Scientific Centre for Care and Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands.
PLoS One. 2011;6(10):e25987. doi: 10.1371/journal.pone.0025987. Epub 2011 Oct 20.
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.
传统的指南通常侧重于单一疾病的诊断和治疗。由于近一半的慢性病患者患有多种疾病，因此指南的适用性可能会受到限制。本研究旨在评估指南对共病的重视程度，并评估与共病相关建议的支持证据。
方法/主要发现：我们对重点关注四种对生活质量影响较大的高发性慢性病（慢性阻塞性肺疾病、抑郁障碍、2 型糖尿病和骨关节炎）的基于证据的指南进行了系统分析。从每个指南中提取有关共病处理程度（一般评论、具体建议）、讨论的共病类型（一致、不一致）以及共病相关建议支持证据（证据水平、证据转化）的数据。在 20 项指南中，有 17 项（85%）涉及共病问题，有 14 项（70%）针对共病提供了具体建议。总体而言，这些指南仅包含少量针对共病患者的建议（每个指南平均 3 条建议，范围 0 至 26 条）。在提供的 59 项与共病相关的建议中，有 46 项（78%）针对一致的共病，8 项（14%）针对不一致的共病，有 5 项（8%）未明确共病类型。支持证据的强度为中度的占 25%（15/59），低度的占 37%（22/59）。此外，对于 73%（43/59）的建议，证据没有充分转化为指南。
结论/意义：我们的研究表明，目前基于证据的指南对患有共病的患者的适用性有限。大多数指南没有明确针对共病患者的治疗指导，特别是针对不一致的组合。指南应该更明确地说明其建议对共病患者的适用性。未来的临床试验也应包括最常见的慢性病组合患者。
