Guidelines tailored to each individual's needs can improve outcomes, reduce costs

Key Points

Individualized guidelines present a much more efficient way of using drugs and other treatments compared to current guidelines, according to a study published recently in the Annals of Internal Medicine.

"This study is focused on hypertension, but the results generalize to many other risk factors and treatments such as cholesterol, glucose, smoking cessation, weight-loss programs, and screening for cancers," he added.

"An example is that if your systolic blood pressure is greater than 140 mmHg, then you should be treated; otherwise you should not," Dr Eddy continued. "This study introduces the idea of individualized guidelines that look at a broad spectrum of risk factors and take into account the fact that the effects of risk factors are continuous-they do not make sharp jumps when they hit particular thresholds."

The study then estimated the potential improvements in quality and cost that can be achieved by using individualized guidelines instead of current guidelines, using hypertension as an example. It showed that compared to not using guidelines at all, individualized guidelines can deliver the same benefit as the national hypertension guideline (called the JNC-7), in terms of reducing heart attacks and strokes, at a 67% greater reduction in cost.

"Or if one wanted to spend the same amount of money as the JNC-7 hypertension guidelines, then individualized guidelines could achieve a 43% greater benefit without any increase in cost," Dr Eddy explained.

In 1 region of Kaiser Permanente, physicians implemented individualized guidelines in 2 clinics for 1-on-1 patient-physician decision-making.

Results showed good acceptance by physicians and patients, improvements in both physician performance and patient adherence as reflected in higher rates of prescription fills, improvements in adherence to existing guidelines, as well as treatment of patients who are missed by existing guidelines, improvements in biomarkers, reductions in risk of adverse clinical events such as heart attacks and strokes, and reductions in expected financial costs, according to Dr Eddy.

DELIVERING INDIVIDUAL GUIDELINES

Individualized guidelines are delivered through clinical information systems or other Web-based applications.

"They provide patients and physicians with quantitative information about each patient's risks of important events such as heart attacks, strokes, and diabetes and its complications," Dr Eddy said. "They also provide patients and physicians with information about how each of those risks can be reduced by a variety of treatments, 1-on-1 and in all possible combinations. This enables physicians and patients to move from simply saying 'you should stop smoking' or 'you should continue to take your hypertension medication' to being able to say something like 'if you stop smoking, your risk of a heart attack or stroke in the next 5 years will go down from 20% to 10%.'"

Evaluations of individualized guidelines in clinical settings have shown that this type of quantitative information is considerably more powerful in changing behaviors than the simple qualitative statements delivered by current guidelines, Dr Eddy added.

The information can be used by:

In terms of the practical aspects of implementation, Dr Eddy and his team developed an application called "IndiGO" (Individualized Guidelines and Outcomes) that can be easily inserted in clinical information systems. It can also be adapted to programs that have data warehouses or the ability to merge legacy information systems.

In such systems, the de-identified information on each person can be automatically downloaded for calculations. Results are then accessed through the electronic health record or other computer-based application. Because individualized guidelines take into account a broad spectrum of information about the patient-including demographics, physical findings, lab values, and past and current medications-they are best used in systems that have some form of electronic records, he said.

THINKING AHEAD

"If healthcare is to become more efficient, it has to develop methods for calculating the magnitudes of the clinical and economic effects of different tests and treatments for different populations," Dr Eddy said.

In the future, he predicted that instead of having dozens of separate guidelines, a single comprehensive guideline will exist that reviews all the important characteristics of each patient simultaneously, identifies all the possible interventions appropriate for that patient, and then presents physicians and patients with a comprehensive picture of the patient's risks and the best ways of reducing those risks, in a single step.

Hospital and managed care decision-makers dealing with formulary decisions, "directly experience the utilization and costs of drugs and other treatments. Therefore they will experience the potential savings, and/or the greater clinical benefits. The greater benefits in turn translate into savings, by preventing costly admissions for heart attacks, strokes, diabetes and its complications, and other conditions," said Dr Eddy.