Guideline Recommendations Are Written in Dry Erase Marker, Not Stone.

A guest post by Anand Swaminathan (@EMSwami) of EM Lyceum and Essentials of EM fame.

Medicine is filled with guidelines, professional recommendations and expert consensus statements. These documents guide clinical practice. In Emergency Medicine, we often rely on non-EM specialty guidelines. For instance, we often state that a patient in whom you consider ACS should get evocative testing (i.e. stress test) within 72 hours of presentation according to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines. As more guidelines and subsequent revisions are released a number of questions arise. Should we adopt the guidelines immediately? If so, which pieces are ready for immediate incorporation into clinical care? At the heart of these questions is the strength and durability of the recommendations.

This article is unique in the question it asked: what is the durability of class I recommendations from the ACC/AHA? The looked at 11 guidelines published between 1998 and 2007 along with revisions to these guidelines from 2006 to 2013. What they found was surprising. Out of 619 original class 1 recommendations, about 80% were retained in subsequent revisions. About 9% were downgraded or reversed and about 11% were omitted.  Not surprisingly, recommendations with multiple randomized studies backing them up tended to stick around (90.5%) but those recommendations supported by opinion only did not (73.7%).

What can we take away from this? First, we shouldn’t adopt recommendations (even level 1) that don’t have good evidence backing them up. Secondly, guidelines should be updated frequently (these authors suggest every 3 to 5 years) to incorporate new evidence that may up or downgrade recommendations. Guideline adherence shouldn’t be used as a performance measure since the recommendations are anything but written in stone. Lastly, this is a further call for our specialty to take the reigns and start writing our own, high-quality guidelines from which we can base clinical practice.

“Durability of Class 1 American College of Cardiology/American Heart Association Clinical Practice Guideline Recommendations”