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PubMed2000

[Previous experiences with the evaluation of guidelines. Disillusionment after an enthusiastic start].

The evaluation of medical guidelines shows that the development and implementation of medical guidelines have failed to meet the high expectations raised both in Germany and internationally. Especially, the quality of German guidelines has been strongly criticized. Since then, several 'guidelines for guidelines' were published, and a variety of other measures were taken to define quality standards for the development and implementation of guidelines. It is expected that the application of these new standards will improve the quality of medical guidelines and therefore increase the chances for a more successful implementation. Only guidelines with high quality and wide acceptance, which are actually applied, will have positive effects on the process and outcome of medical care. But guidelines are only one way to improve the quality of medical care. The decision about the development and use of new guidelines should be based on the careful consideration of possible improvements and disadvantages.

Germany↗

PubMed2000

Lipid screening to prevent coronary artery disease: a quantitative evaluation of evolving guidelines.

BACKGROUND: There is strong evidence to support the treatment of abnormal blood lipid levels among people with cardiovascular disease. Primary prevention is problematic because many individuals with lipid abnormalities may never actually develop cardiovascular disease. We evaluated the 1998 Canadian lipid guidelines to determine whether they accurately identify high-risk adults for primary prevention. METHODS: Using data from the Lipid Research Clinics and receiver operating characteristic (ROC) curves, we compared the diagnostic performance of the 1998 lipid guidelines when risk factors for coronary artery disease (CAD) were counted versus calculating risk using Framingham risk equations. We also compared the diagnostic accuracy of the 1998 guidelines with guidelines previously published by the National Cholesterol Education Program in the United States and the 1988 Canadian Consensus Conference on Cholesterol and then used Canadian Heart Health Survey data to forecast lipid screening and treatment rates for the Canadian population. RESULTS: The Framingham risk equations were more accurate than counting risk factors for predicting CAD risk (areas under the ROC curves, 0.83 [standard deviation (SD) 0.02] v. 0.77 [SD 0.03], p < 0.05). Risk counting was a particularly poor method for predicting risk for women. The 1998 Canadian guidelines identified high-risk individuals more accurately than the earlier guidelines, but the increased accuracy was largely due to a lower false-positive rate or a higher true-negative rate (i.e., increased test specificity). Using the 1998 lipid guidelines we estimate that 5.9 million Canadians currently free of cardiovascular disease would be eligible for lipid screening and 322,705 (5.5%) would require therapy. INTERPRETATION: Calculating risk using risk equations is a more accurate method to identify people at high risk for CAD than counting the number of risk factors present, especially for women, and the 1998 Canadian lipid screening guidelines are significantly better at identifying high-risk patients than the 1988 guidelines. Many of our findings were incorporated into the new 2000 guidelines.

Adult↗

PubMed2000

US low-risk drinking guidelines: an examination of four alternatives.

BACKGROUND: This study compared four sets of US low-risk drinking guidelines (two interpretations of the US Dietary Guidelines and two variations of the NIAAA physicians' guidelines) in terms of adherence and how well they predicted five different alcohol-related outcomes. METHODS: Using data from a nationally representative sample of 17,542 US adults 21 years of age and over who drank 12 or more drinks in the past year, this study assessed the sensitivity, specificity, overall accuracy, positive and negative predictive values, and odds ratios of the various drinking guidelines (specifically, of having exceeded them with different degrees of frequency) as predictors of alcohol dependence, impaired driving, liver disease, peptic ulcer, and hypertension. RESULTS: The proportions of past-year regular drinkers exceeding the four sets of guidelines varied from 20.9%, whose average intake exceeded the weekly limits, to between 21.0% and 42.7% who exceeded the daily guidelines at least once a week, and to between 69.2% and 94.2% who ever exceeded the daily limits in the year preceding the interview. Sensitivity and odds ratios were highest for the ever exceeding the Dietary Guidelines daily limits, intermediate for ever exceeding the two variations based on the NIAAA physicians' guidelines, and lowest for exceeding the Dietary Guidelines interpreted as weekly limits. The opposite pattern was observed for specificity and overall predictive accuracy. When frequently exceeding the daily limits was considered, their sensitivity declined but their specificity and positive predictive value increased. CONCLUSIONS: If sensitivity and specificity are deemed equally important, the NIAAA physicians' guidelines incorporating both daily and weekly limits seem to do the best job of balancing these dimensions in the prediction of a variety of alcohol-related outcomes.

