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J Gen Intern Med. 2017 Aug;32(8):883-890. doi: 10.1007/s11606-017-4039-5. Epub 2017 Mar 27.

Engaging Stakeholders to Inform Clinical Practice Guidelines That Address Multiple Chronic Conditions.

Author information

Division of General Internal Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Kaiser Permanente National Guideline Program, Denver, CO, USA.
Kaiser Permanente, Institute for Health Research, Denver, CO, USA.
Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
Department of Health Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, MD, USA.
Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
Department of Public Health, China Medical University Taichung, Taichung, Taiwan.
Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Informing Patient-Centered Care for People with Multiple Chronic Conditions, Baltimore, MD, USA.
Gerontological Society of America, Washington, DC, USA.



Having more than one chronic condition is common and is associated with greater health care utilization, higher medication burden and complexity of treatment. However, clinical practice guidelines (CPGs) do not routinely address the balance between harms and benefits of treatments for people with multiple chronic conditions (MCCs).


To partner with the Kaiser Permanente Integrated Cardiovascular Health (ICVH) program to engage multiple stakeholders in a mixed-methods approach in order to: 1) identify two high-priority clinical questions related to MCCs, and 2) understand patients' and family caregivers' perceptions of meaningful outcomes to inform benefit/harm assessments for these two high-priority questions. These clinical questions and outcomes will be used to inform CPG recommendations for people with MCCs. DESIGN AND PARTICIPANTS: The ICVH program provided 130 topics rank-ordered by the potential for finding evidence that would change clinical recommendations regarding the topic. We used a modified Delphi method to identify and reword topics into questions relevant to people with MCCs. We used two sets of focus groups (n = 27) to elicit patient and caregiver perspectives on two important research questions and relevant patient-important outcomes on benefit/harm balance for people with MCCs.


Co-investigators, patients and caregivers identified "optimal blood pressure goals" and "diabetes medication management" as important clinical topics for CPGs related to people with MCCs. Stakeholders identified a list of relevant outcomes to be addressed in future CPG development including 1) physical function and energy, 2) emotional health and well-being, 3) avoidance of treatment burden, side effects and risks, 4) interaction with providers and health care system, and 5) prevention of adverse long-term health outcomes.


Through the application of a mixed-methods process, we identified the questions regarding optimal blood pressure goals and diabetes medication management, along with related patient-centered outcomes, to inform novel evidence syntheses for those with MCCs. This study provides the lessons learned and a generalizable process for CPG developers to engage patient and caregivers in priority-setting for the translation of evidence into future CPGs. Ultimately, engaging patient and stakeholders around MCCs could improve the relevance of CPGs for the care of people with MCCs.


multiple chronic conditions; qualitative research; stakeholder engagement

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