Intended for healthcare professionals


Adapting clinical guidelines to take account of multimorbidity

BMJ 2012; 345 doi: (Published 04 October 2012) Cite this as: BMJ 2012;345:e6341
  1. Bruce Guthrie, professor of primary care medicine1,
  2. Katherine Payne, professor of health economics2,
  3. Phil Alderson, associate director3,
  4. Marion E T McMurdo, professor of ageing and health1,
  5. Stewart W Mercer, professor of primary care research4
  1. 1Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee DD2 4BF, UK
  2. 2School of Community Based Medicine, University of Manchester, Manchester, UK
  3. 3Centre for Clinical Practice, National Institute for Health and Clinical Excellence, Manchester, UK
  4. 4University of Glasgow, Glasgow, UK
  1. Correspondence to: B Guthrie b.guthrie{at}

Care of patients with multimorbidity could be improved if new technology is used to bring together guidelines on individual conditions and tailor advice to each patient’s circumstances, say Bruce Guthrie and colleagues

Most people with a chronic condition have multimorbidity, but clinical guidelines almost entirely focus on single conditions. It will never be possible to have good evidence for every possible combination of conditions, but guidelines could be made more useful for people with multimorbidity if they were delivered in a format that brought together relevant recommendations for different chronic conditions and identified synergies, cautions, and outright contradictions. We highlight the problem that multimorbidity poses to clinicians and patients using guidelines for single conditions and propose ways of making them more useful for people with multimorbidity.

Guidelines and multimorbidity

Guidelines have the potential to improve the care of people with chronic disease1 but seldom explicitly account for people with multiple conditions. This reflects the way in which clinical evidence is created but does not match everyday practice, where multimorbidity is common. The figure illustrates this using data from UK primary care electronic health records taken from a study of the prevalence of multimorbidity in 1.75 million people.2 Most people with any chronic condition have multiple conditions, and although the degree of multimorbidity increases with age, this applies to younger patients as well, particularly those living in the most socioeconomically deprived areas, where multimorbidity develops 10-15 years earlier than in more affluent areas.2

Comorbidity of 10 common conditions among UK primary care patients2

Clinical decision making is more difficult in people with multimorbidity because clinicians and patients often struggle to balance the benefits and risks of multiple recommended treatments3 and because patient preference rightly influences the application of clinical and economic evidence.4 Robust synthesis of clinical and …

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