The Development of Outpatient Clinical Glidepaths

Authors

  • Joseph H. Flaherty MD,

    1. Division of Geriatric Medicine, Saint Louis University Medical Center, St. Louis, Missouri;
    2. Geriatric Research Education and Clinical Center, St. Louis Veterans Affairs Medical Center, St. Louis, Missouri; and
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  • John E. Morley MB, BCh,

    1. Division of Geriatric Medicine, Saint Louis University Medical Center, St. Louis, Missouri;
    2. Geriatric Research Education and Clinical Center, St. Louis Veterans Affairs Medical Center, St. Louis, Missouri; and
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  • Donald J. Murphy MD,

    1. Senior Health Care of Colorado, Aurora, Colorado.
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  • Michael R. Wasserman MD

    1. Senior Health Care of Colorado, Aurora, Colorado.
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  • See editorials section for comments on this paper by Dr. David Reuben.

Address correspondence to Dr. Joseph H. Flaherty, Division of Geriatric Medicine, Saint Louis University Medical Center, 1402 S. Grand, St. Louis, MO 63104. E-mail: Flaherty@slu.edu

Abstract

For clinicians who are struggling with the complexities of medical decision-making, practice guidelines and evidence-based medicine (EBM) have become increasingly popular and have potential to positively influence the practice of medicine. Nevertheless, they have their limitations. Guidelines are often rigid, based solely on age, and usually do not take into account a patient's comorbidities, life expectancy, and nonmedical preferences. EBM studies may not always include particular patient populations commonly seen by the geriatric clinician (e.g., studies on lipid-lowering agents or antihypertensive drug usually exclude the very old or patients who are frail, demented, or at the end of life). These limitations have made it difficult for geriatric clinicians to use these guidelines because of the need to individualize evaluation and treatment approaches and take into account the varied preferences of their older patients. The purpose of this paper is to present an alternative model of care for geriatric clinicians called The Clinical Glidepaths. The Clinical Glidepaths are outpatient tools intended to assist geriatric clinicians in their decision-making process. They are based on the following principles. (1) Clinicians need guidance concerning many different types of patients, not rigid guidelines based solely on age. (2) EBM should be used but has some limitations of which to be aware. (3) Clinical experience, which emphasizes individual outcomes instead of populations, is an important component of medical decisions. (4) There needs to be room for patient preferences in medical decision-making. (5) An approach to patients based on probable life expectancy and function, instead of age, will be more applicable and useful. (6) Making a useful tool will focus on common problems seen in every day geriatric practices.

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