Assessing guideline-concordant care for patients with multimorbidity treated in a care management setting

Abstract

Background Disease-specific guidelines are not aligned with multimorbidity care complexity. Meeting all guideline-recommended care for multimorbid patients has been estimated but not demonstrated across multiple guidelines. Objective Measure guideline-concordant care for patients with multimorbidity; assess in what types of care and by whom (clinician or patient) deviation from guidelines occurs and evaluate whether patient characteristics are associated with concordance. Methods A retrospective cohort study of care received over 1 year, conducted across 11 primary care clinics within the context of multimorbidity-focused care management program. Patients were aged 45+ years with more than two common chronic conditions and were sampled based on either being new (≤6 months) or veteran to the program (≥1 year). Measures Three guideline concordance measures were calculated for each patient out of 44 potential guideline-recommended care processes for nine chronic conditions: overall score; referral score (proportion of guideline-recommended care referred) and patient-only score (proportion of referred care completed by patients). Guideline concordance was stratified by care type. Results 4386 care processes evaluated among 204 patients, mean age = 72.3 years (standard deviation = 9.7). Overall, 79.2% of care was guideline concordant, 87.6% was referred according to guidelines and patients followed 91.4% of referred care. Guideline-concordant care varied across care types. Age, morbidity burden and whether patients were new or veteran to the program were associated with guideline concordance. Conclusions Patients with multimorbidity do not receive ~20% of guideline recommendations, mostly due to clinicians not referring care. Determining the types of care for which the greatest deviation from guidelines exists can inform the tailoring of care for multimorbidity patients.

Guideline deviation and its association with specific chronic diseases among patients with multimorbidity: a cross-sectional cohort study in a care management setting

“…Some care processes are recommended by guidelines to be completed several times a year, and, with the exception of medication prescribing and purchases, care completion was assessed based on whether the care was referred or completed at least partially any time within the last year. 27 Patient study population Patients in the CC-MAP were adults aged 45-95 years as described above. The current study sampled patients from the 964 patients enrolled in the second phase of the CC-MAP as of September 2017, who had at least two chronic conditions of the focus conditions (with dyslipidaemia not used for the inclusion criteria because it is sometimes considered a precondition).…”

“…This study was conducted as part of a primary care nursephysician team-based care management intervention at Clalit Health Services in Israel. 27 The intervention, called the Comprehensive Care for Multimorbid Adults Project (CC-MAP), is a multi-site controlled trial, across 12 primary care clinics in Clalit. 29 The specially trained nurses of the programme play an important role as care managers, helping to develop a care plan with the primary care physicians and providing regular follow-up consultations with the patients (on average every 1-3 months).…”

“…31 Nine of the most prevalent chronic conditions in Clalit's population were determined to be the focus conditions of this study (atrial fibrillation (AF), congestive heart failure (CHF), chronic kidney disease (CKD), chronic obstructive pulmonary disorder (COPD), depression, diabetes, dyslipidaemia, hypertension and ischaemic heart disease (IHD)), based on the fact that abbreviated guideline recommendation brief references were developed as part of the CC-MAP for these nine conditions. 27 Sets of key care processes were established in the prior study based on these abbreviated quick guideline references that are an integration of care recommendations for each disease from sets of international guidelines and internal Clalit protocols, with considerations for co-existing chronic conditions (see online supplemental table S1 in Cohen-Stavi et al 2020). A total of 44 guideline-recommended care processes for managing patients' existing diagnoses, including lifestyle, follow-up tests, medications, counselling and procedure interventions, and specialist referrals (table 1), were evaluated for the extent to which they were completed over a 1year timeframe for this multimorbid patient population.…”

“…A total of 44 guideline-recommended care processes for managing patients' existing diagnoses, including lifestyle, follow-up tests, medications, counselling and procedure interventions, and specialist referrals (table 1), were evaluated for the extent to which they were completed over a 1year timeframe for this multimorbid patient population. 27 Patients' electronic medical records were reviewed by treating CC-MAP nurses for the relevant guideline-recommended care processes related to the nine focus conditions.…”

“…The previously derived taxonomy of reasons was used in a data collection instrument, through which 11 CC-MAP nurses were asked during multiple data collection meetings to provide reasons why each care process was either not referred by the clinician or not completed by the patient if it was referred by the clinician (Cohen-Stavi et al, 2020). Mixed methods evaluation of reasons why care deviates from clinical guidelines among patients with multimorbidity.…”