Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus

The complexity and heterogeneity of patients with multimorbidity and polypharmacyrenders traditional disease-oriented guidelines often inadequate and complicates clinical decision making. To address this challenge, guidelines have beendeveloped on multimorbidity or polypharmacy. To systematically analyse theirrecommendations, we conducted a systematic guideline review using the Ariadneprinciples for managing multimorbidity as analytical framework. The informationsynthesis included a multistep consensus process involving 18 multidisciplinaryexperts from seven countries. We included eight guidelines (four each onmultimorbidity and polypharmacy) and extracted about 250 recommendations. Theguideline addressed (i) the identification of the target population (riskfactors); (ii) the assessment of interacting conditions and treatments: medicalhistory, clinical and psychosocial assessment including physiological status and frailty, reviews of medication and encounters with healthcare providershighlighting informational continuity; (iii) the need to incorporate patientpreferences and goal setting: eliciting preferences and expectations, the processof shared decision making in relation to treatment options and the level ofinvolvement of patients and carers; (iv) individualized management: guidingprinciples on optimization of treatment benefits over possible harms, treatmentcommunication and the information content of medication/care plans; (v)monitoring and follow-up: strategies in care planning, self-management andmedication-related aspects, communication with patients including safetyinstructions and adherence, coordination of care regarding referral and dischargemanagement, medication appropriateness and safety concerns. The spectrum ofclinical and self-management issues varied from guiding principles to specificrecommendations and tools providing actionable support. The limited availability of reliable risk prediction models, feasible interventions of proveneffectiveness and decision aids, and limited consensus on appropriate outcomes ofcare highlight major research deficits. An integrated approach to bothmultimorbidity and polypharmacy should be considered in future guidelines.