Clalit Research Institute, Clalit Health Services, Tel Aviv.
Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa.
Fam Pract. 2020 Sep 5;37(4):479-485. doi: 10.1093/fampra/cmaa024.
Disease-specific guidelines are not aligned with multimorbidity care complexity. Meeting all guideline-recommended care for multimorbid patients has been estimated but not demonstrated across multiple guidelines.
Measure guideline-concordant care for patients with multimorbidity; assess in what types of care and by whom (clinician or patient) deviation from guidelines occurs and evaluate whether patient characteristics are associated with concordance.
A retrospective cohort study of care received over 1 year, conducted across 11 primary care clinics within the context of multimorbidity-focused care management program. Patients were aged 45+ years with more than two common chronic conditions and were sampled based on either being new (≤6 months) or veteran to the program (≥1 year).
Three guideline concordance measures were calculated for each patient out of 44 potential guideline-recommended care processes for nine chronic conditions: overall score; referral score (proportion of guideline-recommended care referred) and patient-only score (proportion of referred care completed by patients). Guideline concordance was stratified by care type.
4386 care processes evaluated among 204 patients, mean age = 72.3 years (standard deviation = 9.7). Overall, 79.2% of care was guideline concordant, 87.6% was referred according to guidelines and patients followed 91.4% of referred care. Guideline-concordant care varied across care types. Age, morbidity burden and whether patients were new or veteran to the program were associated with guideline concordance.
Patients with multimorbidity do not receive ~20% of guideline recommendations, mostly due to clinicians not referring care. Determining the types of care for which the greatest deviation from guidelines exists can inform the tailoring of care for multimorbidity patients.
特定疾病的指南与多种疾病的护理复杂性不匹配。虽然已经估计了，但尚未在多项指南中证明对患有多种疾病的患者进行所有符合指南建议的护理。
测量患有多种疾病的患者的符合指南的护理情况；评估在哪些类型的护理中以及由谁（临床医生或患者）偏离指南，并评估患者特征是否与一致性相关。
这是一项回顾性队列研究，在一个多疾病为重点的护理管理计划背景下，在 11 个基层医疗诊所中进行了为期 1 年的护理评估。患者年龄在 45 岁以上，患有两种以上常见慢性病，根据是否为新患者（≤6 个月）或旧患者（≥1 年）进行抽样。
对每个患者计算了 44 项潜在的指南推荐的 9 种慢性病护理流程中的 3 项指南一致性措施：总体评分；转诊评分（指南推荐护理的比例）和患者仅评分（患者完成的转诊护理比例）。根据护理类型对指南一致性进行分层。
在 204 名患者中评估了 4386 个护理流程，平均年龄为 72.3 岁（标准差为 9.7）。总体而言，79.2%的护理是符合指南的，87.6%的护理是根据指南转诊的，患者遵循了 91.4%的转诊护理。指南一致的护理在不同的护理类型中有所不同。年龄、疾病负担以及患者是否为新患者或旧患者与指南的一致性相关。
患有多种疾病的患者未接受约 20%的指南建议，主要是因为临床医生未转诊护理。确定与指南偏离最大的护理类型可以为多种疾病患者的护理调整提供信息。
