Clinical Practice Guidelines (CPG) have been developed to improve the quality of health care for many chronic conditions. However most aren’t applicable to patients with multimorbidity because they are based on evidence for single diseases. Furthermore, they don’t refer to short and long-term goals, burden, or facilitate patient preferences into treatment plans, all of which may enhance care for patients with multimorbidity.
Boyd developed a treatment for a hypothetical patient using a regimen in accordance with CPGs. It was felt to give rise to an unsustainable treatment burden making independent self-management and adherence difficult. Indeed adhering to CPGs in older patients with multimorbidity may have undesirable effects such as conflicting recommendations, and interactions between drugs and diseases, so offering little guidance for HCPs for the complex management of these patients. Boyd recommends that developing measures of quality of care for these patients is critical to improving their care.
Whilst RCTs, on which CPGs are based, are considered the gold standard for evaluating quality of care, Starfield and Fortin argue that they have poor external validity with the result that CPGs may not be applicable to primary care. Cabana agrees that multimorbidity appears to limit the generalizability of research results and may explain why CPGs aren’t currently followed.
Another obstacle to adhering to guidelines is time. One study suggests that guideline recommendations should be written collaboratively to include diseases that are highly correlated in the same guideline. While recommendations may seem reasonable when considered on their own, they become “impossibly burdensome in the aggregate”. Time burden may be alleviated by a team approach and patient education through print, video, internet and group visits.
Attempting to manage all relevant illnesses with equal vigour according to CPGs may be impractical, harmful, and negatively impact the patients QOL. Durso suggests that clinicians be trained in complex decision-making, because most CPGs are disease focused, don’t facilitate patient preferences, don’t provide guidance for prioritizing multiple medical conditions and stratifying older patients for their likelihood of risk or benefit.
There is emerging concern that methods used to measure the quality of care unfairly penalize providers caring for patients with multimorbidity. HCPs may suffer if pay-for-performance programs create incentives that are misaligned with the needs of these patients, for example, adhering to recommendations in CPGs based on evidence of single diseases.
However Min and Higashi argue that there is higher quality of care for patients with multimorbidity than for those with single conditions. Higashi says the quality of care, measured according to whether patients were offered recommended services, increases as a patients’ number of CDs increases. Min says among older persons at increased risk of death or functional decline, multimorbidity results in better, rather than worse, quality of care. Their findings may be flawed, in that they focused on quantifying HCP actions and recommendations, rather than assessing patients’ ability to adhere to or benefit from them without consideration for the severity or burden of the diseases. In fact, Higashi showed contradicting results for patients with more than seven CDs.
Although there is little evidence of any guidelines specifically addressing multimorbidity, one organisation has gone some way to addressing the complex health needs of elderly patients with diabetes. They developed guidelines that rationalize prioritizing and individualizing evidence-based clinical management. The crux of these recommendations is that they are holistic and aid development of a patient-centred care plan.
(Full list of references available on request)