Study examines variation in cardiology practice guidelines over time

May 27, 2014, The JAMA Network Journals
Credit: George Hodan/public domain

An analysis of more than 600 class I (procedure/treatment should be performed/administered) American College of Cardiology/American Heart Association guideline recommendations published or revised since 1998 finds that about 80 percent were retained at the time of the next guideline revision, and that recommendations not supported by multiple randomized studies were more likely to be downgraded, reversed, or omitted, according to a study in the May 28 issue of JAMA.

As adherence to recommended increasingly is used to measure performance, guidelines play a major role in policy efforts to improve the quality and cost-effectiveness of care. Past research has established the importance of revising guidelines over time to address advances in research and population-level changes in health risks. Nonetheless, unwarranted variability across guidelines can reduce trust in guideline processes and complicate efforts to promote consistent use of evidence-based practices. Moreover, policies based on recommendations that prematurely endorse practices subsequently found to be ineffective can lead to waste and potential harm. Little is known regarding the degree to which individual endure or change over time, according to background information in the article.

Mark D. Neuman, M.D., M.Sc., of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and colleagues analyzed variations in class I American College of Cardiology/American Heart Association (ACC/AHA) guidelines (n = 11) published between 1998 and 2007 and revised between 2006 and 2013. The researchers reviewed and recorded all class I recommendations from the first of the 2 most recent versions of each guideline and identified corresponding recommendations in the subsequent version. Recommendations replaced by less determinate or contrary recommendations were classified as having been downgraded or reversed; recommendations for which no corresponding item could be identified were classified as having been omitted.

Out of 619 index recommendations, 495 (80.0 percent) were retained in the subsequent version; 8.9 percent were downgraded, 0.3 percent were reversed, and 10.8 percent were omitted. The percentage of recommendations retained varied across guidelines from 15.4 percent to 94.1 percent.

Among recommendations with available information on level of evidence, 90.5 percent of recommendations supported by multiple randomized studies were retained, vs 81.0 percent of recommendations supported by 1 randomized trial or observational data and 73.7 percent of recommendations supported by opinion. After accounting for guideline-level factors, the odds of a downgrade, reversal, or omission were more than 3 times greater for recommendations based on a single trial, observational data, consensus opinion, or standard of care than for recommendations based on multiple randomized trials.

"… our results may have important implications for health policy and medical practice. The categorization of medical evidence, through guidelines, into stronger and weaker recommendations, influences definitions of good medical practice and informs efforts to measure the quality of care on a large scale. Our findings stress the need for frequent re-evaluation of practices and policies based on guideline recommendations, particularly in cases where such recommendations rely primarily on expert opinion or limited clinical evidence," the authors write.

"Moreover, our results suggest that the effectiveness of clinical practice guidelines as a mechanism for quality improvement may be aided by systematically identifying and reducing unwarranted variability in recommendations. Finally, our work emphasizes the importance of greater efforts on the part of guideline-producing organizations to communicate the reasons that specific recommendations are downgraded, reversed, or omitted over time."

In an accompanying editorial, Paul G. Shekelle, M.D., Ph.D., of the VA West Los Angeles Medical Center, Los Angeles, and RAND Corporation, Santa Monica, discusses the importance of keeping clinical practice guideline up-to-date.

"The need for surveillance and updating of practice guidelines is increasingly gaining attention. 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 up-to-date in a timely way is an important goal for good patient care."

Explore further: Most practice guideline recommendations based on less-than-ideal quality of evidence, study says

More information: DOI: 10.1001/jama.2014.4949
DOI: 10.1001/jama.2014.4950

Related Stories

Most practice guideline recommendations based on less-than-ideal quality of evidence, study says

January 15, 2014
(Medical Xpress)—A study published in the January issue of Mayo Clinic Proceedings shows that most clinical practice guidelines for interventional procedures (e.g., bronchoscopy, angioplasty) are based on lower-quality ...

Facilitation improves PCP adherence to asthma guidelines

May 14, 2014
(HealthDay)—Adding practice facilitation (PF) to other strategies may improve adherence to asthma guidelines in the primary care setting, according to research published in the May/June issue of the Annals of Family Medicine.

Most pediatric procedural pain guidelines of average quality

February 3, 2014
(HealthDay)—Most clinical practice guidelines for procedural pain in children are of average quality and most do not provide tools to help clinicians apply the recommendations in practice settings, according to research ...

Guidelines 2.0: New guideline development checklist for health researchers

December 16, 2013
Researchers hope that a comprehensive new checklist will help guideline developers/organizations around the world create and implement better recommendations for health care. The guideline development checklist, created by ...

Asthma: DMP is largely consistent with guidelines

January 22, 2014
On 22 January 2014 the German Institute for Quality and Efficiency in Health Care (IQWiG) published the results of a literature search for evidence-based clinical practice guidelines on the treatment of people with asthma. ...

Surveillance colonoscopy recommendations for average-risk patients with 1 to 2 small polyps consistent with guidelines

April 16, 2014
According to a new study, endoscopists' recommendations for timing of surveillance colonoscopy in average-risk patients with one to two small polyps are consistent with guideline recommendations in about 90 percent of cases. ...

Recommended for you

A nanoparticle inhalant for treating heart disease

January 18, 2018
A team of researchers from Italy and Germany has developed a nanoparticle inhalant for treating people suffering from heart disease. In their paper published in the journal Science Translational Medicine, the group describes ...

Starting periods before age of 12 linked to heightened risk of heart disease and stroke

January 15, 2018
Starting periods early—before the age of 12—is linked to a heightened risk of heart disease and stroke in later life, suggests an analysis of data from the UK Biobank study, published online in the journal Heart.

'Decorated' stem cells could offer targeted heart repair

January 10, 2018
Although cardiac stem cell therapy is a promising treatment for heart attack patients, directing the cells to the site of an injury - and getting them to stay there - remains challenging. In a new pilot study using an animal ...

Two simple tests could help to pinpoint cause of stroke

January 10, 2018
Detecting the cause of the deadliest form of stroke could be improved by a simple blood test added alongside a routine brain scan, research suggests.

Exercise is good for the heart, high blood pressure is bad—researchers find out why

January 10, 2018
When the heart is put under stress during exercise, it is considered healthy. Yet stress due to high blood pressure is bad for the heart. Why? And is this always the case? Researchers of the German Centre for Cardiovascular ...

Heart-muscle patches made with human cells improve heart attack recovery

January 10, 2018
Large, human cardiac-muscle patches created in the lab have been tested, for the first time, on large animals in a heart attack model. This clinically relevant approach showed that the patches significantly improved recovery ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.