Study examines variation in cardiology practice guidelines over time

May 27, 2014
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

Could aggressive blood pressure treatments lead to kidney damage?

July 18, 2017
Aggressive combination treatments for high blood pressure that are intended to protect the kidneys may actually be damaging the organs, new research from the University of Virginia School of Medicine suggests.

Quantifying effectiveness of treatment for irregular heartbeat

July 17, 2017
In a small proof-of-concept study, researchers at Johns Hopkins report a complex mathematical method to measure electrical communications within the heart can successfully predict the effectiveness of catheter ablation, the ...

Concerns over side effects of statins stopping stroke survivors taking medication

July 17, 2017
Negative media coverage of the side effects associated with taking statins, and patients' own experiences of taking the drugs, are among the reasons cited by stroke survivors and their carers for stopping taking potentially ...

Study discovers anticoagulant drugs are being prescribed against safety advice

July 17, 2017
A study by researchers at the University of Birmingham has shown that GPs are prescribing anticoagulants to patients with an irregular heartbeat against official safety advice.

Protein may protect against heart attack

July 14, 2017
DDK3 could be used as a new therapy to stop the build-up of fatty material inside the arteries

Heart study finds faulty link between biomarkers and clinical outcomes

July 14, 2017
Surrogate endpoints (biomarkers), which are routinely used in clinical research to test new drugs, should not be trusted as the ultimate measure to approve new health interventions in cardiovascular medicine, according to ...

0 comments

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.