Reasons why care does not conform to single-disease guideline recommendations for multimorbid patients have not been systematically measured in practice. Using a mixed methods approach, we identified and quantified types of reasons why care deviates from nine sets of disease guideline recommendations for multimorbid patients. Utilizing a focus group concept mapping technique, we built on a categorization of reasons explaining guideline deviation, and surveyed treating nurses about these reasons for patients’ specific care processes. Directed content analysis was conducted to classify the responses into reasons categories. Of 4,386 guideline-recommended care processes evaluated, 920 were not guideline-concordant (944 reasons). Three broad categories of reasons and 18 specific reasons were identified: Biomedical-related occurred 35.2% of the time, patient personal-related (30.4%), context-related (18.4%), and unknown (16.0%). Patient- and context-related factors are prevalent drivers for guideline deviation in multimorbidity, demonstrating that patient-centered aspects are as much a part of care decisions as biomedical aspects.
Anhang PriceR.ElliottM. N.ZaslavskyA. M.HaysR. D.LehrmanW. G.RybowskiL.Edgman-LevitanS.ClearyP. D. (2014). Examining the role of patient experience surveys in measuring health care quality. Medical Care Research and Review, 71(5), 522-554. https://doi.org/10.1177/1077558714541480
3.
BaylissE. A.BondsD. E.BoydC. M.DavisM. M.FinkeB.FoxM. H.GlasgowR. E.GoodmanR. A.Heurtin-RobertsS.LachenmayrS.LindC.MadiganE. A.MeyersD. S.MintzS.NilsenW. J.OkunS.RuizS.SaliveM. E.StangeK. C. (2014). Understanding the context of health for persons with multiple chronic conditions: Moving from what is the matter to what matters. Annals of Family Medicine, 12(3), 260-269. https://doi.org/10.1370/afm.1643
4.
BaylissE. A.SteinerJ. F.FernaldD. H.CraneL. A.MainD. S. (2003). Descriptions of barriers to self-care by persons with comorbid chronic diseases. Annals of Family Medicine, 1(1), 15-21. https://doi.org/10.1370/afm.4
5.
BodenheimerT.WagnerE. H.GrumbachK. (2002). Improving primary care for patients with chronic illness: The chronic care model, Part 2. Journal of the American Medical Association, 288(15), 1909-1914. https://doi.org/10.1001/jama.288.15.1909
6.
BoydC. M.WolffJ. L.GiovannettiE.ReiderL.WeissC.XueQ. L.BruceL.ChadB.TravoniaH.RandC. (2014). Healthcare task difficulty among older adults with multimorbidity. Medical Care, 52(Suppl. 3), S118-S125. https://doi.org/10.1097/MLR.0b013e3182a977da
7.
ClarfieldA. M.ManorO.NunG. B.ShvartsS.AzzamZ. S.AfekA.BasisF.IsraeliA. (2017). Health and health care in Israel: An introduction. Lancet, 389(10088), 2503-2513. https://doi.org/10.1016/S0140-6736(17)30636-0
8.
ClyneB.CooperJ. A.BolandF.HughesC. M.FaheyT.SmithS. M. (2017). Beliefs about prescribed medication among older patients with polypharmacy: A mixed methods study in primary care. British Journal of General Practice, 67(660), e507-e518. https://doi.org/10.3399/bjgp17X691073
9.
Cohen-StaviC. J.KeyC.GiveonS.MolchoT.BalicerR. D.ShadmiE. (2020). Assessing guideline-concordant care for patients with multimorbidity treated in a care management setting. Family Practice, 37(4), 479-485. https://doi.org/10.1093/fampra/cmaa024
10.
DambergC. L.BakerD. W. (2016). Improving the quality of quality measurement. Journal of General Internal Medicine, 31(Suppl. 1), 8-9. https://doi.org/10.1007/s11606-015-3577-y
11.
DumbreckS.FlynnA.NairnM.WilsonM.TreweekS.MercerS. W.AldersonP.ThompsonA.PayneK.GuthrieB. (2015). Drug-disease and drug-drug interactions: Systematic examination of recommendations in 12 UK national clinical guidelines. British Medical Journal, 350, Article h949. https://doi.org/10.1136/bmj.h949
12.
FerrisR.BlaumC.KiwakE.AustinJ.EstersonJ.HarklessG.OftedahlG.ParchmanM.Van NessP. H.TinettiM. E. (2018). Perspectives of patients, clinicians, and health system leaders on changes needed to improve the health care and outcomes of older adults with multiple chronic conditions. Journal of Aging and Health, 30(5), 778-799. https://doi.org/10.1177/0898264317691166
13.
FurthauerJ.FlammM.SonnichsenA. (2013). Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: A cross sectional study. BMC Family Practice, 14, Article 47. https://doi.org/10.1186/1471-2296-14-47
14.
GoodmanR. A.BoydC.TinettiM. E.Von KohornI.ParekhA. K.McGinnisJ. M. (2014). IOM and DHHS meeting on making clinical practice guidelines appropriate for patients with multiple chronic conditions. Annals of Family Medicine, 12(3), 256-259. https://doi.org/10.1370/afm.1646
15.
GreenC. A.DuanN.GibbonsR. D.HoagwoodK. E.PalinkasL. A.WisdomJ. P. (2015). Approaches to mixed methods dissemination and implementation research: Methods, strengths, caveats, and opportunities. Administration and Policy in Mental Health, 42(5), 508-523. https://doi.org/10.1007/s10488-014-0552-6
16.
