I attended this lecture “Keeping Guidelines Alive,” by Dr Katrin Uhlig, Chair of the KDIGO Methods Committee. This committee is composed of well-published and accomplished individuals, with academic and clinical backgrounds. One of the prominent members is Gordon Guyatt, considered as one of the pioneers of evidence-based medicine (along with David Sackett and Bryan Haynes), who is also credited with being the first to use the term “evidence-based medicine,” in an editorial for ACP Journal Club, around 24 years ago.
It was interesting to know that when they look at the NICE Guidelines after 3 years, 14% of the guidelines were no longer up to date, whereas after 5 years, 50% were no longer up to date. Review of the ACC/AHA Cardiology recommendations showed that it took 4-10 years from initial publication to update. Subsequently, when looking at Class I recommendations (i.e., strong definitive recommendations), whereas 80% were retained, 8.9% were downgraded, 0.3% were reversed, and 10.8% were omitted. They also demonstrated that the probability for downgrade, reversal or omission, was higher for recommendations for those guidelines that were based on lower quality evidence as compared to those of higher quality that were based on RCTs.
So what are the criteria that one may look at to determine if a guideline needs to be updated?
- Changes in available interventions (e.g., new drugs or devices)
- Changes in evidence on the existing benefits and harms of interventions
- Changes in outcomes considered important
- Changes in evidence that current practice is optimal
- Changes in values placed on outcomes
- Changes in resources available for healthcare or costs of interventions
When one looks at Nephrology guidelines however, there are specific issues
- Few RCTs, small size
- Clinical heterogeneity impedes quantitative pooling
- Limited number of guidelines
There is also significant cost issues that may provide some limitation in dissemination, e.g., electronic platforms, etc.
As a clinician, I use these guidelines in daily clinical practice day in and day out. Being involved in a busy practice, I do not have the luxury of sitting down and sifting through the gamut of peer-reviewed journals and publications and decide which ones should affect my practice or not. It is quite reassuring that there are folks like Dr. Uhlig and her team who pay particular close attention to these matters.
Post by Dr. Edgar Lerma, AJKD Blog Advisory Board member.
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