Consistency of Recommendations for Evaluation and Management of Hypertension

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.

Figure.. Classifications by Blood Pressure Thresholds in Clinical Practice Guidelines

Thresholds displayed are based on blood pressure measured in a clinic setting. Many guidelines emphasize the importance of out-of-clinic measurements (ie, home or ambulatory measurements) to establish diagnosis of hypertension. American College of Physicians and American Academy of Family Physicians guidelines are not shown because they did not address diagnostic thresholds. ACC/AHA indicates American College of Cardiology, American Heart Association, American Academy of Physician Assistants, Association of Black Cardiologists, American College of Preventive Medicine, American Geriatrics Society, American Pharmacists Association, American Society of Hypertension, American Society for Preventive Cardiology, National Medical Association, and Preventive Cardiovascular Nurses Association; ESH/ESC, European Society of Hypertension and European Society of Cardiology; HTN Canada, Hypertension Canada; JNC7, Panel Members Appointed to the Seventh Joint National Committee; NHFA, National Heart Foundation of Australia and National Heart Foundation of Australia–National Blood Pressure and Vascular Disease Advisory Committee; NICE indicates National Institute for Health and Care Excellence; and VA/DoD, Department of Veterans Affairs and Department of Defense. ^aIf measured using a nonautomated office blood pressure device; if using an automated office blood pressure device, systolic blood pressure greater than 135 mm Hg is considered high. ^bThe panel members appointed to the Eighth Joint National Committee focused on management, not reaffirming or redefining thresholds; therefore, thresholds from JNC7 were used. ^cNot shown is isolated systolic hypertension, defined as systolic blood pressure greater than 140 mm Hg and a diastolic blood pressure less than 90 mm Hg.