HoffmannT.JansenJ.GlasziouP. (2018). The importance and challenges of shared decision making in older people with multimorbidity. PLOS MEDICINE, 15(3), Article e1002530. https://doi.org/10.1371/journal.pmed.1002530
17.
HsiehH. F.ShannonS. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277-1288. https://doi.org/10.1177/1049732305276687
18.
LugtenbergM.Zegers-van SchaickJ. M.WestertG. P.BurgersJ. S. (2009). Why don’t physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. Implementation Science, 4, Article 54. https://doi.org/10.1186/1748-5908-4-54
19.
LuijksH.LucassenP.van WeelC.LoeffenM.Lagro-JanssenA.SchermerT. (2015). How GPs value guidelines applied to patients with multimorbidity: A qualitative study. BMJ Open, 5(10), Article e007905. https://doi.org/10.1136/bmjopen-2015-007905
20.
MittlerJ. N.MartsolfG. R.TelenkoS. J.ScanlonD. P. (2013). Making sense of “consumer engagement” initiatives to improve health and health care: A conceptual framework to guide policy and practice. Milbank Quarterly, 91(1), 37-77. https://doi.org/10.1111/milq.12002
21.
MuthC.BlomJ. W.SmithS. M.JohnellK.Gonzalez-GonzalezA. I.NguyenT. S.BrueckleM.-S.CesariM.TinettiM. E.ValderasJ. M. (2019). Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: A systematic guideline review and expert consensus. Journal of Internal Medicine, 285(3), 272-288. https://doi.org/10.1111/joim.12842
22.
MutterJ. B.LiawW.MooreM. A.EtzR. S.HoweA.BazemoreA. (2018). Core principles to improve primary care quality management. Journal of the American Board of Family Medicine, 31(6), 931-940. https://doi.org/10.3122/jabfm.2018.06.170172
23.
NolteE. (2017). Implementing person centred approaches. British Medical Journal, 358, Article j4126. https://doi.org/10.1136/bmj.j4126
24.
RosbachM.AndersenJ. S. (2017). Patient-experienced burden of treatment in patients with multimorbidity: A systematic review of qualitative data. PLOS ONE, 12(6), Article e0179916. https://doi.org/10.1371/journal.pone.0179916
25.
SackettD. L.RosenbergW. M.GrayJ. A.HaynesR. B.RichardsonW. S. (1996). Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312(7023), 71-72. https://doi.org/10.1136/bmj.312.7023.71
26.
SinnottC.Mc HughS.BoyceM. B.BradleyC. P. (2015). What to give the patient who has everything? A qualitative study of prescribing for multimorbidity in primary care. British Journal of General Practice, 65(632), e184-e191. https://doi.org/10.3399/bjgp15X684001
27.
SinnottC.Mc HughS.BrowneJ.BradleyC. (2013). GPs’ perspectives on the management of patients with multimorbidity: Systematic review and synthesis of qualitative research. BMJ Open, 3(9), Article e003610. https://doi.org/10.1136/bmjopen-2013-003610
28.
SmithS. M.WallaceE.SalisburyC.SassevilleM.BaylissE.FortinM. (2018). A core outcome set for multimorbidity research (COSmm). Annals of Family Medicine, 16(2), 132-138. https://doi.org/10.1370/afm.2178
29.
SteinmanM. A.DimaanoL.PetersonC. A.HeidenreichP. A.KnightS. J.FungK. Z.KaboliP. J. (2013). Reasons for not prescribing guideline-recommended medications to adults with heart failure. Medical Care, 51(10), 901-907. https://doi.org/10.1097/MLR.0b013e3182a3e525
30.
SteinmanM. A.LowM.BalicerR. D.ShadmiE. (2018). Impact of a nurse-based intervention on medication outcomes in vulnerable older adults. BMC Geriatrics, 18(1), Article 207. https://doi.org/10.1186/s12877-018-0905-1
31.
SteinmanM. A.PatilS.KamatP.PetersonC.KnightS. J. (2010). A taxonomy of reasons for not prescribing guideline-recommended medications for patients with heart failure. American Journal of Geriatric Pharmacotherapy, 8(6), 583-594. https://doi.org/10.1016/S1543-5946(10)80007-8
TinettiM. E.NaikA. D.DodsonJ. A. (2016). Moving from disease-centered to patient goals-directed care for patients with multiple chronic conditions: Patient value-based care. JAMA Cardiology, 1(1), 9-10. https://doi.org/10.1001/jamacardio.2015.0248
34.
ValderasJ. M.GangannagaripalliJ.NolteE.BoydC. M.RolandM.Sarria-SantameraA.JonesE.RijkenM. (2019). Quality of care assessment for people with multimorbidity. Journal of Internal Medicine, 285(3), 289-300. https://doi.org/10.1111/joim.12881
35.
WagnerE. H.AustinB. T.DavisC.HindmarshM.SchaeferJ.BonomiA. (2001). Improving chronic illness care: Translating evidence into action. Health Affairs, 20(6), 64-78. https://doi.org/10.1377/hlthaff.20.6.64
36.
WallaceE.SalisburyC.GuthrieB.LewisC.FaheyT.SmithS. M. (2015). Managing patients with multimorbidity in primary care. British Medical Journal, 350, Article h176. https://doi.org/10.1136/bmj.h176
37.
YoungR. A.RobertsR. G.HoldenR. J. (2017). The challenges of measuring, improving, and reporting quality in primary care. Annals of Family Medicine, 15(2), 175-182. https://doi.org/10.1370/afm.2014
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