Potential workload in applying clinical practice guidelines for patients with chronic conditions and multimorbidity: a systematic analysis

OBJECTIVES: To describe the potential workload for patients with multimorbidity when applying existing clinical practice guidelines. DESIGN: Systematic analysis of clinical practice guidelines for chronic conditions and simulation modelling approach. DATA SOURCES: National Guideline Clearinghouse index of US clinical practice guidelines. STUDY SELECTION: We identified the most recent guidelines for adults with 1 of 6 prevalent chronic conditions in primary care (ie hypertension, diabetes, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), osteoarthritis and depression). DATA EXTRACTION: From the guidelines, we extracted all recommended health-related activities (HRAs) such as drug management, self-monitoring, visits to the doctor, laboratory tests and changes of lifestyle for a patient aged 45–64 years with moderate severity of conditions. SIMULATION MODELLING APPROACH: For each HRA identified, we performed a literature review to determine the potential workload in terms of time spent on this HRA. Then, we used a simulation modelling approach to estimate the potential workload needed to comply with these recommended HRAs for patients with several of these chronic conditions. RESULTS: Depending on the concomitant chronic condition, patients with 3 chronic conditions complying with all the guidelines would have to take a minimum of 6 to a maximum of 13 medications per day, visit a health caregiver a minimum of 1.2 to a maximum of 5.9 times per month and spend a mean (SD) of 49.6 (27.3) to 71.0 (34.5) h/month in HRAs. The potential workload increased greatly with increasing number of concomitant conditions, rising to 18 medications per day, 6.6 visits per month and 80.7 (35.8) h/month in HRAs for patients with 6 chronic conditions.