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Category Archives: Practice guidelines

European guidelines on nutritional support for polymorbid (multimorbid) internal medicine patients

By Filomena Gomes and Philipp Schuetz
The European Society for Clinical Nutrition and Metabolism (ESPEN) holds several guidelines and position papers which guide clinicians in providing nutritional support in particular groups of patients, usually disease or age specific (http://www.espen.org/education/espen-guidelines).
However, many of the patients requiring nutritional support may suffer from multiple diseases. In fact, polymorbidity (multimorbidity) is highly prevalent, affecting more than 70% of the hospitalized adult population, and is associated with higher mortality and costs. In this context, a group of 14 European experts is developing guidelines on nutritional support for polymorbid (multimorbid) internal medicine patients, with the aim to help clinicians who struggle with the uncertainties of applying disease-specific guidelines to their patients who suffer from multiple conditions.
This project, which is endorsed by ESPEN, started with an initial meeting in Zurich, in January 2015, and the methodology used follows the standard operating procedures for ESPEN guidelines (Clinical Nutrition. 2015;34(6):1043-51). The working group has developed 12 important clinical questions, covering different areas of nutritional support: indication, route of feeding, energy, protein, micronutrients, disease-specific nutrients, timing, monitoring and procedure of intervention. Systematic literature searches were conducted in 3 different databases (as well as in secondary sources) resulting in a total of 4532 retrieved abstracts. These abstracts were screened to identify papers which meet the inclusion criteria; the quality of the included papers was evaluated and a level of evidence was assigned, which then resulted in a proposal of 22 recommendations and 4 statements. The first DELPHI online voting for these recommendations and statements is now completed and a final consensus conference will take place in April 2017, which will be followed by the preparation of the manuscript for publication.

Invitation to participate in a study related to the multimorbidity issue

By Walter Wodchis and Yelena Petrosyan

We would like to invite Canadian primary care physicians/geriatricians to participate in the Delphi study that aims to  define the most appropriate set of quality indicators for assessing quality of overall care of older diabetes patients with comorbid concordant and discordant chronic conditions. Various quality measures have been developed for assessing care for single diseases. However, adherence to disease-specific measures for patients with multiple chronic conditions may lead to the unintended consequence of delivering inappropriate care. Therefore, it is crucial to identify measures that would address the heterogeneity and scope of care for a particular individual with particular types of co-existing conditions to improve the quality of care of people with multimorbidity.

Your participation will be anonymous, and will consist of responding to 2-3 electronic questionnaires, and each round will take approximately 20 minutes to complete. After completion of all three rounds, expected by December 20th 2015, you will be given a cheque for $200 to compensate you for any disruption to your practice.
If you might be interested in participating in our study please contact Walter Wodchis at walter.wodchis@utoronto.ca or Yelena Petrosyan at yelena.petrosyan@mail.utoronto.ca for further information.

How to handle multimorbidity in primary care consultations

By Marjan van den Akker
An international group of scientists working around the themes of multimorbidity and polypharmacy have recently published a paper in BMC Medicine [1] on the management of patients with multimorbidity in primary care consultations. The article aims to support decision making in primary care consultations, through a set of guiding principles. These principles are named after the Greek mythological figure Ariadne, who helped the Greek hero Theseus escape from the labyrinth.
The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient’s conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient’s preferences – his or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process.

1-Muth C, van den Akker M, Blom JW, Mallen CD, Rochon J, Schellevis FG, Becker A, Beyer M, Gensichen J, Kirchner H, Perera R, Prados-Torres A, Scherer M, Thiem U, van den Bussche H, Glasziou PP. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Med 2014; 12:223.

