A Framework for Crafting Clinical Practice Guidelines that are Relevant to the Care and Management of People with Multimorbidity

Uhlig, Katrin; Leff, Bruce; Kent, David M.; Dy, Sydney M.; Brunnhuber, Klara; Burgers, Jako; Greenfield, Sheldon; Guyatt, Gordon; High, Kevin P.; Leipzig, Rosanne M.; Mulrow, Cynthia D.; Schmader, Kenneth E.; Schünemann, Holger J.; Walter, Louise C.; Woodcock, James; Boyd, Cynthia M.

doi:10.1007/s11606-013-2659-y

Cited by 132 publications

(160 citation statements)

References 52 publications

(60 reference statements)

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“…Presumably, the CPG workgroup has identified the topic at hand as one where interactions between treatments and comorbidities should be accounted for. The third paper 9 elaborates on these interactions. Briefly, it is important to prioritize the comorbidities that will be included in the systematic review, i.e., comorbidities likely to modify the effect of treatments, and that are not too rare.…”

Section: Systematic Reviewmentioning

confidence: 97%

“…9 Briefly, one can reasonably anticipate that most patients would prioritize "critical" outcomes such as mortality, and "important clinical" outcomes such as myocardial infarction or major depression over surrogates such as cholesterol levels. However, in general, choice of outcomes should be informed by patients' preferences and values.…”

Section: Engage the Cpg Workgroup To Identify Critical Or Important Cmentioning

confidence: 99%

“…Here, we focus on improving evidence synthesis and integration; companion papers discuss the generation, analysis and reporting of primary data, 8 and the development of CPG recommendations themselves. 9 …”

Section: Introductionmentioning

confidence: 99%

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Addressing Multimorbidity in Evidence Integration and Synthesis

2014

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To minimize bias, clinical practice guidelines (CPG) for managing patients with multiple conditions should be informed by well-planned syntheses of the totality of the relevant evidence by means of systematic reviews and meta-analyses. However, deficiencies along the entire evidentiary pathway hinder the development of evidence-based CPGs. Published reports of trials and observational studies often do not provide usable data on treatment effect heterogeneity, perhaps because their design, analysis and presentation is seldom geared towards informing on how multimorbidity modifies the effect of treatments. Systematic reviews and meta-analyses inherit all the limitations of their building blocks and introduce additional of their own, including selection biases at the level of the included studies, ecological biases, and analytical challenges. To generate recommendations to help negotiate some of the challenges in synthesizing the primary literature, so that the results of the evidence synthesis is applicable to the care of those with multiple conditions. Informal group process. We have built upon established general guidance, and provide additional recommendations specific to systematic reviews that could improve the CPGs for multimorbid patients. We suggest that following the additional recommendations is good practice, but acknowledge that not all proposed recommendations are of equal importance, validity and feasibility, and that further work is needed to test and refine the recommendations. INTRODUCTIONMost current clinical practice guidelines (CPG) are typically developed for managing individuals with a single disease, and also apply to patients with multiple conditions, provided that each can be managed separately from the others.1,2 Some patients, however, have conditions that must be considered jointly, perhaps because the management of one affects the management or the course of other. Uncritical adherence to guideline-recommended management of their isolated conditions can be impractical or even harmful for such patients. Tailored guidance is needed at least for specific combinations of conditions. Very few examples of CPGs providing such guidance exist, 1,2 perhaps because developing such guidance is hindered by deficiencies along the entire evidentiary pathway. Pivotal trials or observational studies often exclude individuals with multimorbidity. 4,5 Even when these individuals are included, the treatment effect is typically averaged over all participants, without report of whether and how it is modified in those with important multimorbid conditions. 6 Thus, systematic reviews that inform CPG recommendations often do not or cannot describe the pertinent evidence base. 7This manuscript describes the outcomes of a working session conducted with the goal of generating recommendations to help overcome some of the challenges in synthesizing the primary literature so that the results of the evidence synthesis are applicable to the care of those with multiple conditions that must be considered jointly, or in...

