Improving practice guidelines with patient-specific recommendations

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Clinical practice guidelines aim to help providers make decisions that optimize patient care (1). Both developers and users of guidelines understand that guidelines could be improved by tailoring the recommendations to the specific circumstances of an individual patient. Tailored guideline recommendations may improve health outcomes when a group of patients can be divided into subgroups in which the tailored recommendations would increase benefits, reduce harms, or save costs relative to more generic recommendations. For example, a guideline for hypertension may recommend antihypertensive treatment in patients whose blood pressure is higher than 140/90 mm Hg. However, patients with diabetes or high cardiovascular risk may benefit from receiving treatment at lower blood pressures, whereas other patients may benefit from less aggressive treatment.

However, for both guideline developers and clinicians, tailoring recommendations is easier said than done. Developers of guidelines face a difficult tradeoff: Issue simplified, easy-to-follow guidelines or, instead, guidelines targeted more precisely to each patient, at the cost of greater complexity and more challenging implementation. In addition, little evidence may exist to guide how to tailor recommendations, because trials may exclude patients who have the comorbid conditions and other factors that would warrant tailoring a recommendation.

Clinicians also may have far more information about an individual patient than even complex guidelines can accommodate. Should a patient with atrial fibrillation receive guideline-concordant anticoagulation therapy even if he or she is at increased risk for falls? Such …

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