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Consistency of Recommendations for Evaluation and Management of Hypertension

Brian S Alper¹, Amy Price^2,3, Esther J van Zuuren⁴

¹Innovations and Evidence-Based Medicine Development, EBSCO Health, Department of Family and Community Medicine, University of Missouri-Columbia School of Medicine, Ipswich, Massachusetts.

JAMA Network Open

|November 23, 2019

Insights

Clinical practice guidelines for hypertension management show significant inconsistency in recommendations, impacting patient care. Further research is needed to understand and address these discrepancies for improved clinical guidance.

Area of Science:

Cardiology
Clinical Practice Guidelines
Evidence-Based Medicine

Background:

Hypertension is a prevalent condition with significant health implications.
Clinical practice guidelines (CPGs) aim to standardize hypertension management.
Existing hypertension CPGs have faced scrutiny regarding consistency and clarity.

Purpose of the Study:

To systematically evaluate the consistency of hypertension management recommendations across multiple clinical practice guidelines.
To identify the extent of agreement in both the direction and strength of recommendations.

Main Methods:

A cross-sectional study analyzed hypertension CPGs published up to April 2018.
Reference recommendations were defined using specific population, intervention, and comparison criteria.
Three independent raters coded the direction and strength of each recommendation, reaching consensus.

Main Results:

Analysis of 8 CPGs revealed substantial inconsistency; only 32% of recommendations were consistent in both direction and strength.
41% of recommendations showed inconsistency in direction, with higher rates in lower-importance recommendations.
Sensitivity analyses confirmed that inconsistency persisted even when excluding certain data or sources.

Conclusions:

Clinical practice guidelines for hypertension management exhibit a high degree of inconsistency.
These inconsistencies may pose challenges for clinicians and impact patient care.
Further investigation is crucial to understand the causes and implications of this variability.

Read full analysis

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.

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