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Section: Systematic Reviewmentioning

confidence: 97%

Section: Engage the Cpg Workgroup To Identify Critical Or Important Cmentioning

confidence: 99%

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Addressing Multimorbidity in Evidence Integration and Synthesis

2014

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“…To better address multiple chronic conditions in clinical guidelines, (1) guideline development should harmonize or coordinate comorbidity-related contents across guidelines created by different guidelinedeveloping groups; (2) guideline development panels should include appropriate expert representation (eg, general internal medicine, geriatrics, family medicine and other primary care practitioners) for conditions and domains other than the index condition; (3) to the extent possible, guideline development should comport with the "Standards for Developing Trustworthy Clinical Practice Guidelines" as described in the IOM's report on "Clinical Practice Guidelines We Can Trust" 7,18 and should adapt principles from other relevant guidance (eg, "Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society").…”

Section: Improve the Stakeholder Technical Process For Developing Guimentioning

confidence: 99%

IOM and DHHS Meeting on Making Clinical Practice Guidelines Appropriate for Patients with Multiple Chronic Conditions

Goodman

Boyd

Tinetti

et al. 2014

The Annals of Family Medicine

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BACKGROUND The increasing prevalence of Americans with multiple (2 or more) chronic conditions raises concerns about the appropriateness and applicability of clinical practice guidelines for patient management. Most guidelines clinicians currently rely on have been designed with a single chronic condition in mind, and many such guidelines are inattentive to issues related to comorbidities.PURPOSE In response to the need for guideline developers to address comorbidities in guidelines, the Department of Health and Human Services convened a meeting in May 2012 in partnership with the Institute of Medicine to identify principles and action options.RESULTS Eleven principles to improve guidelines' attentiveness to the population with multiple chronic conditions were identified during the meeting. They are grouped into 3 interrelated categories: (1) principles intended to improve the stakeholder technical process for developing guidelines; (2) principles intended to strengthen content of guidelines in terms of multiple chronic conditions; and (3) principles intended to increase focus on patient-centered care.CONCLUSION This meeting built upon previously recommended actions by identifying additional principles and options for government, guideline developers, and others to use in strengthening the applicability of clinical practice guidelines to the growing population of people with multiple chronic conditions. The suggested principles are helping professional societies to improve guidelines' attentiveness to persons with multiple chronic conditions. Ann Fam Med 2014;256-259. doi:10.1370/afm.1646. INTRODUCTIONT he prevalence of comorbidities is high and increasing in Americans: one-fourth of all adults have multiple (2 or more) chronic conditions.1 Among older adults, the prevalence of multiple chronic conditions is at least 75%. The presence of multiple conditions creates many challenges for family physicians and other clinicians, including the need to decide what evidence to use in making clinical decisions and the need to take into account patients' contexts and personal preferences in relation to clinical decision making. [2][3][4] Clinicians are encouraged to follow evidencebased clinical practice guidelines in managing their patients' conditions, and most often they must rely on guidelines that have been designed for a single chronic condition. Most single-condition guidelines, however, are inattentive to issues related to the coexistence of other chronic conditions. 5-9The failure of condition-specific guidelines to address comorbidities has prompted concerns about the appropriateness of using current singlecondition guidelines in managing patients with multiple chronic conditions. To begin with, results of randomized clinical trials that evaluate medications for single target conditions but exclude individuals with comorbidities Richard A. Goodman, MD, Cynthia Boyd, MD may not be generalizable to persons with comorbid conditions. 5,6,8,[10][11][12][13] Other issues include whether adherence to a medicati...

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“…Here, we focus on improving the generation, analysis and reporting of primary data, while companion papers discuss evidence synthesis and integration, 4 and the development of CPG recommendations themselves. 5 …”

Section: Introductionmentioning

confidence: 99%