Improving Guidelines for Multimorbid Patients

By Cynthia M. Boyd and David M. Kent

With rare exceptions, guidelines focus on the management of a single disease, or a single disease-problem, and do not address how to optimally integrate care for individuals whose multiple problems may make guideline-recommended management of any single disease impractical, irrelevant or even harmful.  Current standards of guideline development or appraisal do not prompt guideline developers to routinely address the issue that not all patients with the same condition benefit similarly from similar therapy, nor do they provide tools for adapting the recommendations to the patient with many diseases or for prioritizing the most important recommendations within a single disease, let alone between diseases. The root of this problem, however, is not narrowly confined to guideline development and implementation. At each phase of the translational path including trial and study design and analysis, the synthesis of trial and observational study results in meta-analyses and systematic reviews, and the guideline development process, the very information necessary to support evidence-based care of the person with multimorbidity is excluded.  Needed, then, is a comprehensive approach built on a firm understanding of each of these phases of evidence generation, synthesis and integration, and guideline development. 

To address these issues, we assembled a collaborative team with complementary expertise spanning the various phases of evidence development and translation to develop a comprehensive description of the problem and provisional recommendations.  These were refined through an iterative process of feedback from researchers (from medicine, public health, biostatistics), guideline developers, and stakeholders from government, other payers and industry, which culminated at a conference on Improving Guidelines for Multimorbid Patients (Baltimore, Maryland October 2010). The results of this project are presented in 4 papers [1-4] in a symposium in the Journal of General Internal Medicine, focused on the following 3 areas: 1) evidence generation (clinical trial and observational study design and analysis), 2) evidence synthesis (systematic review, meta-analyses) and 3) guideline development.


1. Boyd CM and Kent DM. Evidence-Based Medicine and the Hard Problem of Multimorbidity. JGIM 2014 Jan 18. [Epub ahead of print].
2. Weiss CO, Varadhan R, Puhan M, Vickers A, Bandeen-Roche K, Boyd CM, Kent  DM. Multimorbidity and Evidence Generation, JGIM 2014 Jan 18. [Epub ahead of print].
3. Trikalinos T, Segal J, Boyd CM. Addressing Multimorbidity in Evidence Synthesis and Integration., JGIM 2014 Jan 18. [Epub ahead of print].
4. Uhlig K, Leff B, Kent DM, Dy S, Brunnhuber K, Burgers J, Greenfield S, Guyatt G, High K, Leipzig R, Mulrow C, Schmader K, Schunemann H, Walter L, Woodcock J, and Boyd CM. A framework for crafting clinical practice guidelines that are relevant to the care and management of people with multimorbidity. JGIM 2014 Jan 18. [Epub ahead of print].

Canadian clinical guidelines and multimorbidity

By Martin Fortin

Clinical guidelines aim to improve the quality of care provided to patients. However, given that guidelines are mostly disease-oriented, we may discover conflicting recommendations when implementing those guidelines with patients presenting multiple concurrent chronic conditions. As a result, physicians frequently use their own clinical experience and patients’ views on treatment choice instead of national guidelines recommendations.

This situation prompted us to examine the relevance of Canadian clinical guidelines for patients with comorbidity for selected chronic diseases. The study was published by BMC Family Practice and is accessible through their website (http://www.biomedcentral.com/1471-2296/12/74). In summary, we found that despite the good to very good quality of the guidelines, only a few addressed specific recommendations for patients with two or more comorbid conditions.

The subject had been  previously addressed from different angles, but in this study we followed the steps of Australian colleagues [1] in the use of a tool developed by Boyd and colleagues [2] that allows to evaluate the applicability of guidelines on chronic diseases for the treatment of subjects with comorbidity. The tool is a checklist in which each item is scored as “yes” or “no”, and assesses whether guidelines address treatment for people with several comorbid conditions, as well as patient-centered aspects such as patient preferences and quality of life. We improved its comprehensiveness with the addition of items related to medication. To our knowledge, this is the only tool available for this purpose.

This study may potentially stimulate other researchers to follow suit with the assessment of their respective national guidelines, and further highlight the need for improved clinical guidelines relevant to patients with two or more chronic conditions worldwide.

1.    Vitry, A.I. and Y. Zhang, Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions. Med J Aust, 2008. 189: p. 360-5.

2.    Boyd, C.M., et al., Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. J.A.M.A., 2005. 294: p. 716-24.