title: Out of context: clinical practice guidelines and patients with multiple chronic conditions: a systematic review.
abstract: 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.
  
  
  METHODS
  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.
authors: *Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN †Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN ‡Section of Endocrinology, Baylor College of Medicine, Houston, TX §Division of Endocrinology, Diabetes, Metabolism and Nutrition ∥Healthcare Policy and Research ¶Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
authors: Kirk D
authors: KD
authors: Wyatt
authors: Louise M
authors: LM
authors: Stuart
authors: Juan P
authors: JP
authors: Brito
authors: Barbara
authors: B
authors: Carranza Leon
authors: Juan Pablo
authors: JP
authors: Domecq
authors: Gabriela J
authors: GJ
authors: Prutsky
authors: Jason S
authors: JS
authors: Egginton
authors: Andrew D
authors: AD
authors: Calvin
authors: Nilay D
authors: ND
authors: Shah
authors: Mohammad Hassan
authors: MH
authors: Murad
authors: Victor M
authors: VM
authors: Montori
mesh_terms: D048909:Diabetes Complications / Q000453:epidemiology / Q000517:prevention & control*; D003924:Diabetes Mellitus, Type 2 / Q000453:epidemiology / Q000628:therapy*; D019468:Disease Management; D019317:Evidence-Based Medicine; D019983:Guideline Adherence; D006266:Health Education / Q000706:statistics & numerical data; D006293:Health Promotion / Q000706:statistics & numerical data*; D006801:Humans; D018802:Patient-Centered Care / Q000706:statistics & numerical data*; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology