Adapting clinical guidelines to take account of multimorbidityBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6341 (Published 04 October 2012) Cite this as: BMJ 2012;345:e6341
All rapid responses
Not mentioned in the analysis are the nurses who are trained to deal with a single disease using a specific guideline. A consequence of the arrival of these nurses has been the de-skilling of the GPs who have passed the care of patients for example with COPD or asthma to a nurse.
GPs are the only generalists left in the NHS and they are now exposed by the consequences of the single disease/guideline approach of recent years. They now need to deal with patients with multiple morbidities and need help but not from even more complicated guidelines. What is wrong with the basic clinical training of previous generations of medics who knew nothing of guidelines?
Competing interests: No competing interests
Currently multimorbidity is a hot topic in general medical journals [1-4] with a lot of attention to how to adapt clinical guidelines . However, adapted guidelines need good collaboration of the many medical specialists involved to lead to the delivery of optimal care for patients with multimorbidity. The key aspect for a successful collaboration is good communication, which is highly dependent on a clear and concise presentation of these patients’ problems. However, just as summing up guideline recommendations for all problems ends up with an unworkable long and conflicting list of items, presenting all problems complete with an extensive differential diagnosis does not work either. Such a presentation is time-consuming, dull and difficult to remember, let alone that colleagues can pick the most important problems from the list to focus on. This approach also ignores the fact that many problems have multifactorial, interdependent causes . Obviously, a new way to present patients with multimorbidity at clinical meetings is needed to make meetings effective, stimulating and efficient. The one minute preceptor method  may serve as an excellent start by stimulating the presenter to make a short simplified statement, complimented by a clear prioritising of problems and their main underlying causes. This also leaves time to discuss the complex dynamics of multimorbidity of the presented patients. Less is more, even in the presentation of patients with complex multimorbidity.
1. Mercer SW, Gunn J, Bower P, Wyke S, Guthrie B. Managing patients with mental and physical multimorbidity. BMJ 2012;345:e5559
2. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012;380:37-43
3. Guthrie B, Payne K, Alderson P, McMurdo ME, Mercer SW. Adapting clinical guidelines to take account of multimorbidity. BMJ 2012;345:e6341
4. Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition--multimorbidity. JAMA 2012;307:2493-4
5. Olde Rikkert MGM, Rigaud AS, van Hoeyweghen RJ, de Graaf J.Geriatric syndromes: medical misnomer or progress in geriatrics? Neth J Med. 2003;61:83-7.
6. Aagaard E, Teherani A, Irby DM. Effectiveness of the one-minute preceptor model for diagnosing the patient and learner: proof of concept. Acad Med 2004;79:42-9
Competing interests: No competing interests
Guthrie and colleagues are to be congratulated on an excellent article highlighting the limitations of evidence base medicine and guidelines and the challenges of multimorbidity in modern medicine and the importance of clinical judgement and experience in managing chronic disease (1).
The difficulties identified are equally applicable, if not even more acute in emergency medicine, quite literally! Patients with multimorbidity may be admitted with an acute exacerbation of any of the numerous medical diagnoses they have acquired. Furthermore, an acute exacerbation may involve more than one system. Finally, even if the guidelines are right, how do we get doctors to follow them?
This and other important issues were highlighted in the British Thoracic Society (BTS) adult community acquired pneumonia (CAP) audit 2009/2010, which demonstrated a delay in treatment and an inappropriate use of antibiotics in non-severe CAP, both of which are associated with adverse outcomes (2). This was despite the availability on line of excellent evidence based national guidelines (3) that most units had in fact adapted for local purposes (2).
Performing audit against guidelines is integral to doctors training and continued professional development. Repeated studies demonstrate that guideline-compliant antibiotic regimens are associated with reduced mortality (4). So, why was adherence to CAP guidelines so poor but why was non-adherence to CAP guidelines not associated with an adverse 30-day in patient mortality?
It is possible that the format and presentation of the available guidelines could not be readily applied in the busy acute clinical setting and failed to provide confidence to clinical staff to prescribe more appropriate but less aggressive antibiotic regimens. The lack of improvement in mortality despite adherence CAP guidelines, may be due to suboptimal supportive and resuscitative treatments of complications of pneumonia (e.g. hypoxia and respiratory failure administered inappropriate oxygen, dehydration not managed with correct fluid maintenance, or hypotension and renal failure due to systemic inflammatory response syndrome (SIRS) not treated with appropriate intravenous fluids) or of existing co morbidities deteriorating in the presence of pneumonia (e.g. hyperglycaemia in an ill diabetic). The CAP guidelines (3) are not exhaustive in this respect and indeed it would be unreasonable to expect and impossible to deliver national guidelines covering all such eventualities.
