July 14th, 2014
Poor Retention of Guideline Recommendations
In an article published in the May 28th edition of JAMA, a group of physicians addressed the question of the retention of clinical practice guideline recommendations over time. The investigators assessed the durability of Class I recommendations to provide a perspective on how often actions that are deemed mandatory become less enthusiastically endorsed as more evidence emerges.
Of 619 Class I recommendations in 11 index guidelines published between 1998 and 2007, 20% of the recommendations did not appear in the subsequent guideline and 9.2% were downgraded or reversed. Even among the recommendations that were supported by multiple trials, 5.7% were not retained in subsequent versions of guidelines and 3.8% were downgraded or reversed. The Class I recommendations at the highest risk for being omitted, downgraded, or reversed were those based on consensus opinion, followed by those based on a single randomized trial or nonrandomized trials.
I would have thought that the strongest recommendations in a guideline would be very unlikely to change over time. In this disturbing study, a substantial proportion of Class I recommendations were not durable over even a 10-year period, showing us that uncertainty surrounds even the strongest guideline recommendations. I wonder whether the writing committees would have been able to predict which of the Class I recommendations were most likely to be omitted, downgraded, or reversed based on future studies. I’d bet they could not have guessed correctly.
JOIN THE DISCUSSION
Why do you think such a high percentage of guideline recommendations are omitted, downgraded or reversed? Does this information affect your opinion of the importance of existing guidelines?