Durability of class I American College of Cardiology/American Heart Association clinical practice guideline recommendations.
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Clinical Guidelines
Authored By
Neuman MD, Goldstein JN, Cirullo MA, Schwartz JS
Authored On
Interests
Cardiology
Internal/Family Medicine
Speciality
Cardiology
Internal/Family Medicine
Book Detail
volume
311
ISSN
1538-3598
No. of pages
9
Publication Date
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["Neuman MD, Goldstein JN, Cirullo MA, Schwartz JS","Publisher: American Medical Association Country of Publication: United States NLM ID: 7501160 Publication Model: Print Cited Medium: Internet ISSN: 1538-3598 (Electronic) Linking ISSN: 00987484 NLM ISO Abbreviation: JAMA Subsets: MEDLINE","Journal Article; Research Support, N.I.H., Extramural","2014-05-01","JAMA [JAMA] 2014 May; Vol. 311 (20), pp. 2092-100.","English","1538-3598","Cardiology\/*standards , Practice Guidelines as Topic\/*standards, American Heart Association ; Evidence-Based Medicine\/standards ; Humans ; Randomized Controlled Trials as Topic ; Societies, Medical ; Time Factors ; United States","American Heart Association, Evidence-Based Medicine standards, Humans, Randomized Controlled Trials as Topic, Societies, Medical, Time Factors, United States, Cardiology standards, Practice Guidelines as Topic standards","JAMA","311"]
Description
Importance: Little is known regarding the durability of clinical practice guideline recommendations over time.<br />Objective: To characterize variations in the durability of class I ("procedure/treatment should be performed/administered") American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations.<br />Design, Setting, and Participants: Textual analysis by 4 independent reviewers of 11 guidelines published between 1998 and 2007 and revised between 2006 and 2013.<br />Main Outcomes and Measures: We abstracted all class I recommendations from the first of the 2 most recent versions of each guideline and identified corresponding recommendations in the subsequent version. We classified recommendations replaced by less determinate or contrary recommendations as having been downgraded or reversed; we classified recommendations for which no corresponding item could be identified as having been omitted. We tested for differences in the durability of recommendations according to guideline topic and underlying level of evidence using bivariable hypothesis tests and conditional logistic regression.<br />Results: Of 619 index recommendations, 495 (80.0%; 95% CI, 76.6%-83.1%) were retained in the subsequent guideline version, 57 (9.2%; 95% CI, 7.0%-11.8%) were downgraded or reversed, and 67 (10.8%; 95% CI, 8.4%-13.3%) were omitted. The percentage of recommendations retained varied across guidelines from 15.4% (95% CI, 1.9%-45.4%) to 94.1% (95% CI, 80.3%-99.3%; P < .001). Among recommendations with available information on level of evidence, 90.5% (95% CI, 83.2%-95.3%) of recommendations supported by multiple randomized studies were retained, vs 81.0% (95% CI, 74.8%-86.3%) of recommendations supported by 1 randomized trial or observational data and 73.7% (95% CI, 65.8%-80.5%) of recommendations supported by opinion (P = .001). After 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% CI, 1.69-5.85; P < .001) or on 1 trial or observational data (odds ratio, 3.49; 95% CI, 1.45-8.41; P = .005) vs recommendations based on multiple trials.<br />Conclusions and Relevance: The durability of class I cardiology guideline recommendations for procedures and treatments promulgated by the ACC/AHA varied across individual guidelines and levels of evidence. Downgrades, reversals, and omissions were most common among recommendations not supported by multiple randomized studies.
