Out of context: clinical practice guidelines and patients with multiple chronic conditions: a systematic review

Med Care. 2014 Mar;52 Suppl 3:S92-S100. doi: 10.1097/MLR.0b013e3182a51b3d.


Background: 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.

Objective: 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.

Research design: 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.

Results: 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.

Conclusions: 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.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Diabetes Complications / epidemiology
  • Diabetes Complications / prevention & control*
  • Diabetes Mellitus, Type 2 / epidemiology
  • Diabetes Mellitus, Type 2 / therapy*
  • Disease Management
  • Evidence-Based Medicine
  • Guideline Adherence
  • Health Education / statistics & numerical data
  • Health Promotion / statistics & numerical data*
  • Humans
  • Patient-Centered Care / statistics & numerical data*
  • Randomized Controlled Trials as Topic / statistics & numerical data*
  • United States / epidemiology