Study Assesses Strength of Clinical Practice Guidelines Over Time

Over the year clinical practice guidelines have become a permeating aspect of medical care and are increasingly used to measure performance, and improve the quality and cost-effectiveness of care. While the U.S. Institute of Medicine and other organizations have made steps to improve the guideline development, little however, is known on the durability of these guideline recommendations and how they may endure or change over time.

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In a report published May 27 in the Journal of the American Medical Association, Mark Neuman, MD, MSc, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, and his colleagues examined the lasting strength of class I – i.e. procedure/treatment should be performed/administered – recommendations across serial versions of selected American College of Cardiology/American Heart Association guidelines, and found that durability of the guidelines "varied across individual guidelines and levels of evidence."

Identifying 619 class I recommendations in 11 index guidelines published between 1998 and 2007, the investigation found that 495 recommendations (80.0 percent) were retained in the subsequent guideline version, 57 (9.2 percent) were downgraded or reversed, and 67 (10.8 percent) were omitted. The ultimate percentage of recommendations that were retained varied across guidelines from 15.4 percent to 94.1 percent.

The endurance of individual recommendations proved to vary according to their underlying level of evidence. Amidst the 448 index class I recommendations for which level-of-evidence data was available, 90.5 percent of recommendations supported by multiple randomized studies were retained, compared to 81 percent of recommendations supported by one randomized trial or observational data and 73.7 percent of recommendations supported by opinion.

Accounting for guideline-level factors, the probability of being downgraded, reversed, or omitted was greater for recommendations based on opinion (odds ratio, 3.14; 95 percent CI, 1.69 – 5.85; P < .001) or on one trial or observational data (odds ratio, 3.49; 95 percent CI, 1.45 – 8.41; P = .005) compared to recommendations based on multiple trials.

Offering what they feel to be practical insight related to the application of guideline recommendations to clinical care and health policy, highlighting the overall durability of cardiovascular disease guideline recommendations and emphasizing the particular subsets of recommendations, Neuman et al. stress the need for frequent reevaluation of practices and policies based on guideline recommendations, particularly in cases where such recommendations rely primarily on expert opinion or limited clinical evidence.

"The need for surveillance and updating of practice guidelines is increasingly gaining attention," writes Paul Shekelle, MD, PHD in a commenting editorial. "To meet the need, guideline development organizations need to change their focus. This change is not easy. It is not just a matter of resources, although guideline organizations are going to have to devote more resources to active surveillance and maintenance of their guidelines than most probably do at present. It also has to be a change to the mindset, recognizing that keeping existing guidelines up-to-date in a timely way is an important goal for good patient care."

Keywords: Health Policy, Odds Ratio, Expert Testimony, Probability, Critical Care, National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division

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