Consistency of Recommendations for Evaluation and Management of Hypertension

Abstract

IMPORTANCE Hypertension is very common, but guideline recommendations for hypertension have been controversial, are of increasing interest, and have profound implications. OBJECTIVE To systematically assess the consistency of recommendations regarding hypertension management across clinical practice guidelines (CPGs). DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of hypertension management recommendations included CPGs that had been published as of April 2018. Two point-of-care resources that provided graded recommendations were included for secondary analyses. Discrete and unambiguous specifications of the population, intervention, and comparison states were used to define a series of reference recommendations. Three raters reached consensus on coding the direction and strength of each recommendation made by each CPG. Three independent raters reached consensus on the importance of each reference recommendation. MAIN OUTCOMES AND MEASURES The main outcomes were rates of consistency for direction and strength among CPGs. Sensitivity analyses testing the robustness were conducted by excluding recommendation statements that were described as insufficient evidence, excluding single recommendation sources, and stratifying by importance of recommendations. RESULTS The analysis included 8 CPGs with a total of 71 reference recommendations, 68 of which had clear recommendations from 2 or more CPGs. Across CPGs, 22 recommendations (32%) were consistent in direction and strength, 18 recommendations (27%) were consistent in direction but inconsistent in strength, and 28 recommendations (41%) were inconsistent in direction. The rate of consistency was lower in secondary analyses. When insufficient evidence ratings were excluded, there was still substantial inconsistency, and a leave-one-out sensitivity analysis suggested the inconsistency could not be attributed to any single recommendation source. Inconsistency in direction was more common for recommendations deemed to be of lower importance (11 of 20 recommendations [55%]), but 17 of 48 high-importance recommendations (35%) had inconsistency in direction. CONCLUSIONS AND RELEVANCE Hypertension is a common chronic condition with widespread expectations surrounding guideline-based care, yet CPGs have a high rate of inconsistency. Further investigations should determine the reasons for inconsistency, the implications for recommendation development, and the role of synthesis across recommendations for optimal guidance of clinical care.

Concordance of recommendations across clinical practice guidelines for the management of hypertension in Southeast Asia with internationally reputable sources

“…However, differences in the interpretations of population, intervention, and comparator concepts for a given reference recommendation precluded direct analysis of concordance of recommendations. In order to avoid ambiguity that might arise, generation of the reference recommendations was adapted from a previously validated population (P)-intervention (I)-comparison (C) combinations approach [ 29 ] in order to provide a coherent framework to define the frames of reference for the interpretation of reference recommendations [ 29 ]. The population (P) was (adapted from a previous similar study [ 29 ]) for whom the recommendations from either the 2017 ACC/AHA guideline [ 22 ] or the 2018 ESC/ESH guideline [ 23 ] were intended; the intervention (I) was defined as the standard approach adopted in either the 2017 ACC/AHA guideline [ 22 ] or the 2018 ESC/ESH guideline [ 23 ]; whereas the comparator (C) was defined as the approach in contrast to the standard approach specified in either the 2017 ACC/AHA guideline [ 22 ] or the 2018 ESC/ESH guideline [ 23 ].…”

Consistency of recommendations from clinical practice guidelines for the management of critically ill COVID-19 patients

“…This cross-sectional study adapted methods from Alper et al 2 to evaluate consistency in CPGs that had been published as of 30 April 2020. We searched four sources that listed links to national and international CPGs: DynaMed Plus, 3 UpToDate, 4 BMJ Best Practice, 5 and Turning Research into Practice, 6 to identify CPGs on the management of critically ill COVID-19 patients.…”

The Challenge of External Validity: Why Specialties Interpret Evidence Differently

“…Hypertension is an example of a preventive intervention for patients at risk based on an arbitrary cut point on a continuous scale. 3,4 More aggressive cut points identify more individuals at risk, thus identifying more patients for treatment. The primary care community perceives that labeling lower-risk patients with hypertension requiring daily medicines may not be justifiable, based on ARR.…”