient preferences with evidence from the literature when facing choices about options in therapeutic decisions. (1)
They state, "Patient preferences refer to patient perspectives, beliefs, expectations, and goals for health and life, and to the processes that individuals use in considering the potential benefits, harms, costs, and inconveniences of the management options in relation to one another. Patients may have preferences when it comes to defining the problem, identifying the range of management options, selecting the outcomes used to compare these options, and ranking these outcomes by importance."
The authors conclude: "Although guidelines may simplify [taking care of patients], when patient preferences and context matter, guidelines must not replace clinicians’ compassionate and mindful engagement of the patient in making decisions together. This is the optimal practice of evidence-based medicine."
This principle is especially important with older adults. In a study with community-dwelling older adults, for example, Tinetti and colleagues (2) explored whether older adults had greater concerns about harm from adverse cardiovascular events (stroke and heart attack) or harm from falls. They found that the study participants were about equally divided, with half more concerned about CV risks and half more concerned about falls. This highlights the importance of discussions between the clinician and patient to determine patient priorities, rather than making assumptions.
Another study by Fried and TInetti highlights the importance of discussing both the expected benefits and potential harms of therapy with older adults. (3) In a study of a population of older persons of diverse race/ethnicity and socioeconomic and health status, they found that the willingness of older persons to take medications for cardiovascular prevention was relatively insensitive to benefit, but very sensitive to potential harms from the therapy. Unwillingness to take the medication increased significantly when adverse effects were considered likely, especially if interference might occur with activities of daily living.
Unfortunately, clinical practice guidelines frequently lack information on incorporating patient preferences and also lack information on risks or harms of medications or therapeutic options. Clinicians must figure out how to address these issues as they try to apply CPGs in the care of older adults.
1. Montori VM, Brito JP, Murad MH. The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines. JAMA, October 28, 2013, online first. [Free full text]
2. Tinetti ME, McAvay GJ, Fried TR, et al. Health Outcome Priorities Among Competing Cardiovascular, Fall Injury, and Medication-Related Symptom Outcomes. JAGS 2008;56(8):409-16.
3. Fried TR, Tinetti ME, Towle V, et al. Effects of Benefits and Harms on Older Persons' Willingness to Take Medication for Primary Cardiovascular Prevention. Arch Intern Med. 2011;171(10):923-928.
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