The development of clinical practice guidelines (CPGs) has transformed significantly over the past decade. Guidelines are increasingly less dependent on consensus of expert opinion, and more reliant on published evidence from randomised controlled trials [1
]. The intention of CPGs has also widened. Not only are guidelines designed to inform clinicians about the appropriate management of specific health conditions, they are also intended to 'improve the quality of health care...reduce the use of unnecessary, ineffective or harmful interventions, and...facilitate the treatment of patients with maximum chance of benefit, with minimum risk of harm, and at an acceptable cost' [2
Whilst the growing emphasis on evidence-based practice is welcome, it is not without its challenges. Evidence hierarchy's privilege randomised controlled trials to maximise internal validity, but this can be at the cost of external validity. This occurs where trial populations are narrowly defined by inclusion and exclusion criteria, so that they do not well represent the patients seen in clinical practice. Participants recruited into clinical trials often differ from the patient population in terms of education level, social class, age, race and disease severity; this makes translating evidence-based CPGs into clinical practice and policy problematic [3
]. That this is an issue is indicated by clinician concerns with the usefulness of CPGs, and the lack of breadth and depth of CPGs.
A systematic review of thirty surveys investigating clinician attitudes to CPGs supports the abovementioned position, with many physicians concerned that clinical guidelines are not applicable to individual patients [4
]. According to a review of 28 CPGs of nine chronic diseases typically managed in primary care [5
], little consideration is given to the patient with complex co-morbid illness, or to pertinent psychosocial elements such as culture, education level, socioeconomic status, patient preference and burden of treatment [5
Given that these biological, psychological and social factors may impact on the best approach to [6
], and effectiveness of patient care, neglecting these elements in clinical practice could result in poorer patient outcomes [5
]. Furthermore, failure to understand and describe the patient population, in relation to the biopsychosocial attributes that are critical to the preferred approach to care, could in the context of health services and health workforce planning, lead to (1) the under-provision of necessary clinical services, and (2) primary care teams with insufficient skill-mix to adequately address patient needs [1
This paper considers which patient attributes are likely to demand a unique approach to management; in terms of objectives of care, membership of the care team, and pattern of clinical appointments (e.g. frequency and duration of consultations). We also describe a conceptual framework devised to assist clinicians, educators, researchers, authors of CPGs, health services and health workforce planners to assess and handle the diverse patient populations seen in clinical practice.
Diabetes mellitus was chosen as a case exemplar to explore this issue; as a chronic and debilitating disease of high and increasing prevalence across the globe, for which adoption of best practice care has been demonstrated to improve outcomes, and for which there is considerable diversity in patient population across a range of factors that might be expected to impinge on appropriate management.