title: Influence of patient age and comorbid burden on clinician attitudes toward heart failure guidelines.
abstract: BACKGROUND
  Clinical practice guidelines have been criticized for insufficient attention to the unique needs of patients of advanced age and with multiple comorbid conditions. However, little empiric research is available to inform this topic.
  
  
  METHODS
  We conducted telephone interviews with staff physicians and nurse practitioners in 4 VA health care systems. Respondents were asked to rate the usefulness of national heart failure guidelines for patients of different ages and levels of comorbid burden on a 5-point scale and to comment on the reasons for their ratings.
  
  
  RESULTS
  Of 139 clinicians contacted, 65 (47%) completed the interview. Almost half (49%) were women, and 48 (74%) were general internists or family practitioners. On a 5-point scale assessing the usefulness of clinical practice guidelines for heart failure, the mean (SD) response ranged from 4.4 (0.7) for patients younger than 65 years with few comorbid conditions to 3.5 (1.2) for patients older than 80 years with multiple comorbid conditions (P<0.001). The difference in perceived usefulness varied more by patient age than by degree of comorbidity (P = 0.02). Four major concepts underlay the perceived usefulness of guidelines across different patient types: (1) harm of treatment and complexity of the patient's clinical condition and pharmacologic needs, (2) expected benefits of treatment, (3) patient preferences and abilities, and (4) confidence in the validity of guideline recommendations.
  
  
  CONCLUSIONS
  Clinicians perceive heart failure guidelines to be substantially less useful in patients of older age and with greater comorbid burden. Concerns about the clinical and pharmacologic complexity of these patients and the expected benefits of drug therapy were commonly invoked as reasons for this skepticism.
authors.affiliation: Health Services Research and Development Research Enhancement Award Program, San Francisco VA Medical Center, California, USA. mike.steinman@ucsf.edu
authors.forename: Michael A
authors.initials: MA
authors.lastname: Steinman
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Sudore
authors.forename: Carolyn A
authors.initials: CA
authors.lastname: Peterson
authors.forename: John B
authors.initials: JB
authors.lastname: Harlow
authors.forename: Terri R
authors.initials: TR
authors.lastname: Fried
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D015897:Comorbidity; D004358:Drug Therapy; D005260:Female; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D009722:Nurse Practitioners; D057240:Patient Preference; D017410:Practice Guidelines as Topic; D014481:United States; D014493:United States Department of Veterans Affairs