The Bedside Clinical Guideline Partnership (BCGP) has been providing evidence based annually updated guidelines for its member trusts (currently more than 20) since 1995. The aim has been to design them from a users’ perspective. The BCGP also provide surgical, obstetric, nursing, paediatric and will be adding emergency medicine later this year, in the same formats, therefore junior doctors are familiar with the layout throughout their training. The all-encompassing national society guidelines can appear as a series of ‘ingredients’, from which health care professionals are still required to select the most appropriate plan for the individual patient. The BCGP guidelines, however, are more of a ‘recipe’, with more direct advice, relevant at the point of care. Furthermore, the BCGP guidelines include guidelines on intravenous fluid treatment (for resuscitation and fluid maintenance), oxygen delivery, which are easily accessible and cross-referenced in the BCGP CAP guideline, a ‘recipe for all courses of a meal’ rather than a ‘single dish’. Such guidelines may be the ‘missing link’ between national society guidelines and practical clinical care at the point of delivery (5).
It is important to develop strategies and guidelines to manage patients with multimorbidity associated with chronic disease but these should also address potential exacerbations of these conditions which may involve more than one system. Furthermore, we need to improve guideline adherence and patient outcome.
Dr Naveed Mustfa
On behalf of the Bedside Clinical Partnership Group
1.Guthrie et al. BMJ 2012; 345:e6341
2.Lim WS, Woodhead M. British Thoracic Society adult community acquired pneumonia audit 2009/10. Thorax;66(6):548-9.
3.Lim WS, Baudouin SV, George RC, et al. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009;64 Suppl 3:iii1-55.
4.Wilson KC, Schunemann HJ. An Appraisal of the Evidence Underlying Performance Measures for Community-acquired Pneumonia. Am J Respir Crit Care Med;183(11):1454-62.
5.Pantin C, Mucklow J, Rogers D, Cross M, Wall J. Bedside clinical guidelines: the missing link. Clin Med 2006;6(1):98-104.
Competing interests: Clinical Lead Bedside Clinical Guideline Partnership
Every clinician would do well to read Guthrie and colleagues’ paper (1)and then Nigel Crisp’s at least as thought provoking one on patient power(2). Each concerns a different aspect of the same problem. Crisp catalogues the difficulties of truly involving patients in their healthcare – of making them central to it. Guthrie et al propose ways in which guidelines could be improved to ensure more joined-up care for people with multimorbidities as medicine becomes increasingly specialised and compartmentalised.
Science and medicine have become very much better at extending people’s lives, but doctors appear to have come to see extension of life as the ultimate goal regardless of people’s quality of life. This is one of the chief reasons for health services’ repeated failures, across the world, to place patients at the heart of healthcare.
I have long argued that each patient with multi-morbidities should be actively involved in the development of a personal care plan. It should begin with exploration and consideration of the patient as a person with aspirations. Everyone is different. Some people may simply wish to be able to carry on knitting or to do a bit of carpentry. Others may wish to be able to go shopping or to take grandchildren to the park. And there will be those who would like to be able to carry on working, to engage in physically active pursuits or to travel abroad.
Once people’s aspirations have been identified, the primary care team should work with them to develop treatment regimens for their conditions that enable them to fulfil them as far as may be practicable, almost regardless of whether it extends their lives or not. Such care plans could include lifestyle changes as well as medical treatment. Everyone concerned (and especially the person concerned) should sign up to that care plan which could then be shared with – and if necessary adjusted by – the patient’s secondary care providers in consultation with the patient. That should not be difficult if specialist’s letters to GPs about patients’ consultations with them are comprehensive, timely and accurate, for GPs will have been able to take the content of those letters into account in developing the care plan. Care plans should be reviewed annually or when a person’s health circumstances change significantly.
Doctors’ immediate response to this suggestion is sometimes that it would be time-consuming and costly. They may be right in the short term but they are mistaken in terms of overall health costs and patient satisfaction. It would give patients a strong sense of active involvement in their care. Because the patient would have signed up to it, it should greatly increase adherence, non-adherence being one of the most persistent causes of waste in health services. The care plan could be relatively simple and formulaic, saving a considerable amount of time-consuming note-reading by a succession of healthcare professionals. And, above all, it would enable many patients to lead the lives they want to lead and, in some cases, help them to understand why there are some things that are simply not practicable.
It may be that such a care plan would not necessarily extend people’s lives greatly, but it would surely make them happier, and that is the direction in which medicine might most usefully be heading.