Adolescent↗

PubMed1996

Heterogeneity of physician agreement with recommended therapeutic guidelines for the management of HIV-associated disease.

The aims of this study were to assess the degree of heterogeneity in the knowledge of therapeutic management of HIV infection among HIV-experienced physicians in British Columbia, Canada, and to identify associations between physician characteristics and their agreement with contemporary therapeutic guidelines. A self-administered anonymous questionnaire was mailed to 6500 physician members of the British Columbia Medical Association. The questionnaire provided information about demographic and personal characteristics, including sex, age, medical specialization and practice location; level of experience in treating HIV-infected patients; use of HIV testing procedures; use of preventative vaccinations and tests; and preferred approaches to antiretroviral therapy and the prophylaxis and acute treatment of opportunistic infections. We compared physicians' patterns of knowledge with contemporary recommendations. Logistic regression identified associations between physician characteristics and their agreement with contemporary guidelines. A total of 463 HIV-experienced physicians (a high proportion of the HIV-experienced physicians in British Columbia, Canada) responded to the questionnaire. The agreement with contemporary guidelines about HIV testing and preventative vaccinations and tests among responders ranged from 27% to 71%. For antiretroviral therapy, agreement with the guidelines ranged from 12% to 35%. For the prophylaxis and treatment of opportunistic infections, agreement with the guidelines ranged from 11% to 89% (prophylaxis) and from 46% to 91% (treatment). Regression analysis revealed that physicians actively involved in the care of HIV-infected patients were more likely to agree with the guidelines in all areas of patient care. General practitioners were more likely to agree with the guidelines regarding preventative therapies, and male general practitioners under 45 years old were more likely to agree with the guidelines on antiretroviral therapy. Our data confirm that there is substantial heterogeneity in the management of HIV-associated disease, including some deviations from contemporary guidelines. Concordance with contemporary guidelines increased with the physician's level of HIV-related experience. Our results support the idea that adherence to state-of-the-art practices may be responsible, at least in part, for the recently described association between physician experience and improved survival of HIV-infected individuals.

AIDS-Related Opportunistic Infections↗

PubMedDate not supplied

Value of XML in the implementation of clinical practice guidelines--the issue of content retrieval and presentation.

The purpose of guidelines in clinical practice is to improve the effectiveness and efficiency of clinical care. It is known that nationally or internationally produced guidelines which, in particular, do not involve medical processes at the time of consultation, do not take local factors into account, and have no consistent implementation strategy, have limited impact in changing either the behaviour of physicians, or patterns of care. The literature provides evidence for the effectiveness of computerization of CPGs for increasing compliance and improving patient outcomes. Probably the most effective concepts are knowledge-based functions for decision support or monitoring that are integrated in clinical information systems. This approach is mostly restricted by the effort required for development and maintenance of the information systems and the limited number of implemented medical rules. Most of the guidelines are text-based, and are primarily published in medical journals and posted on the internet. However, internet-published guidelines have little impact on the behaviour of physicians. It can be difficult and time-consuming to browse the internet to find (a) the correct guidelines to an existing diagnosis and (b) and adequate recommendation for a specific clinical problem. Our objective is to provide a web-based guideline service that takes as input clinical data on a particular patient and returns as output a customizable set of recommendations regarding diagnosis and treatment. Information in healthcare is to a very large extent transmitted and stored as unstructured or slightly structured text such as discharge letters, reports, forms, etc. The same applies for facilities containing medical information resources for clinical purposes and research such as text books, articles, guidelines, etc. Physicians are used to obtaining information from text-based sources. Since most guidelines are text-based, it would be practical to use a document-based solution that preserves the original cohesiveness. The lack of structure limits the automatic identification and extraction of the information contained in these resources. For this reason, we have chosen a document-based approach using eXtensible Markup Language (XML) with its schema definition and related technologies. XML empowers the applications for in-context searching. In addition it allows the same content to be represented in different ways. Our XML reference clinical data model for guidelines has been realized with the XML schema definition. The schema is used for structuring new text-based guidelines and updating existing documents. It is also used to establish search strategies on the document base. We hypothesize that enabling the physicians to query the available CPGs easily, and to get access to selected and specific information at the point of care will foster increased use. Based on current evidence we are confident that it will have substantial impact on the care provided, and will improve health outcomes.

