Multimorbidity and Evidence Generation

Weiss, Carlos O.; Varadhan, Ravi; Puhan, Milo A.; Vickers, Andrew J.; Bandeen‐Roche, Karen; Boyd, Cynthia M.; Kent, David M.

doi:10.1007/s11606-013-2660-5

Cited by 57 publications

(67 citation statements)

References 45 publications

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“…[42][43][44] Analyses can be challenging to interpret. 11 If trial evidence for the target population or the outcomes of interest is limited, review of observational studies may yield additional insights, giving rise to the attendant challenges of assessing methodological rigor and synthesizing across different study designs. Further, extrapolation of evidence from people with single conditions to people with multimorbidity may be necessary, even though this decreases the certainty in the conclusions by introducing indirectness (or reducing applicability).…”

Section: Steps 1 and 2: Topic Nomination And Topic Scopingmentioning

confidence: 99%

“…10 A major barrier to developing CPGs relevant to people with multimorbidity is that CPGs are built on an evidence base typically focused on the management of a single disease. 2,11,12 Only rarely are data available that are directly applicable to patients with multimorbidity. Extrapolation of evidence from groups with lesser complexity to individuals with greater complexity may increase clinical uncertainty, weaken the strength of the recommendation and/or reduce its applicability.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2014

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Many patients of all ages have multiple conditions, yet clinicians often lack explicit guidance on how to approach clinical decision-making for such people. Most recommendations from clinical practice guidelines (CPGs) focus on the management of single diseases, and may be harmful or impractical for patients with multimorbidity. A major barrier to the development of guidance for people with multimorbidity stems from the fact that the evidence underlying CPGs derives from studies predominantly focused on the management of a single disease. In this paper, the investigators from the Improving Guidelines for Multimorbid Patients Study Group present consensusbased recommendations for guideline developers to make guidelines more useful for the care of people with multimorbidity. In an iterative process informed by review of key literature and experience, we drafted a list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes. The recommended approaches address consideration of coexisting conditions at all major steps in CPG development, from nominating and scoping the topic, commissioning the work group, refining key questions, ranking importance of outcomes, conducting systematic reviews, assessing quality of evidence and applicability, summarizing benefits and harms, to formulating recommendations and grading their strength. The list of issues and recommendations was reviewed and refined iteratively by stakeholders. This framework acknowledges the challenges faced by CPG developers who must make complex judgments in the absence of high-quality or direct evidence. These recommendations require validation through implementation, evaluation and refinement.

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Section: Steps 1 and 2: Topic Nomination And Topic Scopingmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

et al. 2014

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“…Prevalence and incidence of comorbidity have increased during the last two decades and comorbidity might be a source of bias when comparing populations [24]. First, registration practices might differ across countries and perhaps also over time.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Survival of ovarian cancer patients in Denmark: Results from the Danish gynaecological cancer group (DGCG) database, 1995–2012

et al. 2016

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Background: Ovarian cancer has a high mortality rate, especially in Denmark where mortality rates have been reported higher than in adjacent countries with similar demographics. This study therefore examined recent survival and mortality among Danish ovarian cancer patients over an 18-year study period.Methods: This nationwide registry-based observational study used data from the Danish Gynecology Cancer Database, Danish Pathology Registry, and Danish National Patient Registry. All patients with ovarian cancer diagnosed between 1995 and 2012 were included in the study. The data sources were linked via the patients' personal identification number and the analyses included data on cancer stage, age, survival, surgery status and comorbidity. The computed outcome measures were age-adjusted mortality rates and age-adjusted overall and relative survival rates for one and five years.

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“…7 This 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 other words, cannot be considered separately from each other. 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%

“…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.…”

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confidence: 99%

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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Multimorbidity and Evidence Generation

Cited by 57 publications

References 45 publications

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

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

Survival of ovarian cancer patients in Denmark: Results from the Danish gynaecological cancer group (DGCG) database, 1995–2012

Addressing Multimorbidity in Evidence Integration and Synthesis

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