Glidepath Tools

 


 

Clinical GLIDEPATH® Tools are a new integrated model of care for clinicians. They combine the principles of practice guidelines and EBM with the principles of clinical experience and patient preferences.

Clinical GLIDEPATH® Tools exist to assist clinicians with the complexities of medical decision-making. Evidence-based medicine (EBM) and practice guidelines have limitations in that they are often rigid, standardized, based solely on age, and may not take into account a patient’s comorbidities, life expectancy, and nonmedical preferences. Clinical GLIDEPATH® Tools are based on these 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 its limitations and clinicians must be aware of these limitations.
  3. Clinical experience, emphasizing individual outcomes instead of populations, is an important component of medical decisions.
  4. There must be room for patient preferences in medical decision-making.
  5. Instead of age, a more applicable and useful approach will be based on probable life expectancy and function.
  6. Common problems seen in every day practices will be the focus.

Volume 1 of the Clinical GLIDEPATH® Tools is intended to assist clinicians who treat geriatric patients.

Instead of using chronological age to guide decision-making, life expectancy and functional status have been used to create four categories of older patients:

1) robust older people: life expectancy > 5 years and functionally independent 2) frail older people: life expectancy of < 5 years and significant functional impairment 3) moderately demented older people: life expectancy from 2 to 10 years and may or may not be functionally impaired 4) end-of-life older people: usually a life expectancy of < 2 years.

Overlap between categories may exist, functional status may fluctuate, and predicting life expectancy may be challenging, but compared with age alone, functional capacity in older persons has been found to be a good predictor of mortality and overall health status.

The recommendations allow for decisions to be made on a “graded” rather than an “all-or-nothing” basis and allow for better patient involvement in decision-making. The four levels are:

  1. Do (strongest recommendation)
  2. Discuss (recommends that the clinician discusses the risk:benefit of the decision with the patient)
  3. Consider (the clinician should consider but does not necessarily need to discuss the decision with the patient)
  4. **** (Don’t do.This evaluation or management measure is not recommended.)

Aviators define a glide path as the path of descent of an airplane as marked out by a radio beam along which a pilot may bring an airplane safely to the runway when flying on instruments. Pilots, ultimately, are in control of the landing, but the airport control tower assists them to the runway using the glide path. The term “glidepath” was chosen to emphasize that physicians, together with their patients, are in control; just as the airport control tower uses the glide path to assist pilots to the runway but does not tell them how to land, a Clinical Glidepath® gives guidance to clinicians based on the standard of care for specific diseases while allowing them to decide with the patient the final course of action. Also, just as a pilot will not encounter the same weather conditions during every landing, the Clinical GLIDEPATH® Tools cover a variety of types of patients. It is not a prescription for caring for patients, rather it is a model of care that is adjusted or modified to the needs and values of each individual patient.

For more information on how Clinical GLIDEPATH® Tools were developed and tested, please see the article, Flaherty JH, Morley JE, Murphy DJ, and Wasserman, MR. The Development of Outpatient Clinical Glidepaths® . J Am Geriatr Soc 50:1886-901, 2002.


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