Entete 3

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].

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