Computer Systems↗

PubMedDate not supplied

[Analysis and comparison of the guidelines regarding recovery-room management].

The purpose of this study was to analyse and compare the guidelines regarding Recovery-Room (RR) management at international level, pointing out the main differences and common aspects. The guidelines on the RR management in various countries have been compared in particular the Italian, French, German, Australian, Canadian and American guidelines. In addition, the management of postoperative patients in some of these countries where guidelines on the subject have not yet been published have been analysed. In some countries, France for instance, the guidelines have been published as a ministerial decree (Décret n degrees 94-1050 du Décembre 1994) and are therefore a law with proper articles, in others (Italy for instance), they are mere recommendations, which do not have immediate effect and are regarded as a target to be achieved. SIAARTI considers that this is due to the dishomogeneity of the Italian hospital situation as far as medical and nursing staff as well as buildings and applied technology are concerned. The comparison between guidelines of different countries has shown that RR is a reality which has now existed for many years at international level and it has demonstrated that all guidelines agree on the fact that postoperative patients must be observed in a protected and safe environment. The following rules are common to all guidelines: the anaesthetist is responsible for the RR and for discharging the patient; there must be a clinical record and a written report which are considered to be essential (not in Italy); RR must be next to the surgical rooms; the patient must be escorted to RR by the anesthetist; monitoring must be guaranteed during transfer; monitoring continuity in RR (at regular and a appropriate intervals) is essential. The following rules are not common to all guidelines: numbers of beds in RR; the proportion between the number of nurses and the number of patients; regulation for day-surgery; specific regulations for obstetrical patients. Guidelines are subject, as any regulation, to continuous revision, and this is a very important requirement which helps keeping them always update and in line with scientific research.

Guidelines as Topic↗

PubMed2001

[A cross-sectional study on the promotion and execution of "the practiced guidelines for the management of common malignant gynecological tumors"].

OBJECTIVE: To evaluate the promotion and execution of "the practice guidelines for the management of common malignant gynecological tumors (draft)" (guidelines). METHODS: Cross sectional study was applied. All obstetricians and gynecologists (Obs/Gyns) who attended the Chinese Medical Association's Senior Workshop for Department Chairmen of Obstetrics and Gynecology were included. RESULTS: Three hundred and fifty Obs/Gyns were inquired, while two hundred and eighty-one questionnaires were available. Ninety percent (253/281) of Obs/Gyns declared that they had read the guidelines, and 96.4% (271/281) of them thought it necessary to establish the guidelines. In those Obs/Gyns who read the guidelines, 87.7% (222/253) of them managed gynecological tumors according to the guidelines. In those who did not read the guidelines, most were obstetricians or worked in special hospitals, while all gynecological oncologists read the guidelines. In addition, there were still many suggestions on the guidelines. CONCLUSION: The guidelines has been playing a role in the management of common malignant gynecological tumors and need to be revised regularly.

Cross-Sectional Studies↗

PubMed2002

The process of developing best practice guidelines for nurses in Ontario: risk assessment and prevention of pressure ulcers.

Linking practice to current evidence-based wound care guidelines is a challenge for healthcare professionals, especially because of the quantity of wound care guidelines available. In 1999, the Registered Nurses Association of Ontario, Canada, with funding from the Province of Ontario's Ministry of Health and Long Term Care, established a process for the development and implementation of 17 best practice guidelines to support nurses using evidence-based practice. Four of the 17 guidelines pertain to wound care. The consensus development, pilot testing, and evaluation process of one of the guidelines, Risk Assessment and Prevention of Pressure Ulcers in Adults, is described. Following a comprehensive and systematic search for existing guidelines, a formal quality appraisal of five selected guidelines, decisions for adoption and/or adaptation of best practice recommendations, and stakeholder feedback on the draft guidelines, a pilot implementation testing of the guidelines was conducted. In early 2002, the nursing best practice guideline was disseminated through conferences, publications, and the Registered Nurses Association of Ontario website www.rnao.org.

Benchmarking↗

PubMed2004

A methodology for modular representation of guidelines.

