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A Framework for Crafting Clinical Practice Guidelines that are Relevant to the Care and Management of People with Multimorbidity
Open accessAbstract
Many patients of all ages have multiple conditions, yet clinicians often lack explicit guidance on how to approach clinical decision-making for such people. Most recommendations from clinical practice guidelines (CPGs) focus on the management of single diseases, and may be harmful or impractical for patients with multimorbidity. A major barrier to the development of guidance for people with multimorbidity stems from the fact that the evidence underlying CPGs derives from studies predominantly focused on the management of a single disease. In this paper, the investigators from the Improving Guidelines for Multimorbid Patients Study Group present consensus-based recommendations for guideline developers to make guidelines more useful for the care of people with multimorbidity. In an iterative process informed by review of key literature and experience, we drafted a list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes. The recommended approaches address consideration of coexisting conditions at all major steps in CPG development, from nominating and scoping the topic, commissioning the work group, refining key questions, ranking importance of outcomes, conducting systematic reviews, assessing quality of evidence and applicability, summarizing benefits and harms, to formulating recommendations and grading their strength. The list of issues and recommendations was reviewed and refined iteratively by stakeholders. This framework acknowledges the challenges faced by CPG developers who must make complex judgments in the absence of high-quality or direct evidence. These recommendations require validation through implementation, evaluation and refinement.
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“In addition to the aforementioned issues with diagnostic error definitions, most clinical practice guidelines target specific diseases, ignoring their relevance for patients with various comorbidities [148,149,150].”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [149]
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Cited by
Sorted by citations
Skou, S. T., Mair, F. S., Fortin, M., Guthrie, B., Nunes, B. P., Miranda, J. J., Boyd, C. M., Pati, S., Mtenga, S., & Smith, S. M. (2022) · Nature Reviews Disease Primers · doi:10.1038/s41572-022-00376-4 · Cited by 1,499
“Chan School of Public Health (BLSCHP-1902), Bloomberg Philanthropies (via University of North Carolina at Chapel Hill School of Public Health), FONDECYT via CIENCIACTIVA/CONCYTEC, British Council, British Embassy and the NewtonPaulet Fund (223-2018, 224-2018), DFID/ MRC/Wellcome Global Health Trials (MR/M007405/1), Fo…”
MethodSelf-citationAdler, R. A., Fuleihan, G. E., Bauer, D. C., Camacho, P. M., Clarke, B. L., Clines, G. A., Compston, J. E., Drake, M. T., Edwards, B. J.-A., Favus, M. J., et al. (2015) · Journal of Bone and Mineral Research · doi:10.1002/jbmr.2708 · Cited by 689
“As has been discussed in a series of papers on guidelines,((146)) basing guidelines on randomized trials does not address the impact of coexisting conditions in many patients with a given disorder.”
The multimorbidity interaction severity index (MISI)
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“Health care systems are still largely single disease oriented and lack clinical guidelines for multimorbidity (Barnett et al., 2012a; Salisbury et al., 2011; Uhlig et al., 2014).”
Fabbri, E., Zoli, M., González‐Freire, M., Salive, M. E., Studenski, S. A., & Ferrucci, L. (2015) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2015.03.013 · Cited by 589
Metadata
- Authors
- Uhlig, K., Leff, B., Kent, D., Dy, S., Brunnhuber, K., Burgers, J. S., Greenfield, S., Guyatt, G., High, K., Leipzig, R., Mulrow, C., Schmader, K., Schunemann, H., Walter, L. C., Woodcock, J., & Boyd, C. M.
- Affiliations
- Tufts University (US)
- Johns Hopkins University (US)
- Tufts Medical Center (US)
- BMJ Group (United Kingdom) (GB)
- Dutch College of General Practitioners (NL)
- University of California, Irvine (US)
- McMaster University (CA)
- Wake Forest University Health Sciences (US)
- Icahn School of Medicine at Mount Sinai (US)
- The University of Texas at San Antonio Health Science Center (US)
- Duke Medical Center (US)
- San Francisco VA Medical Center (US)
- University of Cambridge (GB)
- Corresponding author
- Boyd, Cynthia M.
- ORCID
- Venue
- Journal of General Internal Medicine
- Published
- 2014-01-18
- Volume
- 29
- Issue
- 4
- Pages
- 670-679
- ISSN
- 0884-8734 (ISSN-L)
- 1525-1497
- PMC
- PMC3965742
- OpenAlex
- W2146328920
- Cited by
- 158
- References
- 0
- Citations by year
- 2026: 5 · 2025: 8 · 2024: 7 · 2023: 10 · 2022: 12 · 2021: 9 · 2020: 10 · 2019: 18 · 2018: 13 · 2017: 22 · 2016: 18 · 2015: 14 · 2014: 10
- FWCI
- 2.85
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Journal of General Internal Medicine (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- Robert Wood Johnson Foundation
- John A. Hartford Foundation
- Hartford Foundation for Public Giving
- Atlantic Philanthropies
- Brown University
- Tufts Medical Center
- Johns Hopkins University
- Starr Foundation
- Agency for Healthcare Research and Quality (R21HS017653, R21HS018597, AHRQ R21 HS017653, AHRQ R21 HS018597-01)
- Johns Hopkins Bloomberg School of Public Health
- Medical Research Council (MR/K021796/1, MR/K023187/1)
- Economic and Social Research Council (ES/G007462/1)
- Center for Innovative Medicine
- National Institute on Aging (K23AG032910, K24AG041180, NIA K23 AG032910, P30AG028716)
- National Cancer Institute (R01CA134425)
- Topics
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Keywords
- multimorbidity, guideline development, comorbidities, clinical decision-making, guideline applicability, evidence quality assessment, benefit-harm assessment, consensus recommendations, stakeholder engagement
- MeSH terms
- Congresses as Topic, Patient Care, Humans, Comorbidity, Practice Guidelines as Topic, Evidence-Based Medicine, Disease Management
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