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The challenge of reconciling multiple clinical guidelines in the context of multi-morbidity
Published on 17 March 2022

Modern medical practice relies on the delivery of high quality evidence based care. The translation of that evidence base into clinical practice is supported by clinical guidelines. These guidelines are typically focused on supporting clinicians to manage an individual medical condition, for example type 2 diabetes, chronic obstructive pulmonary disease or cognitive impairment. There is a true wealth of up-to-date, evidence based guidelines available internationally. Whilst guidelines underpin the delivery of standardised medical care in countries internationally, there is a profound emerging challenge facing the medical community, patients and wider society in the use of these guidelines.

This challenge to guideline driven care is the rise of multi-morbidity in patient populations. Multi-morbidity can be defined as “the presence of two or more long-term health conditions, which can include: defined physical or mental health conditions, such as diabetes or schizophrenia; ongoing conditions, such as learning disability; and symptom complexes, such as frailty or chronic pain.” Levels of multi-morbidity are rising rapidly in patient populations as people are living longer, and we are more able to diagnose and screen for medical conditions. Multi-morbidity poses a challenge because guidelines are often not written to take account of multi-morbid conditions, rather they focus only on the management of a single index medical condition. Guidelines for individual conditions fail to account for how that condition, the monitoring of that condition or the treatment for that condition may interact with other coexisting diseases.

This is particularly important as multi-morbidity may require a particular medical condition to be treated radically differently than it would be on its own, and without this included within a guideline, thus, we may lose the valuable evidence based standardised care models that guidelines allow. A key challenge however is the true myriad of almost infinite combinations of multi-morbid conditions that can occur in each unique patient, creating a profound difficulty for healthcare practitioners and scientists.

To that aim, the present EU Horizon 2020 funded project (CAREPATH) looks to develop an integrated solution for sustainable care for multi-morbid patients with dementia.

The delivery of CAREPATH’s ambitious goals relies on utilising the existing evidence base in the management of patients with multi-morbidity. This therefore requires clinical guidelines for disparate medical conditions to be brought together as a consensus clinical guideline. The development of consensus guidelines for multi-morbid conditions will become increasingly important to medicine over the coming decade and beyond.

To date however, following exhaustive search by our team and the University Hospitals Coventry & Warwickshire (UHCW) NHS Trust’s Clinical Evidence Based Information Service (CEBIS), we have found limited information on how to pragmatically develop a consensus clinical guideline.

Deliverable 6.2 of the CAREPATH project will demonstrate and deliver a clinical consensus guideline suited both to the CAREPATH project, but also demonstrating an optimum approach to international consensus clinical guidelines. This builds on the work led by Dr. Pedro Abizanda Soler from Complejo Hospitalario Universitario de Albacete that has systematically collated a full list of all recent guidelines relevant to the CAREAPTH project.

The approach proposed by the CAREPATH team to consensus multi-morbidity guideline development is to utilise existing proven methodology for guideline development, namely the modified Delphi method. We will systematically asses the quality, robustness and completeness of internationally available recent clinical guidelines for each of the index medical conditions, before selecting the top two guidelines to include in our initial consensus combined model.

Through a modified Delphi method, this combined consensus model will be assessed by clinical experts from each of the project’s pilot sites to undergo a process of progressive optimisation (including identified whether any previously discounted guidelines should be included), before the final consensus clinical guideline is completed.

We believe that this process will allow one of the first ever international coordinated clinical consensus guidelines, with the inclusion of cognitive impairment making it a particularly relevant and impactful output from CAREPATH. We hope that this will lead to further development of consensus clinical guidelines, and semi-automated digitally enabled approaches to be developed in the future to meet the needs of patients, clinicians and society more generally.