Computer-based clinical practice guidelines often need to be modified when medical knowledge evolves or when guidelines are implemented in a local setting with specific constraints and preferences. To enable easy modifications to guidelines and maintain their integrity, we have developed a methodology for modular representation of guidelines. Using this approach, we create guidelines in a hierarchical and modular manner. We use the Axiomatic Design methodology to facilitate the development of independent modules. Design matrices capture the interactions among modules. The design matrices can be used during guideline modification to create a change process and to enable identification of other modules that are affected by a change to a module. We implemented this modular knowledge representation approach by incorporating it into the Guideline Interchange Format (GLIF) language. We applied this approach to encode parts of three outdated guidelines released during 2000-2001, and we revised these designs to model updated releases of the guideline. Qualitative and quantitative metrics were developed to assess the types of changes made to the encoded guidelines.

Adult↗

PubMed2004

A multiple-ontology customizable search interface for retrieval of clinical guidelines.

A major problem in the effective use of clinical guidelines is fast and accurate access at the point of care. Thus, we are developing a digital electronic guideline library (DeGeL) and a set of tools for incremental conversion of free-text guidelines into increasingly machine-comprehensible representations, which support automated application. Even if guidelines are represented in electronic fashion, care providers need to be able to quickly retrieve the guidelines that best fit the clinical situation at hand. We describe Vaidurya, a search and retrieval engine that exploits the hybrid nature of guideline representation in the DeGeL architecture. Vaidurya can use not only free-text keywords, but also multiple semantic indices along which the guidelines are classified, and the mark up of guidelines in DeGeL, using the semantic roles of one or more guideline-representation languages (ontologies). Vaidurya offers a wide variety of querying options, in order to enable different types of users to query the guideline library in a manner that is both efficient and user friendly. We describe the customizable query interface, in which each user can create their own personal query interface.

Expert Systems↗

PubMed2005

Development of national guidelines for the prevention and control of nosocomial infections.

OBJECTIVE: To develop a national evidence-based guidelines for the prevention and control of nosocomial infection. MATERIAL AND METHOD: Draft guidelines for the prevention and control of nosocomial infection were developed by the researchers and reviewed by a 10 member panel of experts. The guidelines were modified by brainstorming of 55 practitioners in July 2002. The guidelines were tested for their applicability in 20 hospitals across the country in 2002. The participants gave suggestions on the guidelines which were modified accordingly. The guidelines were finalized by brainstorming of the 55 practitioners in August 2003. RESULTS: National guidelines for the prevention and control of nosocomial infections were developed. Twenty-one topics were included. Modifications of the drafted guidelines were made four times according to the opinions of 10 experts, twice by brainstorming of 55 practitioners and by the suggestions of participants from 20 hospitals where they were tested. The practices in hospitals with different facilities were also suggested in the guidelines. CONCLUSION: National guidelines for prevention and control of nosocomial infection were formulated. Their application for use in every hospital and periodic reviews are expected.

Consensus Statements as Topic↗

PubMed2006

[Health services research and guidelines--from the Association of the Scientific Medical Societies' (AWMF) perspective].

The Association of the Scientific Medical Societies (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften) is an umbrella organization. It currently represents 151 scientific societies and thus the majority of medical researchers in Germany. Through the coordination and support of the scientific medical societies, the AWMF significantly contributes to health services research by establishing guidelines that ensure a high quality of healthcare. To this purpose, AWMF founded a guideline committee in 1995, whose objective is to assist AWMF member societies in the establishment of guidelines, the organization of training sessions for AWMF guideline representatives, the hosting of regular guideline conferences and the close cooperation with the German Medical Association (Bundesärztekammer, BAK) and the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) in the development of national disease management guidelines (Nationale Versorgungs Leitlinien, NVL). Together with the Agency for Quality in Medicine [AQuMed; Arztliches Zentrum für Qualität in der Medizin (AZQ)], AWMF published a 'German Instrument for Methodological Guideline Appraisal' ('Deutsches Instrument zur methodischen Leitlinien-Bewertung', DELBI) in order to assure the quality of the guideline development process. A close cooperation has also developed between AWMF and the German Medical Association within the scope of their program for promoting health services research and with the Board of the German Network for Health Services Research (Deutsches Netzwerk for Versorgungsforschung, DNVF). Furthermore, AMWF has acknowledged a special need for improving the financial and conceptual promotion of a systematic evaluation of guideline development and the implementation and application of guidelines in everyday clinical practice.

