Lead/Presenter: Timothy Hofer, COIN - Ann Arbor
All Authors: Markovitz A (VA Center for Clinical Management Research and University of Michigan)
Hofer TP (VA Center for Clinical Management Research and University of Michigan)
Froehlich W (VA Center for Clinical Management Research and University of Michigan)
Lohman S (VA Center for Clinical Management Research)
Sussman J (VA Center for Clinical Management Research and University of Michigan)
Caverly T (VA Center for Clinical Management Research and University of Michigan)
Kerr EA (VA Center for Clinical Management Research and University of Michigan)
Objectives:
While initiatives like the Choosing Wisely campaign have focused on reducing one-time services during discrete episodes of care, clinical guidelines rarely address when to reduce long-term use of routine services for ongoing or chronic conditions such as diabetes or cardiovascular disease. We examined how frequently clinical practice guidelines recommend deintensification - stopping or scaling back the intensity or frequency of routine medical services currently part of a patient's ongoing care.
Methods:
We identified all current diabetes and cardiovascular disease guidelines published between January 2012-April 2016 by the following organizations: US Preventive Services Task Force? Veterans Health Administration? American Geriatric Society? American Diabetes Association? American College Physicians? American College of Cardiology/American Heart Association? and American Academy of Family Physicians. Recommendations were included if they pertained to services performed in the ambulatory setting, for the same patient over time, and under a PCP's discretion. We excluded palliative, perioperative, and prenatal care. Recommendations were categorized as intensification (i.e., medical care should be initiated, continued, or intensified) or deintensification (i.e., medical care should be discontinued or delivered less frequently or at a lower intensity) and tabulated across: (1) societies? (2) testing/treatment? and (3) prescriptive (e.g., "is indicated," "should be given") or suggestive (e.g., "is reasonable," "should be considered").
Results:
372 recommendations, across 22 guidelines, met the inclusion criteria. 105 (28%) were categorized as deintensification (Example: Antiarrhythmic drugs for rhythm control should not be continued when atrial fibrillation becomes permanent) and 267 (72%) as intensification (Example: In most adult patients with diabetes, measure lipid profile at least annually). Only 25% of treatment recommendations and 36% of testing recommendations were categorized as deintensification. Further, only two organizations had more than 25% of recommendations categorized as deintensification. Among deintensification recommendations, 34% were suggestive and 66% were prescriptive, as compared to 38% and 63% among intensification recommendations.
Implications:
Current guidelines make substantially more recommendations for intensification of routine services for cardiovascular disease and diabetes than deintensification. There is considerable inconsistency in how often organizations develop and publish deintensification recommendations.
Impacts:
If guidelines are to effectively improve the quality and appropriateness of care, guideline developers need to pay much more consistent attention to recommending not only when care should be escalated but also when clinicians should stop or scale back routine services.