Related Experiment Video
Updated: Nov 21, 2025
Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit
Published on: September 30, 2020
Guideline deviation and its association with specific chronic diseases among patients with multimorbidity: a
Chandra J Cohen-Stavi1,2, Shmuel Giveon3, Calanit Key4
1Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel chandraco278@gmail.com.
Insights
Guideline deviation in multimorbid patients varies more by specific disease than by combined care. Reasons for deviation often include non-disease-specific factors, highlighting the need for holistic patient assessment.
Area of Science:
- Health Services Research
- Chronic Disease Management
- Patient Care Quality
Background:
- Multimorbid patients present complex care needs, often managed through disease-specific guidelines.
- Assessing adherence to chronic disease guidelines in multimorbidity requires evaluating both disease-specific and combined-care deviations.
- Understanding reasons for guideline deviation is crucial for improving care quality in patients with multiple chronic conditions.
Purpose of the Study:
- To compare the extent of guideline deviation for specific chronic diseases versus combined care in multimorbid patients.
- To identify specific diseases with more prominent guideline deviations.
- To examine the underlying reasons contributing to guideline deviations in multimorbid individuals.
Main Methods:
- A cross-sectional cohort study was conducted within a multimorbidity care management program across 11 primary care clinics.
- Patients aged 45-95 with at least two chronic conditions were sampled.
- Guideline deviation was measured for specific conditions (e.g., atrial fibrillation, diabetes, hypertension) and aggregated for combined care. Reasons for deviation were categorized and analyzed.
Main Results:
- Disease-specific guideline deviation (14.7%–48.2%) varied more across conditions than combined-care deviation (14.7%–25.6%).
- Depression and diabetes showed significantly higher deviations (6% and 5%, respectively).
- Reasons for deviation were frequently non-disease-specific (e.g., physical limitations, care burden) as well as disease-specific.
Conclusions:
- Focusing solely on disease groups may obscure cross-cutting care delivery issues in multimorbid patients.
- The specific reasons for guideline deviation can differ between diseases, suggesting tailored improvement strategies.
- A holistic 'whole person' approach is essential for effective multimorbidity care management.
Objectives:
To assess whether the extent of deviation from chronic disease guideline recommendations is more prominent for specific diseases compared with combined-care across multiple conditions among multimorbid patients, and to examine reasons for this deviation.
Design:
A cross-sectional cohort.
Setting:
Multimorbidity care management programme across 11 primary care clinics.
Patients:
Patients aged 45-95 years with at least two common chronic conditions, sampled according to being new (≤6 months) or veteran (≥1 year) to the programme.
Main Outcome Measures:
Deviation from guideline-recommended care was measured for each patient's relevant conditions, aggregated and stratified across disease groups, calculated as measures of 'disease-specific' guideline deviation and 'combined-care' (all conditions) guideline deviation for: atrial fibrillation, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disorder, depression, diabetes, dyslipidaemia, hypertension and ischaemic heart disease. Combined-care deviation was evaluated for its association with specific diseases. Frequencies of previously derived reason types for deviation (biomedical, patient personal and contextual) were reported by nurse care managers, assessed across diseases and evaluated for their association with specific diseases.
Results:
Among 204 patients, disease-specific deviation varied more (from 14.7% to 48.2%) across diseases than combined-care deviation (from 14.7% to 25.6%). Depression and diabetes were significantly associated with more deviation (mean: 6% (95% CI: 2% to 10%) and 5% (95% CI: 2% to 9%), respectively). For some conditions, assessments were among small patient samples. Guideline deviation was often attributed to non-disease-specific reasons, such as physical limitations or care burden, as much as disease-specific reasons, which was reflected in the likelihood for guideline deviation to be due to different types of reasons for some diseases.
Conclusions:
When multimorbid patients are considered in disease groups rather than as 'whole persons', as in many quality of care studies, the cross-cutting factors in their care delivery can be missed. The types of reasons more likely to occur for specific diseases may inform improvement strategies.
Trial Registration Number:
NCT01811173; Pre-results.
Related Concept Videos
01:15Methods of Documentation VI: Case Management Model
For example, a patient with a chronic...
01:29Chronic Obstructive Pulmonary Disease-V: Management
Smoking Cessation
01:29Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities
01:28Chronic Kidney Disease III: Interprofessional Care
01:19Guidelines For Measuring Vital Signs
Before taking a patient's vital signs, a nurse would consider and assess the patient's comfort level and ensure appropriate equipment is available.
01:30Chronic Obstructive Pulmonary Disease-V: Nursing Management
Assessment