CoChat
Sign Up
Cited by 220Chronic Disease Management StrategiesClinical practice guidelines implementationPharmaceutical Practices and Patient Outcomes

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

Open access
Lugtenberg, Marjolein, Burgers, Jako S., Clancy, Carolyn, Westert, Gert P., Schneider, Eric C.·2011·PLoS ONE
DOI 10.1371/journal.pone.0025987PMC PMC3197602
Open this paper in CoChat — free accountOpen PDF

Abstract

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.

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1371/journal.pone.0025987

Cites

3 of 3 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Many diagnostic guidelines are incomplete and have limitations including lack of clear definitions, inadequate consideration for comorbidities, and lacking standardized testing methods.

    “However, many diagnostic guidelines are incomplete and have several limitations, including a lack of clear definitions [141,142], inadequate consideration for comorbidities [143,144], and lacking standardized testing methods [145,146].”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [143]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Research works printed but not linked: 26

  1. [1]Tinetti ME Fried T 2004 The end of the disease era. Am J Med 116 179 185 14749162
  2. [2]Gross CP Mallory R Heiat A Krumholz HM 2002 Reporting the recruitment process in clinical trials: who are these patients and how did they get there? Ann Intern Med 137 10 16 12093240
  3. [3]Guyatt GH Sackett DL Cook DJ 1994 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? JAMA 271 59 63 8258890
  4. [4]Grol R 2001 Improving the quality of medical care: building bridges among professional pride, payer profit, and patient satisfaction. JAMA 286 2578 2585 11722272
  5. [5]Van Weel C Schellevis FG 2006 Comorbidity and guidelines: conflicting interests [Comment]. Lancet 367 550 551 16488782
  6. [6]Hoffman C Rice D Sung HY 1996 Persons with chronic conditions: their prevalence and costs. JAMA 276 1473 1479 8903258
  7. [7]Schoen C Osborn R Doty M Bishop M Peugh J Murukutla N 2007 Toward higher-performance health systems: adults' health care experiences in seven countries. Health Aff 26 w717 734 17978360
  8. [8]Wolff JL Starfield B Anderson G 2002 Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 162 2269 2276 12418941
  9. [9]Vogeli C Shields AE Lee TA Gibson TB Marder WD 2007 Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med 22 S391 395 PMC2150598 18026807
  10. [10]Fortin M Soubhi H Hudon C Bayliss EA Van den Akker M 2007 Multimorbidity's many challenges. BMJ 334 1016 1017 17510108 PMC1871747
  11. [11]Redelmeier DA Tan SH Booth GL 1998 The treatment of unrelated disorders in patients with chronic medical diseases. N Engl J Med 338 1516 1520 9593791
  12. [12]Piette JD Kerr EA 2006 The impact of comorbid chronic conditions on diabetes care. Diabetes Care 29 725 731 16505540
  13. [13]Burgers JS Voerman GE Grol R Faber MJ Schneider EC 2010 Quality and coordination of care for patients with multiple conditions: results from an international survey of patient experience. Eval Health Prof 33 343 364 20801976
  14. [14]Francke A Smit M De Veer A Mistiaen P 2008 Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Med Inform Decis Mak 8 38 18789150 PMC2551591
  15. [15]Lugtenberg M Zegers-van Schaick JM Westert GP Burgers JS 2009 Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. Implement Sci 4 54 19674440 PMC2734568
  16. [18]Alonso J Angermeyer MC Bernert S Bruffaerts TS Brugha TS 2004 Disability and quality of life impact of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand 109 38 46 15128386
  17. [19]Rubin RR Peyrot M 1999 Quality of life and diabetes. Diabetes Metab Res Rev 15 205 218 10441043
  18. [20]De Grauw WJC Van de Lisdonk EH Behr RRA Van Gerwen WHEM Van den Hoogen HJM 1999 The impact of type 2 diabetes mellitus on daily functioning. Fam Pract 16 133 139 10381018
  19. [21]Schram MT Baan CA Pouwer F 2009 Depression and quality of life in patients with diabetes: a systematic review from the European depression in diabetes (EDID) research consortium. Curr Diabetes Rev 5 112 119 19442096 PMC2764861
  20. [22]Hussain T Michel G Shiffman RN 2009 The Yale Guideline Recommendation Corpus: a representative sample of the knowledge content of guidelines. Int J Med Inform 78 354 363 19131270
  21. [23]Vitry AI Zhang Y 2008 Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions. Med J Aust 189 360 366 18837677
  22. [24]Schoen C Osborn R How SKH Doty MM Puegh J 2008 In chronic condition: experiences of patients with complex health care needs, in eight countries. Health Aff 28 w1 16 19008253
  23. [26]Altman DG Bland JM 1995 Absence of evidence is not evidence of absence. BMJ 311 485 7647644 PMC2550545
  24. [27]Alderson P 2004 Absence of evidence is not evidence of absence. BMJ 328 476 477 14988165 PMC351831
  25. [28]Burgers JS Bailey JV Klazinga NS Van der Bij AK Grol R 2002 Inside Guidelines. Diabetes Care 25 1933 1939 12401735
  26. [29]Scottish Intercollegiate Guidelines Network (SIGN) 2008 SIGN 50: A guideline developer's handbook. Revised edition Edinburgh Scottish Intercollegiate Guidelines Network

Cited by

Sorted by citations

Authors
Lugtenberg, M., Burgers, J. S., Clancy, C., Westert, G. P., & Schneider, E. C.
Affiliations
  • Tilburg University (NL)
  • Radboud University Medical Center (NL)
  • Agency for Healthcare Research and Quality (US)
  • Brigham and Women's Hospital (US)
Corresponding author
Lugtenberg, Marjolein
ORCID
Venue
PLoS ONE
Publisher
Public Library of Science (PLoS)
Published
2011-10-20
Volume
6
Issue
10
Pages
e25987
ISSN
1932-6203 (ISSN-L)
DOI
10.1371/journal.pone.0025987
PMC
PMC3197602
OpenAlex
W2171544285
Cited by
220
References
3
Citations by year
2026: 7 · 2025: 7 · 2024: 16 · 2023: 5 · 2022: 15 · 2021: 12 · 2020: 13 · 2019: 17 · 2018: 7 · 2017: 20 · 2016: 16 · 2015: 25 · 2014: 31 · 2013: 15 · 2012: 14
FWCI
14.46
Type
journal article
Language
en
Open access
Licence
Locations
  • PLoS ONE (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • Research portal (Tilburg University) (publishedVersion, other-oa)
  • PubMed (publishedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Radboud Repository (Radboud University) (submittedVersion)
  • Radboud Repository (Radboud University) (submittedVersion, other-oa)
Funders
  • Commonwealth Fund
  • London School of Hygiene and Tropical Medicine
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
comorbidities, guideline applicability, chronic obstructive pulmonary disease, depressive disorders, type 2 diabetes, osteoarthritis, level of evidence, chronic disease
MeSH terms
Depressive Disorder, Diabetes Mellitus, Type 2, Humans, Osteoarthritis, Quality Control, Comorbidity, Practice Guidelines as Topic, Evidence-Based Medicine, Pulmonary Disease, Chronic Obstructive

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review