Mixed Methods Evaluation of Reasons Why Care Deviates From Clinical Guidelines Among Patients With Multimorbidity

Chandra J. Cohen-Stavi, Calanit Key, Tchiya Molcho, Mili Yacobi, Ran D. Balicer, Efrat Shadmi

Research output: Contribution to journalArticlepeer-review


Reasons why care does not conform to single-disease guideline recommendations for multimorbid patients have not been systematically measured in practice. Using a mixed methods approach, we identified and quantified types of reasons why care deviates from nine sets of disease guideline recommendations for multimorbid patients. Utilizing a focus group concept mapping technique, we built on a categorization of reasons explaining guideline deviation, and surveyed treating nurses about these reasons for patients’ specific care processes. Directed content analysis was conducted to classify the responses into reasons categories. Of 4,386 guideline-recommended care processes evaluated, 920 were not guideline-concordant (944 reasons). Three broad categories of reasons and 18 specific reasons were identified: Biomedical-related occurred 35.2% of the time, patient personal-related (30.4%), context-related (18.4%), and unknown (16.0%). Patient- and context-related factors are prevalent drivers for guideline deviation in multimorbidity, demonstrating that patient-centered aspects are as much a part of care decisions as biomedical aspects.

Original languageEnglish
Pages (from-to)102-113
Number of pages12
JournalMedical Care Research and Review
Issue number1
StatePublished - Feb 2022

Bibliographical note

Funding Information:
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was supported by the Gertner Institute, Clalit Health Services, and in part by a grant from the Israel National Institute for Health Policy Research (Grant #2015/190).

Publisher Copyright:
© The Author(s) 2020.


  • clinical practice guidelines
  • multimorbidity
  • patient centered care
  • primary health care

ASJC Scopus subject areas

  • Health Policy


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