Author + information
- †Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah
- ‡University of Utah School of Medicine, Salt Lake City, Utah
- ↵∗Reprint requests and correspondence:
Dr. Jeffrey L. Anderson, Intermountain Heart Institute, Intermountain Medical Center, 5121 South Cottonwood Street, Sorensen Heart and Lung Building, L6, Salt Lake City, Utah 84107.
ACC/AHA Clinical Practice Guidelines: A Brief History and Current Impact
The joint American College of Cardiology and American Heart Association (ACC/AHA) Clinical Practice Guidelines (CPGs) have been in existence for >30 years, and their influence continues to grow (1). Initiated in response to the U.S. government’s concern about a potential overuse of pacemakers, these guidelines have evolved to address a shared sense of responsibility to foster excellence in clinical care across the spectrum of cardiovascular (CV) disease. The impact of CPGs is difficult to quantify, but it was highlighted in a 2012 survey among ACC/AHA cardiologists: >90% found ACC/AHA CPGs to be routinely useful in practice. In addition, audits of access to CPGs online and other observations confirm intense and broad reader interest, which extends beyond clinicians and allied health care workers to insurers, regulators, governmental bodies, the pharmaceutical and device industry, the legal community, and the general population.
Recent CPG Developments
Aware of the growing impact of CPGs and concerned about their quality, the U.S. Congress commissioned the Institute of Medicine (IOM) to propose a set of standards for CPG development. In response, the IOM issued 2 reports in 2011: “Clinical Practice Guidelines We Can Trust” (2) and “Finding What Works in Health Care: Standards for Systematic Reviews” (3). To review implications of the IOM reports for its CPGs as well as ongoing improvement processes, ACC/AHA convened a Methodology Summit in December 2011 among CPG Task Force members and other CPG experts and stakeholders. Upon review of CPG processes, summit attendees found ACC/AHA standards generally to be of high quality, but they recommended additional features be added to existing methods (4).
A key recommendation was to form evidence review committees (ERCs) to ensure independent, unbiased systematic reviews of the evidence base for critical CPG recommendations and to do so by using standardized protocols and grading tools, with Level of Evidence (LOE) grading refined and expanded to accommodate additional granularity. A second recommendation was to extend ACC/AHA’s already restrictive conflict of interest policy beyond relations with industry to include intellectual and practice perspectives. A third was to expand the review process beyond its already robust internal review practice to include relevant external experts and stakeholders, and a fourth was to incorporate patient/lay representatives in CPG development.
The recent update of the CPG on perioperative cardiovascular evaluation represents a successful initial application of an ERC-driven systematic review (5,6). Authorized because of both new evidence and controversy regarding the legitimacy of data from previously published clinical trials, the ERC report on perioperative beta-blocker use represents an important example of basing a CPG recommendation on the highest level of scientific rigor and credibility.
In parallel with this initiative to improve CPG scientific rigor and credibility, ACC/AHA initiated efforts to better address user needs. In the 2012 survey cited earlier (1), ACC/AHA members were asked to rate the relevance to their practice of CPG recommendations supported by weaker Class of Recommendation and LOE grades (i.e., Classes IIa and IIb and LOE: C). Of note, more than two-thirds of cardiologists responded that these weaker class/levels were helpful or very helpful in their practice in making informed therapeutic and diagnostic decisions. A similar two-thirds of responders indicated a preference for “dynamic” updates of CPGs and a “living document” format (i.e., with frequent, timely updates in step with the rapid pace of clinical science). Furthermore, they almost uniformly indicated interest in electronic means of CPG access, by multiple mechanisms, with CPG recommendations accessible at the point-of-care.
To address clinician needs, the format of ACC/AHA CPGs has already been changed to include less text, links to evidence tables, and color-coded recommendation tables. The recent valvular heart disease guidelines initiated another important innovation, by dividing CPGs into a “knowledge-byte” format, with limited text and appropriate links for each recommendation. In this format, recommendations can be easily stored in a central electronic databank, accessed for individual guideline updates as new evidence emerges, shared among overlapping CPGs, and made accessible digitally at points-of-care through handheld devices (7).
