Current Guidelines Have Limited Applicability to Patients with Comorbid Conditions: A Systematic Analysis of Evidence-Based Guidelines

Background Guidelines traditionally focus on the diagnosis and treatment of single diseases. As almost half of the patients with a chronic disease have more than one disease, the applicability of guidelines may be limited. The aim of this study was to assess the extent that guidelines address comorbidity and to assess the supporting evidence of recommendations related to comorbidity. Methodology/Principal Findings We conducted a systematic analysis of evidence-based guidelines focusing on four highly prevalent chronic conditions with a high impact on quality of life: chronic obstructive pulmonary disease, depressive disorder, diabetes mellitus type 2, and osteoarthritis. Data were abstracted from each guideline on the extent that comorbidity was addressed (general comments, specific recommendations), the type of comorbidity discussed (concordant, discordant), and the supporting evidence of the comorbidity-related recommendations (level of evidence, translation of evidence). Of the 20 guidelines, 17 (85%) addressed the issue of comorbidity and 14 (70%) provided specific recommendations on comorbidity. In general, the guidelines included few recommendations on patients with comorbidity (mean 3 recommendations per guideline, range 0 to 26). Of the 59 comorbidity-related recommendations provided, 46 (78%) addressed concordant comorbidities, 8 (14%) discordant comorbidities, and for 5 (8%) the type of comorbidity was not specified. The strength of the supporting evidence was moderate for 25% (15/59) and low for 37% (22/59) of the recommendations. In addition, for 73% (43/59) of the recommendations the evidence was not adequately translated into the guidelines. Conclusions/Significance Our study showed that the applicability of current evidence-based guidelines to patients with comorbid conditions is limited. Most guidelines do not provide explicit guidance on treatment of patients with comorbidity, particularly for discordant combinations. Guidelines should be more explicit about the applicability of their recommendations to patients with comorbidity. Future clinical trials should also include patients with the most prevalent combinations of chronic conditions.

[1]  C. Gross,et al.  Reporting the Recruitment Process in Clinical Trials: Who Are These Patients and How Did They Get There? , 2002, Annals of Internal Medicine.

[2]  A. Dhar,et al.  National Institute for Health and Clinical Excellence , 2005 .

[3]  C. van Weel,et al.  Microalbuminuria in patients with Type 2 diabetes mellitus from general practice: course and predictive value , 2001, Diabetic medicine : a journal of the British Diabetic Association.

[4]  D G Altman,et al.  Statistics notes: Absence of evidence is not evidence of absence , 1995 .

[5]  C. Hoffman,et al.  Persons with chronic conditions. Their prevalence and costs. , 1996, JAMA.

[6]  J. Os,et al.  Childhood abuse as a risk factor for psychotic experiences , 2003, Schizophrenia Research.

[7]  G. Guyatt,et al.  Users' guides to the medical literature. , 1993, JAMA.

[8]  C. van Weel,et al.  The impact of type 2 diabetes mellitus on daily functioning. , 1999, Family practice.

[9]  Vikram Patel,et al.  Depression, chronic diseases, and decrements in health: results from the World Health Surveys , 2007, The Lancet.

[10]  M. Tinetti,et al.  The end of the disease era. , 2004, The American journal of medicine.

[11]  F. Mazzi,et al.  Disability and quality of life impact of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project , 2004, Acta psychiatrica Scandinavica. Supplementum.

[12]  R. Grol,et al.  Inside guidelines: comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries. , 2002, Diabetes care.

[13]  Richard N. Shiffman,et al.  The Yale Guideline Recommendation Corpus: A representative sample of the knowledge content of guidelines , 2009, Int. J. Medical Informatics.

[14]  C. Schoen,et al.  In chronic condition: experiences of patients with complex health care needs, in eight countries, 2008. , 2008, Health affairs.

[15]  R. Grol.  Improving the quality of medical care: building bridges among professional pride, payer profit, and patient satisfaction. , 2001, JAMA.

[16]  Gordon H. Guyatt,et al.  How to Use an Article About Therapy or Prevention , 1995 .

[17]  R. Rubin,et al.  Quality of life and diabetes , 1999, Diabetes/metabolism research and reviews.

[18]  F. Pouwer,et al.  Depression and Quality of Life in Patients with Diabetes: A Systematic Review from the European Depression in Diabetes (EDID) Research Consortium , 2009, Current diabetes reviews.

[19]  G. Voerman,et al.  Quality and Coordination of Care for Patients With Multiple Conditions: Results From an International Survey of Patient Experience , 2010, Evaluation & the health professions.

[20]  A. Wu,et al.  Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. , 2005, JAMA.

[21]  Eve A Kerr,et al.  The impact of comorbid chronic conditions on diabetes care. , 2006, Diabetes care.

[22]  William D. Marder,et al.  Multiple Chronic Conditions: Prevalence, Health Consequences, and Implications for Quality, Care Management, and Costs , 2007, Journal of General Internal Medicine.

[23]  Gordon H. Guyatt,et al.  Users' Guides to the Medical Literature: II. How to Use an Article About Therapy or Prevention B. What Were the Results and Will They Help Me in Caring for My Patients? , 1994 .

[24]  Anke J. E. de Veer,et al.  Factors influencing the implementation of clinical guidelines for health care professionals: A systematic meta-review , 2008, BMC Medical Informatics Decis. Mak..

[25]  Marjan van den Akker,et al.  Multimorbidity's many challenges , 2007, BMJ : British Medical Journal.

[26]  D. Redelmeier,et al.  The treatment of unrelated disorders in patients with chronic medical diseases. , 1998, The New England journal of medicine.

[27]  François G Schellevis,et al.  Comorbidity and guidelines: conflicting interests , 2006, The Lancet.

[28]  V. Preedy,et al.  Scottish Intercollegiate Guidelines Network , 2010 .

[29]  J. Avorn,et al.  The exclusion of the elderly and women from clinical trials in acute myocardial infarction. , 1992, JAMA.

[30]  B. Starfield,et al.  Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. , 2002, Archives of internal medicine.

[31]  Cathy Schoen,et al.  Toward higher-performance health systems: adults' health care experiences in seven countries, 2007. , 2007, Health affairs.

[32]  A. Vitry,et al.  Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions , 2008, The Medical journal of Australia.

[33]  Marjolein Lugtenberg,et al.  Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners , 2009, Implementation science : IS.