Applying Clinical Practice Guidelines to the Complex Patient: Insights for Practice and Policy from Stroke Rehabilitation.

In Canada, policy makers are working to align services with the Stroke Rehabilitation Best Practice Recommendations (SRBPR). Complicating the application of clinical practice guidelines (CPGs) is the fact that most strokes occur in the context of other diagnoses. We sought to understand clinicians' use of the CPGs and ascertain how much guidance regarding multimorbidity was available in the SRBPR. Study results indicated that using the recommendations was problematic due to a perceived lack of guidance regarding comorbidities and multimorbidity, and concerns regarding the applicability to "real-life patients." Comorbidities were mentioned in less than half of the recommendations, but no explicit guidance was provided regarding the management of comorbidities. Given the prevalence of multimorbidity in stroke rehabilitation, this clinical context is ideal for development and testing of CPGs that account for multimorbidity and other complexity factors. Results may also suggest limitations to using CPGs in the development of activity-based funding models.

[1]  M. Fortin,et al.  Canadian guidelines for clinical practice: an analysis of their quality and relevance to the care of adults with comorbidity , 2011, BMC family practice.

[2]  Gillian E. Caughey,et al.  Multimorbidity research challenges: where to go from here? , 2011, Journal of comorbidity.

[3]  C. Manski.  USEFUL VARIATION IN CLINICAL PRACTICE UNDER UNCERTAINTY : Diversification and Learning , 2013 .

[4]  R. Kane,et al.  Are we ready for multimorbidity , 2012 .

[5]  B. Guthrie,et al.  Adapting clinical guidelines to take account of multimorbidity , 2012, BMJ : British Medical Journal.

[6]  E. Hanna,et al.  What makes stroke rehabilitation patients complex? Clinician perspectives and the role of discharge pressure , 2016, Journal of comorbidity.

[7]  A. Jadad,et al.  Consideration of multiple chronic diseases in randomized controlled trials. , 2011, JAMA.

[8]  R. Teasell,et al.  Social issues in the rehabilitation of younger stroke patients. , 2000, Archives of physical medicine and rehabilitation.

[9]  Altinay Goksel Karatepe,et al.  Comorbidity in patients after stroke: impact on functional outcome. , 2008, Journal of rehabilitation medicine.

[10]  T. Tsuji,et al.  Comorbidities in stroke patients as assessed with a newly developed comorbidity scale. , 1999, American journal of physical medicine & rehabilitation.

[11]  S. Dinneen,et al.  Multimorbidity and risk among patients with established cardiovascular disease: a cohort study. , 2008, The British journal of general practice : the journal of the Royal College of General Practitioners.

[12]  Psychosocial Outcomes in StrokE: the POISE observational stroke study protocol , 2009, BMC neurology.

[13]  G. Schroth,et al.  Impact of comorbidity on ischemic stroke outcome , 2006, Acta neurologica Scandinavica.

[14]  B. Guthrie,et al.  Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. , 2013, Age and ageing.

[15]  R. W. Grove,et al.  An analysis of the constant comparative method , 1988 .

[16]  J. Wasserman,et al.  Medications, Comorbidities, and Medical Complications in Stroke Survivors: The CAReS Study , 2006, Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses.

[17]  Mark Bayley,et al.  Toward a more effective approach to stroke: Canadian Best Practice Recommendations for Stroke Care , 2008, Canadian Medical Association Journal.

[18]  P. Langhorne,et al.  Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1,424,378 patients in Scotland: implications for treatment burden , 2014, BMC Medicine.

[19]  Martin Fortin,et al.  Future of Multimorbidity Research: How Should Understanding of Multimorbidity Inform Health System Design? , 2010 .

[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.