Biomedical Research↗

PubMed1986

Potential responses to and impacts of epidemiological and experimental data on dietary fat and cancer. Dietary guidelines.

The majority of dietary guidelines discussed above suggest a reduction in the % of dietary calories derived from fat. Currently, approximately 40% of calories in Western countries come from fat. Some of the more recent guidelines call for a reduction in fat intake to 30% of calories. Indeed, the Committee on Diet, Nutrition and Cancer (National Academy of Sciences 1982) and the World Health Organization Report on Prevention of Coronary Heart Disease (WHO 1982) suggested that the evidence warranted an even lower fat intake, but 30% of calories is a moderate and practical target. Diets containing 30% of calories as fat are undoubtedly safe for the general population. During and immediately after the Second World War in Britain, dietary fat intake was at or about this level and no deleterious effects in the population were noted. (Greaves and Hollingsworth 1966). Indeed, the overall state of health of the population seemed improved. Furthermore, most of the world population exists and has existed on a primarily plant based diet, low in fat content, with no apparent ill effects and lower rates of chronic disease. (Mintz 1985). Most dietary guidelines recommend a reduction in saturated fat intake. The more recent guidelines suggest saturated fat should be restricted to less than 10% of total calories. While some of the earlier guidelines suggested an increase in polyunsaturated fat intake, more recent guidelines stress that polyunsaturated fat intake should not exceed 10% of calories. Thus, the focus of more recent guidelines appears to be to decrease total fat intake. Essentially all guidelines stress avoidance of obesity by avoiding excess caloric intake and increasing caloric expenditure. Diets low in total fat content are beneficial in this regard, a fact acknowledged in the Food and Nutrition Board's report "Towards Healthful Diets." (Food and Nutrition Board 1980 b) Most guidelines advise a decrease in calories derived from processed sugars and a concomitant increase in complex carbohydrate intake. This is best achieved by stressing whole grain cereals, fruits and vegetables in the diet. More recent recommendations advise moderation in the use of alcohol. Moderation in salt use is also a common theme. It is our belief that guidelines should be general in nature and not identify specific nutrients, e.g. vitamin A and C in foods, or specific foods themselves, e.g. cabbage, as conferring special benefits. The available data base does not support such specific claims.(ABSTRACT TRUNCATED AT 400 WORDS)

Arteriosclerosis↗

PubMed1996

Qualitative evaluation of the Canadian Medical Association's counselling guidelines for HIV serologic testing.

OBJECTIVE: To evaluate the face and content validity of the CMA's counselling guidelines for HIV serologic testing in order to prepare a revised edition. DESIGN: Qualitative evaluation by structured focus groups in September and October 1994 to assess the relevance, clarity and practicality of the guidelines, followed by content analysis of the discussions. SETTING: Vancouver, Winnipeg, Toronto, Montreal, Quebec City and St. John's. PARTICIPANTS: Primary care physicians randomly selected from the CMA database and nonrandomly selected from the Canadian Medical Directory who had limited experience with HIV testing and counselling and who provided an appropriate mix of characteristics in terms of practice type (solo and group), setting (urban and rural), age and sex. A total of 1247 physicians were approached for the study; a convenience sample of 68 were recruited, of whom 56 participated. The average size of each focus group was eight physicians. OUTCOME MEASURES: Clinical experience and information sources with respect to HIV testing, reactions to the counselling guidelines, and suggestions for revisions and improvements to the guidelines. RESULTS: Most (96% [54/56] of the participants had ordered HIV serologic testing for patients in the 6 months preceding the focus groups, and about half of them (52% [28/54]) had at least one patient with a positive test result. Many (59% [33/56]) of the participants had a copy of the guidelines at the time of recruitment; 19 (58%) of them had used the guidelines in the months before the focus groups. The parts of the guidelines most often read were the checklists and inset boxes. Recommendations for revisions in content were for more information on legal and ethical issues, information on new issues (e.g., rapid testing) and guidelines on how best to tell a patient about a positive test result; recommendations for revisions in format included more tables, algorithms, bulleted points and white space, less text, larger type and plainer language. CONCLUSIONS: The focus groups provided detailed, credible and consistent information about the face and content validity of the HIV counselling guidelines. They are a useful qualitative method for evaluating the relevance, clarity and practicality of clinical practice guidelines at the inception or revision stage.

