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Individualized guidelines: the potential for increasing quality and reducing costs
David M Eddy1, Joshua Adler, Bradley Patterson
1Archimedes, 201 Mission Street, San Francisco, CA 91405, USA. author@archimedesmodel.com
Background:
Current guidelines focus on a particular risk factor and specify criteria for categorizing persons into a small number of treatment groups.
Objective:
To compare current guidelines with individualized guidelines (that use readily available characteristics from each person to calculate the risk reduction expected from treatment and to identify persons for treatment in ranked order of decreasing expected benefit), in the context of blood pressure management.
Design:
Analysis of person-specific, longitudinal data.
Setting:
The ARIC (Atherosclerosis Risk in Communities) Study.
Participants:
Persons aged 45 to 64 years without preexisting cardiovascular disease who currently do not receive antihypertensive treatment.
Intervention:
Treatment according to the criteria of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 guidelines); individualized guidelines, or treatment in decreasing order of expected benefit; and random care, or treatment of persons selected at random.
Measurements:
Number of myocardial infarctions (MIs) and strokes and medical costs.
Results:
Compared with treating people according to random care, individualized guidelines could prevent the same number of MIs and strokes as JNC 7 guidelines at savings that are 67% greater than using JNC 7 guidelines, or it could prevent 43% more MIs and strokes for the same cost as treatment according to JNC 7 guidelines. The superiority of individualized guidelines was not sensitive to a wide range of assumptions about costs, treatment effectiveness, level of risk for cardiovascular disease in the population, or effects on workflow. The degree of superiority was sensitive to the accuracy of the method used to rank patients and to its span (the proportion of the population for whom all of the outcomes of interest can be calculated).
Limitations:
Specific results apply to the effects of blood pressure management on MI and stroke in the ARIC Study population. The methods for calculating individual benefits require quantitative evidence about the relationships among risk factors, long-term outcomes, and treatment effects.
Conclusion:
Use of individualized guidelines can help to increase the quality and reduce the cost of care.
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