“Pay particular attention to those guideline recommendations that have a high level of supporting evidence (level A) and high strength of recommendation (class I),” he advised. “These are not that common, but they have the best evidence and a high ratio of benefit to harm, so for the appropriate patients, these recommendations should almost always be performed.”
Dr. Janet Pope from University of Western Ontario, where she is the head of rheumatology, and St. Joseph’s Health Care, London, Ontario, told Reuters Health by email, “This study demonstrates that guidelines are a combination of evidence and expert opinion, but that the level of evidence can become blurred, so if the background to guidelines is not fully known, there can be misleading strengths of the recommendations.”
“For physicians overall this comes as no surprise, and the lack of evidence for guidelines seems to be common for all specialties,” she said. “For other readers, I guess thinking about the expression ‘buyer beware’ may come to mind, as you can’t fully know all the literature review that comes in to the recommendations.”
“I think that guidelines are also often giving us the minimum standard and that evidence of a better standard of care may not be included in guidelines as they are not yet included in a literature review (because) guidelines take time to be developed and disseminated,” Dr. Pope added. “Often there is a tradeoff between bringing the lowest standard of care to a slightly better level of care, but not necessarily recommending beyond to the highest evidence-based practice.”
The ACR said it was not able to have a representative comment on the report at this time.
- Duarte-García A, Zamore R, Wong JB. The Evidence Basis for the American College of Rheumatology Practice Guidelines. JAMA Internal Medicine. 2017 Nov 27. [Epub ahead of print]