Journal of General Internal Medicine

, Volume 29, Issue 4, pp 670–679

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

  • Katrin Uhlig
  • Bruce Leff
  • David Kent
  • Sydney Dy
  • Klara Brunnhuber
  • Jako S. Burgers
  • Sheldon Greenfield
  • Gordon Guyatt
  • Kevin High
  • Rosanne Leipzig
  • Cynthia Mulrow
  • Kenneth Schmader
  • Holger Schunemann
  • Louise C. Walter
  • James Woodcock
  • Cynthia M. Boyd
Multimorbidity Symposium

ABSTRACT

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 WORDS

guidelines multimorbidity comorbidity grading evidence 

Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Katrin Uhlig
    • 1
  • Bruce Leff
    • 2
    • 4
  • David Kent
    • 3
  • Sydney Dy
    • 4
  • Klara Brunnhuber
    • 5
  • Jako S. Burgers
    • 6
  • Sheldon Greenfield
    • 7
  • Gordon Guyatt
    • 8
  • Kevin High
    • 9
  • Rosanne Leipzig
    • 10
  • Cynthia Mulrow
    • 11
  • Kenneth Schmader
    • 12
  • Holger Schunemann
    • 8
  • Louise C. Walter
    • 13
  • James Woodcock
    • 14
  • Cynthia M. Boyd
    • 2
    • 4
  1. 1.Department of Medicine, Division of Nephrology, and Institute for Clinical Research and Health Policy Studies, Center for Clinical Evidence Synthesis, Tufts Medical CenterTufts University School of MedicineBostonUSA
  2. 2.Division of Geriatric Medicine and Gerontology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Institute for Clinical Research and Health Policy StudiesTufts Medical CenterBostonUSA
  4. 4.Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  5. 5.BMJ Evidence CentreLondonUK
  6. 6.Department of Guideline Development and ResearchDutch College of General PractitionersUtrechtThe Netherlands
  7. 7.Health Policy Research Institute, School of MedicineUniversity of California at IrvineIrvineUSA
  8. 8.Clinical Epidemiology & BiostatisticsMcMaster UniversityHamiltonCanada
  9. 9.Section on Infectious DiseasesWake Forest School of MedicineWinston-SalemUSA
  10. 10.Brookdale Department of Geriatrics and Palliative MedicineMount Sinai School of MedicineNew YorkUSA
  11. 11.University of Texas Health Science Center at San AntonioSan AntonioUSA
  12. 12.Kenneth E. Schmader, Division of Geriatrics, Department of MedicineDuke University Medical Center and GRECC, Durham VA Medical CenterDurhamUSA
  13. 13.Division of GeriatricsSan Francisco VA Medical Center and University of CaliforniaSan FranciscoUSA
  14. 14.UKCRC Centre for Diet and Activity Research (CEDAR), Institute of Public HealthUniversity of CambridgeCambridgeUK

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