How Durable Are the Strong Recommendations Made in Practice Guidelines?

Summary and Comment |
June 5, 2014

How Durable Are the Strong Recommendations Made in Practice Guidelines?

  1. Harlan M. Krumholz, MD, SM

Many Class I recommendations don't survive to the 10-year mark — especially those based merely on opinion or observational data.

  1. Harlan M. Krumholz, MD, SM

Class I recommendations proclaim which practices should be followed in given clinical situations, and they are the strongest made within the American College of Cardiology/American Heart Association guideline framework. 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.

Editor Disclosures at Time of Publication

  • Disclosures for Harlan M. Krumholz, MD, SM at time of publication Consultant / Advisory board United Healthcare; VHA, Inc.; Premier, Inc. Equity ImageCor Grant / Research support FDA; NIH-NHLBI; Commonwealth Fund; The Catherine and Patrick Weldon Donaghue Medical Research Foundation; Robert Wood Johnson Foundation; Medtronic Editorial boards; American Journal of Managed Care; American Journal of Medicine; Archives of Medical Science; Central European Journal of Medicine; Critical Pathways in Cardiology; Current Cardiovascular Risk Reports; JACC: Cardiovascular Imaging; Journal of Cardiovascular Medicine; Circulation: Cardiovascular Quality and Outcomes Leadership positions in professional societies American Board of Internal Medicine (Chair, Assessment 2020 Task Force)


Reader Comments (4)

Caliann T. Lum, MD, PhD Physician, Surgery, Specialized, Health informatics company

I congratulate the willingness of practice leadership to shuck superseded class I recommendations as new evidence accrues. We live in a changing environment. To me it's reassuring that at the institutional level we embrace and integrate evidence-based medicine by regularly replacing outmoded guidance based on best-guess consensus or outdated evidence with the best scientific evidence available.

SS Iyengar, MD, DM(Cardiology),FRCP(E) Physician, Cardiology, Manipal Hospital, Bangalore, India

Not surprising at all.
Science is not stagnant

GEORGE BARBER Physician, Family Medicine/General Practice, Clinic

So this article tells me Class 1 guidelines probably won't survive 10 years and further down JW the article on antibiotics chastises me for not following guidelines ! Ooo Vey

John Physician, Unspecified

Because we all know medical science is a very static field and rarely changes. I'm not seeing why this is so shocking. Even the best of evidence can be overthrown by even better evidence. That's the entire point of science/evidence based medicine. Do we criticise best medical practices of the 1860s, 1930s, or even early 2000s (thinking of Xigris) just because they don't meet the standards of today?

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