Traditionally, the costs of interventions and resource utilization have been explicitly excluded from CPG considerations, although they often have been implicitly considered. A recent ACC/AHA document represents a change in this policy (8). Given accelerating health care costs and ever more limited resources, ACC/AHA recognizes the need to promote best value health care. This document proposes adding levels of value to CPGs as a supplement to scientific Class of Recommendation/LOE grades when cost-effectiveness information is available and where value issues are important.
A further direction planned for future CPGs is greater consideration of common comorbidities in patients with CV diseases (9). With the aging population, it is common for CV patients to have at least 1, and more often multiple, comorbidities. Although several of these share common risk factors and pathophysiology (e.g., diabetes, hypertension, renal disease) with CV diseases, others are distinct (e.g., arthritis, cancer, gastrointestinal, many pulmonary conditions), and they sometimes present conflicting treatment recommendations. The complex process of current CPG development is outlined in Figure 1.
Summary of Current Paper
The objective of the paper by Han et al. (10) in this issue of the Journal was to evaluate recent changes in ACC/AHA CPG recommendations. The authors compared 11 CPG updates (either full or focused) published between 2008 and 2014 with the previous versions (published a mean of 6.5 years earlier). Overall, the updated CPGs exhibited a distribution of recommendations that was more evidence based, with fewer recommendations, fewer supported by a low level of evidence (LOE: C, 34% vs. 45%), slightly more by a high LOE (LOE: A, 15% vs. 13%), and a similar percentage of strong, Class I recommendations (50%). This recent assessment of CPGs represents a timely update of an earlier, less favorable analysis (11). The findings of Han et al. generally concur with those of an internal ACC/AHA audit of the 3,271 recommendations across 19 CPGs published by 2013 (1), but they present more detailed analyses with temporal trends.
Despite the positive (although modest) overall changes, a review of individual paired CPG comparisons found marked heterogeneity. Han et al. (10) recognized this, and they proposed that the observed variability may be the result of differing guideline topics and types (full rewrite vs. focused update), the year of publication (whether before or after intervening changes in CPG methods [1,4]), and the extent of writing committee membership change. They also appropriately point out the delicate balance between the sometimes competing goals of increased scientific rigor and comprehensive clinical guidance, including issues where evidence is weak but clinical need is great. Nevertheless, this paper offers an informative “audit” of the current state of ACC/AHA CPGs, and it represents an important landmark in the evolution of CPGs during a time of rapid and ongoing change.
Implications and Future Directions
The impact of CPGs continues to grow as the current health care environment stresses ever higher scientific standards of care as well as cost-effective care. These objectives must coexist with clinician-stated needs for easily accessed yet comprehensive guidelines. These guidelines should include not only a clear delineation of diagnostic and therapeutic strategies for which a sound scientific basis exists but also guidance by experts on important clinical issues for which the evidence base is weak. This natural tension between the goals of scientific rigor and clinical need represents an ongoing challenge to CPG development and requires sound judgment to achieve a delicate, optimal balance.
By recognizing and highlighting critical gaps in knowledge, CPGs also importantly serve as a resource to focus future research efforts. For the clinician, CPGs must evolve to become more accessible at point-of-care and useable within the context of the flow of practice (i.e., at the clinician’s fingertips in digital format in response to specific clinical questions) and updated in “living document” format, so as to lead rather than follow common clinical practice. Ideally, future CPGs may be imbedded into electronic medical order and record systems, providing electronic prompts or even provisional orders. CPGs also will play an important role in “learning health care systems,” in which a continuous cycle of evidence-based practice can lead to feedback with practice-based evidence to validate or further refine clinical practice (1).
Regardless of the future directions in CPG evolution, the overall goal of enhancing the quality of care and improving outcomes of patients with CV disease must remain. As CPGs continue to evolve, interval “audits,” such as that of Han et al. (10), will serve as useful landmarks along the way, to be correlated with and judged by trends in CV disease incidence and outcomes.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Anderson has reported that he has no relationships relevant to the contents of this paper to disclose. Jeffrey Kuvin, MD, served as Guest Editor for this paper.
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