Patient editor, BMJ
1. Guthrie B, Payne K, Anderson P, McMurdo M, Mercer S. Adapting clinical guidelines to take account of multimorbity. BMJ 2012;3345:e6341
2. Crisp N. Patient power needs to be built on strong intellectual foundations. BMJ 2012;345:e6177
Competing interests: No competing interests
We thank Guthrie and colleagues for highlighting the need for better integration of guidelines in the management of multimorbidity and Kadam for his suggestions for the redesign of the general practice consultation to improve care for people with multiple morbidities.1,2 These are developments long neglected but urgently needed. Currently, disease reviews may occur singly (almost invariably so in secondary care, we suggest, but also commonly in general practice). In addition to the need to better manage multimorbid conditions from the medical perspective, we agree that there is an equally important need to focus better on the priorities of those living with multiple morbidities when agreeing a management plan.2,3 Helping patients to manage their own conditions is one of the tenets of the NHS Outcomes Framework 2012/13.4
Although electronic cross-referencing of guidelines is a necessary component of integration, we do not consider it to be sufficient. Simple cross-referencing between guidelines would become cumbersome in the presence of more than two morbidities. Development of new guidelines that take into account multimorbidities and the evidence available in managing conditions in the context of multimorbidity is ultimately desirable but will not be completed soon enough. It should not be unduly difficult to arrange tailored reviews for patients, taking into account the overlapping principles of guidelines and unique management approaches for each morbidity. A holistic review of patients with multiple morbidities at appropriate intervals, as Guthrie and colleagues suggest, can thus start to become a reality.
Electronically integrated guidelines, created with the support of the clinical IT system suppliers, would identify the relevant morbidities and recommended targets with treatment strategies. Information would thus be supplied to the clinician, including a clinical management decision support tool. Data would also be recorded though the guideline, including modification of targets or treatment strategies by the clinician-patient partnership. Prompts for concurrent consideration of patient priorities and needs would ensure that both patient and healthcare professionals’ agenda are addressed. The resulting agreed, shared management plan could then be printed for the patient‘s own reference.
We envisage an integrated review to entail an initial visit to a practice nurse for relevant tests (such as those required for the Quality & Outcomes Framework) and for a review of aspects often at the core of single disease guidelines (healthy diet, weight management, exercise, and smoking cessation). A subsequent review with an appropriately qualified clinician would then utilise the integrated guidelines, taking account of individual patient needs to diverge from the usual guidance for clinical reasons or those of personal patient preference.
This format of review would inevitably take longer than a single disease-based approach, but would have the benefit of saving on the number of visits and would facilitate a more holistic view of clinical management. A printed form of the self-management plan might also help to keep the patient and all the treating clinicians on the same page when reviews take place!
1. Guthrie B, Payne K, Alderson P, McMurdo MET, Mercer SE. Adapting clinical guidelines to take account of multimorbidity. BMJ 2012;345:e6341 doi: 10.1136/bmj.e6341
2. Kadam U. Redesigning the general practice consultation to improve care for patients with multimorbidity BMJ 2012;345:e6202 doi: 10.1136/bmj.e6202
3. Fried, T, McGraw, S, Agostini, J, & Tinetti, M 2008, 'Views of older persons with multiple morbidities on competing outcomes and clinical decision-making', Journal Of The American Geriatrics Society, 56, 10, pp. 1839-1844
4. Elizabeth A Bayliss, Allison E Edwards, John F Steiner, and Deborah S Main
Processes of care desired by elderly patients with multimorbidities
Family Practice (2008) 25(4): 287-293 first published online July 14, 2008 doi:10.1093/fampra/cmn040
5. The NHS Outcomes Framework 2012/13. Department of Health. London, 2012.
Competing interests: JE is also a GP Principal and stands to gain from any improvement in QOF points resulting from more efficient reviews.
Forcing reality into inappropriate disciplinary frameworks.
The article on adapting clinical guidelines to take account of multimorbidity (BMJ 2012 345 e6150) builds upon the reductionist misconception of previous work in that each disease can be identified and managed individually. Rather than forcing reality into the prevailing disciplinary matrix it is more appropriate to match the analytical approach to the complexity of the task within a broader theoretical framework. For example, ordered domains (simple, complicated), transitional domains, and unordered domains (complex and chaotic). (1)
There is also a danger that organisational arrangements and incentive structures are created that lead to conditions favouring the predictions made in theory thus reinforcing inappropriate models of care, service delivery and clinical governance.
Confronting the challenges of multi morbidity will need an understanding and sensitivity of different analytical perspectives and a diversity of health care delivery frameworks that are appropriate for the particular nature of the system under consideration.
1. Kernick D. From simple to chaotic. A theoretical model for mutimorbidity. From simple to Chaotic. Br J Gen Pract. 2012 ;62 :659-62.
Competing interests: No competing interests