Bennett Wendy L, Robbins Craig W, Bayliss Elizabeth A, Wilson Renee, Tabano Heather, Mularski Richard A, Chan Wiley V, Puhan Milo, Yu Tsung, Leff Bruce, Li Tianjing, Dickersin Kay, Glover Carol, Maslow Katie, Armacost Karen, Mintz Suzanne, Boyd Cynthia M
Division of General Internal Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
J Gen Intern Med. 2017 Aug;32(8):883-890. doi: 10.1007/s11606-017-4039-5. Epub 2017 Mar 27.
Having more than one chronic condition is common and is associated with greater health care utilization, higher medication burden and complexity of treatment. However, clinical practice guidelines (CPGs) do not routinely address the balance between harms and benefits of treatments for people with multiple chronic conditions (MCCs).
To partner with the Kaiser Permanente Integrated Cardiovascular Health (ICVH) program to engage multiple stakeholders in a mixed-methods approach in order to: 1) identify two high-priority clinical questions related to MCCs, and 2) understand patients' and family caregivers' perceptions of meaningful outcomes to inform benefit/harm assessments for these two high-priority questions. These clinical questions and outcomes will be used to inform CPG recommendations for people with MCCs. DESIGN AND PARTICIPANTS: The ICVH program provided 130 topics rank-ordered by the potential for finding evidence that would change clinical recommendations regarding the topic. We used a modified Delphi method to identify and reword topics into questions relevant to people with MCCs. We used two sets of focus groups (n = 27) to elicit patient and caregiver perspectives on two important research questions and relevant patient-important outcomes on benefit/harm balance for people with MCCs.
Co-investigators, patients and caregivers identified "optimal blood pressure goals" and "diabetes medication management" as important clinical topics for CPGs related to people with MCCs. Stakeholders identified a list of relevant outcomes to be addressed in future CPG development including 1) physical function and energy, 2) emotional health and well-being, 3) avoidance of treatment burden, side effects and risks, 4) interaction with providers and health care system, and 5) prevention of adverse long-term health outcomes.
Through the application of a mixed-methods process, we identified the questions regarding optimal blood pressure goals and diabetes medication management, along with related patient-centered outcomes, to inform novel evidence syntheses for those with MCCs. This study provides the lessons learned and a generalizable process for CPG developers to engage patient and caregivers in priority-setting for the translation of evidence into future CPGs. Ultimately, engaging patient and stakeholders around MCCs could improve the relevance of CPGs for the care of people with MCCs.
患有多种慢性病很常见，且与更多的医疗保健利用、更高的用药负担和治疗复杂性相关。然而，临床实践指南（CPG）通常并未涉及针对患有多种慢性病（MCC）患者的治疗利弊平衡问题。
与凯撒医疗集团综合心血管健康（ICVH）项目合作，采用混合方法让多个利益相关者参与进来，以便：1）确定两个与MCC相关的高度优先临床问题，2）了解患者和家庭护理人员对有意义结果的看法，为这两个高度优先问题的利弊评估提供参考。这些临床问题和结果将用于为患有MCC的患者提供CPG建议。
ICVH项目提供了130个主题，并根据找到可能改变有关该主题临床建议的证据的可能性进行了排序。我们使用改良的德尔菲法来识别主题并将其重新表述为与患有MCC的患者相关的问题。我们使用了两组焦点小组（n = 27）来收集患者和护理人员对两个重要研究问题以及MCC患者在利弊平衡方面相关的患者重要结果的看法。
共同研究者、患者和护理人员将“最佳血压目标”和“糖尿病药物管理”确定为与患有MCC的患者相关的CPG重要临床主题。利益相关者确定了一系列在未来CPG制定中要解决的相关结果，包括：1）身体功能和能量，2）情绪健康和幸福感，3）避免治疗负担、副作用和风险，4）与医疗服务提供者和医疗保健系统的互动，5）预防长期不良健康结果。
通过应用混合方法，我们确定了关于最佳血压目标和糖尿病药物管理的问题，以及相关的以患者为中心的结果，为患有MCC的患者进行新的证据综合提供参考。本研究为CPG开发者提供了经验教训以及一个可推广的流程，以便让患者和护理人员参与到确定优先事项中，将证据转化为未来的CPG。最终，让围绕MCC的患者和利益相关者参与进来可以提高CPG对患有MCC的患者护理的相关性。
