A Framework for Tailoring Clinical Guidelines to Comorbidity at the Point of Care

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Abstract
Evidence is accumulating to suggest that some clinical guidelines should be modified for patients with severe comorbidities.1-5 Patients with comorbid illness have higher competing risks of death and therefore may be unlikely to survive long enough to benefit from disease-specific guidelines that have delayed benefits but immediate harms.2,3 For example, it seems unwise to recommend colorectal cancer screening for a woman with severe congestive heart failure (CHF) because she may die before the benefits from colonoscopy outweigh the harms. Data supporting clinical guidelines usually exclude patients with substantial comorbidity burdens and therefore do not suggest how guidelines should be individualized for patients with comorbidities that substantially affect life expectancy.1-3,5