• R Scott Braithwaite, John Concato, Chung Chou Chang, Mark S Roberts, and Amy C Justice.
• Section of General Internal Medicine, Yale University School of Medicine, West Haven Veterans Affairs Connecticut Healthcare System, VACS 11 ACSL-G, 950 Campbell Ave, West Haven, CT 06516, USA. Ronald.braithwaite@va.gov
• Arch Intern Med. 2007 Nov 26;167(21):2361-5.

BackgroundEvidence is accumulating to suggest that clinical guidelines should be modified for patients with comorbidities, yet there is no quantitative and objective approach that considers benefits together with risks.MethodsWe outline a framework using a payoff time, which we define as the minimum elapsed time until the cumulative incremental benefits of a guideline exceed its cumulative incremental harms. If the payoff time of a guideline exceeds a patient's comorbidity-adjusted life expectancy, then the guideline is unlikely to offer a benefit and should be modified. We illustrate the framework by applying this method to colorectal cancer screening guidelines for 50-year-old men with human immunodeficiency virus (HIV) and 60-year-old women with congestive heart failure (CHF).ResultsWe estimated that colorectal cancer screening payoff times for 50-year-old men with HIV would range from 1.9 to 5.0 years and that colorectal cancer screening payoff times for 60-year-old women with CHF would range from 0.7 to 2.9 years. Because the payoff times for 50-year-old men with HIV were lower than their life expectancies (12.5-24.0 years), colorectal cancer screening may be beneficial for these patients. In contrast, because payoff times for 60-year-old women with CHF were sometimes greater than their life expectancies (0.6 to >5 years), colorectal cancer screening is likely to be harmful for some of these patients.ConclusionUse of a payoff time calculation may be a feasible framework to tailor clinical guidelines to the comorbidity profiles of individual patients.

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