The next step in guideline development: incorporating patient preferences.

CLINICAL PRACTICE GUIDELINES (CPGS) ARE SYSTEMatically developed statements to assist both patient and practitioner decisions. A fixture of modern medical care, guidelines link the practice of medicine more closely to the body of underlying evidence, shift the burden of evidence review from the individual practitioner to experts, and aim to improve the quality of care. But do guidelines take into account what patients want and value? Consider the following examples. A patient with mild to moderate hypertension has shown some lowering of blood pressure but has not achieved her guideline-recommended target with salt reduction, exercise, and weight reduction. After considering the potential risks and benefits, she prefers to avoid drugs and continue with her behavioral interventions. Another patient with atrial fibrillation prefers to begin taking warfarin rather than aspirin, even though he is at low risk of stroke. He is a surgeon, and a stroke would be a career-ending event. Both of these patients have made what appear to be rational choices, but choices that are at odds with what guidelines recommend. One potential reason for this discordance is that guidelines do not sufficiently take patient preferences into account. They may not include published evidence about preferences, include patient perspectives in the process of guideline formulation, acknowledge that an optimal decision in some circumstances is determined by preference, and actively encourage patients and practitioners to make decisions on the basis of preferences. The term preferences, in its broadest sense, represents the desirability of a health-related outcome, process, or treatment choice. For example, in considering options for atrial fibrillation, a patient may have strong feelings about preventing stroke (an outcome), taking warfarin and having her international normalized ratio monitored (the process), or warfarin as a treatment strategy, which includes the prospect of all potential outcomes (a treatment choice). Concepts of greatest relevance would include health values in the bioethics literature; concerns, desires, and expectations in the psychology literature; and utility in the decision analysis and economics literature. In the context of practice guidelines, the idea of tailoring treatment to preference is distinct from the notion of clinical tailoring. Tailoring treatment to age, sex, disease severity, overall risk profile, and combinations of comorbidity is an important part of the modern evolution of CPGs. This, however, is different than taking an individual’s values and priorities into account.

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