The National Institute of Health and Clinical Excellence (NICE) develops management guidelines for the UK NHS based on international best evidence.
This study looked at five recent guidelines for commen conditions and the implications of using these in practice for real patients – at least two thirds of patients with each of these conditions will have significant comorbidities.
The guidelines chosen were for
- type 2 diabetes,
- care of patients after acute myocardial infarction,
- degenerative joint disease,
- chronic obstructive pulmonary disease
- and depression.
In general, the guidelines addressed co-morbidity poorly, were non-specific on patient self-management skills and patient centred care, did not deal with the ‘burden of treatment’, and were not developed with evidence from studies on older people.
For example, a hypothetical patient with 2 of these conditions 5 medications are required and up to 8 more recommended. Additionally, the patient would have to make 6 self-care or lifestyle changes, make 5 to 8 primary care visits, and attend multiple appointments for smoking cessation and pulmonary rehabilitation.
The authors concluded:
Clinical guidelines have played an important role in improving healthcare for people with long-term conditions. However, in people with multimorbidity current guideline recommendations rapidly cumulate to drive polypharmacy, without providing guidance on how best to prioritise recommendations for individuals in whom treatment burden will sometimes be overwhelming.
