A Framework for Crafting Clinical Practice Guidelines that are Relevant to the Care and Management of People with Multimorbidity
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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 consensus-based 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.
KEY WORDSguidelines multimorbidity comorbidity grading evidence
The expert panel included Klara Brunnhuber, Jako S. Burgers, Sheldon Greenfield, Gordon Guyatt, Kevin High, Rosanne Leipzig, Cynthia Mulrow, Kenneth Schmader, Holger Schunemann, Louise C. Walter, and James Woodcock.
We acknowledge Anand Parekh and Kay Dickersin for their attendance for part of the ‘Improving Guidelines for Multimorbid Patients Stakeholder Conference.’
We acknowledge the Participants in the Guideline Breakout Groups who attended the ‘Improving Guidelines for Multimorbid Patients Stakeholder Conference’ (See below), Baltimore, Maryland, Fall 2010
Lewis, Sandra Zelman
This work was funded by AHRQ R21 HS018597-01 (PI Boyd) and AHRQ R21 HS017653. Dr. Boyd’s effort was supported in part by the Johns Hopkins Bayview Center for Innovative Medicine, The Robert Wood Johnson Foundation Physician Faculty Scholars Program, and the Paul Beeson Career Development Award Program (NIA K23 AG032910, AFAR, The John A. Hartford Foundation, The Atlantic Philanthropies, The Starr Foundation, and an anonymous donor). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Dr. Walter’s effort was supported by the National Cancer Institute (grant number R01 CA134425) and the National Institute on Aging (grant number K24 AG041180).
Improving Guidelines for Multimorbid Patients Investigator Group
Cynthia Boyd, Johns Hopkins Medical Institutions (JHMI), Sydney Dy, Johns Hopkins Bloomberg School of Public Health (JHSPH), David M. Kent, Tufts Medical Center (TMC), Bruce Leff, JHMI, Jodi Segal (JHMI) Thomas A. Trikalinos, Brown University, Katrin Uhlig, TMC, Ravi Varadhan, JHMI, Carlos Weiss, JHMI.
Conflict of Interest
Dr. Boyd is a co-author of an article on multimorbidity for UpToDate.
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