S.Z.SIM1, G.T.S.YEO1, J.H.FOO2, S.K.ONG1, E.A.L.CHEW1, S.P.S.LEE1, H.L.KOH1, S.Y.TAN1, E.S.LEE1
National Healthcare Group Polyclinics1, Nanyang Technological University Singapore2
Clinical Practice Guidelines(CPGs) often focus on single diseases and are developed from trials that usually exclude patients with multimorbidity. We conducted a qualitative evidence synthesis to understand the challenges encountered by healthcare providers(HCPs) when managing patients with multimorbidity, and how they overcome these challenges.
MEDLINE, CINAHL, Embase, Scopus and Web of Science were searched for qualitative studies in English from inception till 9/3/2020. Critical Appraisal Skills Program checklist was used to assess study quality. Data were synthesized using thematic analysis, and review findings were assessed by Confidence in the Evidence from Reviews of Qualitative Research(GRADE-CERQual).
The synthesis included thirty-one studies, of which only five focused on CPG use in patients. There were ten review findings, with GRADE-CERQual assessments ranging from low to moderate confidence mainly due to data inadequacy. HCPs had varying attitudes towards using CPGs in patients with multimorbidity(Finding1). Challenges included the inapplicability of CPGs(Finding2), the burden of CPGs on healthcare stakeholders(Finding3), conflicts between CPGs and stakeholders(Findings4,5,6), variation in practice despite the same CPGs(Finding7), and difficulties implementing CPGs(Finding8). To overcome the challenges, HCPs adopted more patient-centred approaches in their management(Finding9). They also suggested involving various stakeholders in research and CPG development, utilising different forms of research, making CPGs more user-friendly, and providing training on their use(Finding10).
Due to the multiple challenges, many HCPs deviated from CPGs and relied more on patient-centred approaches. To improve CPG relevance, it is important to understand the clinicians’ decision-making processes and consider the incorporation of patient preferences in CPG recommendations.