NICE should consider multimorbidity in guidelines
NICE guidelines should take into account multimorbidity to help doctors provide better care for people with more than one chronic illness, say researchers.
The research team - made up of members from the Universities of Dundee, Glasgow and Manchester and NICE - believe that existing guidelines which concentrate on individual diseases are not best serving clinicians or patients where a number of chronic conditions have to be treated.
Most people with any chronic condition have multiple conditions, and although the degree of multimorbidity increases with age, this applies to younger patients as well, particularly those living in the most socioeconomically deprived areas, where multimorbidity develops 10-15 years earlier than in more affluent areas.
Writing in the BMJ, the researchers warn that clinical decision making is more difficult in people with multimorbidity because clinicians and patients often struggle to balance the benefits and risks of multiple recommended treatments.
Existing guidelines also require clinicians and patients to read separate documents for every condition that a patient has, and there is little cross referencing between guidelines.
A notable exception is the NICE guideline on depression in adults with a chronic physical health problem, which provides advice on choice of antidepressant medicine depending on physical co-morbidity and co-prescribing, as well as guidance on collaborative care approaches when there is evidence that they improve physical or depression outcomes.
Lead author Professor Bruce Guthrie, of the Medical Research Institute at the University of Dundee, said: “Doctors and other professionals often use guidelines to inform their clinical decision making, and clinical guidelines have played an important part in making healthcare more consistent, efficient, and systematic.
“Through NICE and the Scottish Intercollegiate Guidelines Network (SIGN), the UK is a world leader in guideline methodology, and guideline development and implementation.
“Despite their success, clinical guidelines are almost always focused on making recommendations about the treatment of individual diseases, which can make their use in clinical practice problematic.
“This is because most people with long term conditions have more than one chronic illness, particularly older people in whom multiple chronic illnesses are the norm.
“For example, 93 per cent of people with coronary heart have at least one other chronic condition, and a fifth have five or more other conditions.”
Dr Phil Alderson, Associate Director for the Centre for Clinical Practice at NICE and one of the authors of the paper, added: “NICE will be working with the other authors on this paper to examine ways in which NICE clinical guidelines can be more helpful for making decisions in people with multimorbidity.
“This will build on experience and ideas used in, for example, the guideline on depression in people with a chronic physical illness and the links between guidelines that are presented in NICE Pathways.”
Speaking earlier this year at the NICE Annual Conference, Professor Sir Mike Rawlins, Chair of NICE, called for NICE guidelines to take into account co or multiple morbidities.
“We are thinking about producing a guideline on managing co-morbidities and GPs will be the key audience for this.
“We need to empower GPs and, secondly, when we produce a guideline we need to find out the three main co-morbidities that are related to it and take that into account,” he said.
9 October 2012