*Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN †Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN ‡Section of Endocrinology, Baylor College of Medicine, Houston, TX §Division of Endocrinology, Diabetes, Metabolism and Nutrition ∥Healthcare Policy and Research ¶Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
Med Care. 2014 Mar;52 Suppl 3:S92-S100. doi: 10.1097/MLR.0b013e3182a51b3d.
Poor fidelity to practice guidelines in the care of people with multiple chronic conditions (MCC) may result from patients and clinicians struggling to apply recommendations that do not consider the interplay of MCC, socio-personal context, and patient preferences.
The objective of the study was to assess the quality of guideline development and the extent to which guidelines take into account 3 important factors: the impact of MCC, patients' socio-personal contexts, and patients' personal values and preferences.
We conducted a systematic search of clinical practice guidelines for patients with type 2 diabetes mellitus published between 2006 and 2012. Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Scopus, EBSCO CINAHL, and the National Guideline Clearinghouse were searched. Two reviewers working independently selected studies, extracted data, and evaluated the quality of the guidelines.
We found 28 eligible guidelines, which, on average, had major methodological limitations (AGREE II mean score 3.8 of 7, SD=1.6). Patients or methodologists were not included in the guideline development process in 20 (71%) and 24 (86%) guidelines, respectively. There was a complete absence of incorporating the impact of MCC, socio-personal context, and patient preferences in 8 (29%), 11 (39%), and 16 (57%) of the 28 guidelines, respectively. When mentioned, MCC were considered biologically, but not as contributors of complexity or patient work or as motivation to focus on patient-centered outcomes.
Extant clinical practice guidelines for one chronic disease sometimes consider the context of the patient with that disease, but only do so narrowly. Guideline panels must remove their contextual blinders if they want to practically guide the care of patients with MCC.
在患有多种慢性疾病（MCC）的人群的护理中，实践指南的保真度较差，可能是由于患者和临床医生难以应用不考虑 MCC 相互作用、社会个人背景和患者偏好的建议。
本研究旨在评估指南制定的质量以及指南在多大程度上考虑了 3 个重要因素：MCC 的影响、患者的社会个人背景以及患者的个人价值观和偏好。
我们对 2006 年至 2012 年间发表的针对 2 型糖尿病患者的临床实践指南进行了系统搜索。检索了 Ovid Medline In-Process & Other Non-Indexed Citations、Ovid MEDLINE、Ovid EMBASE、Scopus、EBSCO CINAHL 和国家指南清除中心。两名独立工作的审查员选择研究、提取数据并评估指南的质量。
我们发现了 28 项符合条件的指南，这些指南的平均方法学局限性较大（AGREE II 平均得分为 7 分中的 3.8，标准差=1.6）。分别有 20 项（71%）和 24 项（86%）指南没有患者或方法学家参与指南制定过程。在 28 项指南中，分别有 8 项（29%）、11 项（39%）和 16 项（57%）完全没有纳入 MCC 的影响、社会个人背景和患者偏好。当提到 MCC 时，它们被认为是生物学上的，但不是复杂性或患者工作的贡献者，也不是关注以患者为中心的结果的动机。
现有的针对一种慢性疾病的临床实践指南有时会考虑到患有该疾病的患者的背景，但只是狭隘地考虑。如果指南小组想要实际指导患有 MCC 的患者的护理，就必须消除他们的背景盲区。
