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31 (In)consistency of recommendations for evaluation and management of hypertension
  1. Martin Mayer1,2,
  2. Brian Alper1,3,
  3. Amy Price4,5,
  4. Esther van Zuuren6,
  5. Zbys Fedorowicz7,
  6. Allen Shaughnessy8,
  7. Peter Oettgen1,
  8. Glyn Elwyn9,
  9. Amir Qaseem10,
  10. Ilkka Kunnamo11,
  11. Urvi Gupta4,
  12. Deborah Carter12,
  13. Michael Mittelman13,
  14. Carla Berg-Nelson14
  1. 1EBSCO Health, Ipswich, MA, USA
  2. 2Cone Health, Greensboro, NC, USA
  3. 3University of Missouri-Columbia School of Medicine, Columbia, MO, USA
  4. 4Stanford Medicine X, Stanford, CA, USA
  5. 5University of Oxford, Oxford, UK
  6. 6Leiden University Medical Centre, Leiden, Netherlands
  7. 7Veritas Health Sciences Consultancy, London, UK
  8. 8Tufts University School of Medicine, Medford, MA, USA
  9. 9The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
  10. 10American College of Physicians, Philadelphia, PA, USA
  11. 11Duodecim, Helsinki, Finland
  12. 12Murdy Consultant Group, Newark, OH, USA
  13. 13American Living Organ Donor Fund, Philadelphia, PA, USA
  14. 14Society for Participatory Medicine, Nutting Lake, MA, USA


Objectives To systematically assess the consistency of recommendations regarding hypertension management across clinical practice guidelines (CPGs) and electronic point-of-care (POC) resources

Method We identified hypertension management recommendations from eight CPGs and two POC resources in April 2018. We described discrete and unambiguous specifications of the population, intervention, and comparison states to define a series of reference recommendations. Three raters reached consensus on coding the direction and strength of each related recommendation made by each CPG and POC resource.

For each reference recommendation, we analyzed the rate of consistency for direction and strength. We did this for the eight CPGs and for the group of ten recommendation sources. We also conducted sensitivity analyses testing the robustness of our findings to the exclusion of recommendation statements of ‘insufficient evidence’ and to the exclusion of single recommendation sources. We also assessed the CPG and POC resources for evidence of public and patient involvement, patient-facing information, and shared decision-making tools, and we involved patient and public representatives in this assessment.

Results Considering all 10 recommendation sources, 12 of 71 recommendations (16.9%) were consistent in direction and strength, 21 (29.6%) consistent in direction but inconsistent in strength, and 38 (53.5%) inconsistent in direction. Considering only the CPGs, 25 recommendations (35.2%) were consistent in direction and strength, 13 (18.3%) consistent in direction but inconsistent in strength, and 33 (46.5%) inconsistent in direction. Excluding ‘insufficient evidence’ ratings did not explain the inconsistency, and a leave-one-out sensitivity analysis suggested the inconsistency is not due to any single recommendation source. These findings held whether considering all recommendation sources or only CPGs. One recommendation source reported patient or public involvement. Six included very general information about how to include patients in individual decision-making, and three provided direct-to-patient guidance. Two made tools available to help patients participate in individual decision-making, one suggesting an existing tool, and the other integrating the tool within the POC recommendation.

Conclusions Hypertension is a common chronic condition with widespread expectations surrounding guideline-based care, but CPGs have high degrees of inconsistency. Further investigation should determine the reasons for inconsistency, the implications for recommendation development, and the role of synthesis across recommendations for optimal guidance of clinical care.

Consideration of a patient’s values and preferences is a fundamental part of practicing evidence-based medicine. Therefore, public and patient involvement is encouraged in CPG development just as shared decision-making is encouraged in clinical practice. With a substantial proportion of hypertension management guidance being weak or inconsistent, shared decision-making could replace algorithmic instructions as a primary framework for an approach to healthcare, but this will require development of patient decision aids and workflow support tools to make it practical.

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