Strongest Cardiology Guideline Recommendations Last Longer

Marlene Busko

May 27, 2014

PHILADELPHIA, PA — In a study examining how the two most recent versions of major cardiology clinical practice guidelines changed over time, researchers report that recommendations based on multiple randomized trials were the most durable[1]. They looked at 600 class 1 recommendations in 11 American College of Cardiology (ACC)/American Heart Association (AHA) clinical practice guidelines.

Four out of five class 1 recommendations were retained. The odds that a recommendation was not retained—ie, it was reversed, downgraded, or omitted—were more than three times greater for a recommendation based on one randomized trial, observational data, or expert opinion as opposed to one based on multiple randomized controlled trials.

"For policy makers and clinicians, deciding to make policies on practices and treatments that are supported by multiple randomized trials seems a safer thing to do . . . in terms of their durability," Dr Mark D Neuman (University of Pennsylvania, Philadelphia, PA) told heartwire .

It would be helpful for clinicians and policy makers if the reasons that a recommendation was downgraded, reversed, or omitted were included in the update, which was not always the case, he added. Only a small fraction of these changes were explained in focused updates, he added.

The article was published in the May 28, 2014 issue of the Journal of the American Medical Association.

"I use clinical guidelines to guide the care I deliver, and the care I deliver has changed over time by changes in practice guidelines," Neuman explained. "I wanted to see how big a phenomenon these changes were."

Neuman and colleagues identified 11 cardiology guidelines that were published from 2006 until September 1, 2013 that had had a previous version published from 1998 and 2007. They reviewed and recorded all class 1 recommendations and identified recommendations that had been reversed, downgraded, or omitted in the most recent guidelines.

Out of 619 index recommendations, 80% were retained in the subsequent version, 8.9% were downgraded, 0.3% were reversed, and 10.8% were omitted. The percentage of recommendations retained varied across guidelines from 15.4% to 94.1%.

Of the recommendations where level of evidence was available, 90.5% of recommendations supported by multiple randomized studies were retained, vs 81.0 % of recommendations supported by one randomized trial or observational data and 73.7% of recommendations supported by opinion.

"Our findings 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 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."

Need to Improve Update Process

"Clinical practice guidelines are used by clinicians to determine patient care, by patients to understand treatment options, and by policy makers to create clinician-performance measures and set payment policies," Dr Paul G Shekelle (West Los Angeles VA Medical Center, CA) writes in an accompanying editorial[2].

"As the preferred method of accessing information moves increasingly to the internet, guideline developers ought to be able to produce electronic versions of guidelines that have hypertext links to take users directly to the information they are most interested in, and one of these links should be to a table outlining 'what’s new?' and 'what’s different?' " he suggested.

To meet the need for timely, updated guidelines, "guidelines-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 mind-set, recognizing that keeping existing guidelines up-to-date in a timely way is an important goal for good patient care," he writes.

Dynamic Online Guidelines

"I was pleased to see that after due consideration of everything in the paper and the editorial that we have attended to all these suggestions and have thought of them already, which I find comforting, because it endorses that we are heading in the right direction," AHA president-elect Dr Elliott Antman (Harvard Medical School, Boston, MA) told heartwire .

"We survey the writing committee of these guidelines at least three times a year, when major cardiology meetings are taking place, and ask if there are any new trials that were presented that warrant a focused update or even a full revision of a guideline," he said.

It is critical that guidelines are accurate, because so many stakeholders rely on them. The AHA and ACC are taking steps to make guidelines more "nimble" to incorporate new evidence. For example, the recent valvular heart disease guideline[3] is a "living, dynamic" online document. "If a new piece of evidence comes along, that particular knowledge bite can be updated [in this online guideline] and that becomes the guideline of record," Antman said.

Neuman received funding from the National Institute on Aging. Disclosures for the coauthors are listed in the article. Shekelle reported having consulted for the National Guideline Clearinghouse and National Quality Measures Clearinghouse for the ECRI Institute; having grants or grants pending from the Agency for Healthcare Research and Quality, Department of Veterans Affairs, Centers for Medicare & Medicaid Services, and the Office of the National Coordinator for Health Information Technology; receiving royalties from UpToDate; and having served on the American College of Physicians Clinical Guidelines Committee.


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