AIDS Serodiagnosis↗

PubMed1996

Current trends in guideline development: a cause for concern.

Although the development and use of practice-related guidelines as educational aids has a long history in the health professions, scientific assessment indicates that they have had limited success in changing practice patterns. This is principally due to the exclusion of practitioners from the development process, and the lack of a credible scientific basis for many guidelines. Past failures have led to new methods of guideline development based on a critical analysis of scientific data. These methods, which involve legitimate professional organizations at all stages of the development process, are clearly a step in the right direction. Unfortunately, there are signs that current guideline developers still fail to recognize the critical nature of the new methods or the need for an open and inclusive development process. It is even more disquieting that the objective of some guideline developers, such as licensing bodies, is the formulation of standards or review criteria, particularly when there are very few therapeutic practices with a sufficient scientific basis to justify such a designation. National and provincial societies, as well as dental educators, need to assume a leadership role to ensure that if guidelines are required, they will be developed as credible aids for the improvement of patient care. In this paper, the authors recount why the "traditional process" of guideline development resulted in guidelines that were mistrusted by the profession and, as a result, ineffective. They also outline the widely-documented current methodology, which should be followed if guidelines are to be accepted by the profession. Finally, they discuss the critical issue of who should develop guidelines, and examine their role in dental practice and education.

Canada↗

PubMed1996

Evaluating the use of the appropriateness method in the Agency for Health Care Policy and Research Clinical Practice Guideline Development process.

OBJECTIVE: To assess the feasibility of the appropriateness method in the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Development process, and to compare the results of the appropriateness method with those obtained using evidence tables and an informal consensus method. SETTING: AHCPR Low Back Problems Clinical Practice Guideline. DESIGN: Two different group process methods with the same panel of experts were used in observational comparison of results of and satisfaction with guideline development. DATA COLLECTION: Practice guideline statements were created for topics using the conventional AHCPR method; then six months later new guideline statements for four topics were created using the appropriateness method. Panelist satisfaction with each process and resulting set of guideline statements was assessed. PRINCIPAL FINDINGS: Results of the appropriateness method for TENS, discography, and traction showed no disagreement among panel members and no appropriate indications for their use in the patient scenarios considered. These results are qualitatively similar to the guideline statements produced using evidence tables and informal consensus. Clinical practice guideline statements about electro-diagnostics created from appropriateness ratings were much more clinically specific than those created using evidence tables and informal consensus. Neither informal consensus building nor the appropriateness method was clearly preferred by a majority of panelists. CONCLUSIONS: It is feasible to use the appropriateness method in the AHCPR Clinical Practice Guideline Development process, and in some instances it produces more clinically specific guideline statements than does informal consensus.

Acute Disease↗

PubMed1996

Making generic guidelines site-specific.

Health care providers are more likely to follow a clinical guideline if the guideline's recommendations are consistent with the way in which their organization does its work. Unfortunately, developing guidelines that are specific to an organization is expensive, and limits the ability to share guidelines among different institutions. We describe a methodology that separates the site-independent information of guidelines from site-specific information, and that facilitates the development of site-specific guidelines from generic guidelines. We have used this methodology in a prototype system that assists developers in creating generic guidelines that are sharable across different sites. When combined with site information, generic guidelines can be used to generate site-specific guidelines that are responsive to organizational change and that can be implemented at a level of detail that makes site-specific computer-based workflow management and simulation possible.

Artificial Intelligence↗

PubMed1996

Interpretation of prospective trials in hypertension: do treatment guidelines accurately reflect current evidence?

OBJECTIVE: To review the findings of prospective controlled trials of antihypertensive treatment and determine whether the evidence they have provided is embodied satisfactorily in current national and international guidelines for hypertension management. MANAGEMENT GUIDELINES: Conventional guidelines all advise prompt treatment of moderate-to-severe hypertension and treatment of even mild hypertension in subjects with cardiovascular disease, target organ damage or diabetes, and in the elderly; and treatment of isolated systolic hypertension in the elderly. All acknowledge that evidence for efficacy and safety of treatment is strongest for thiazide diuretics and beta-blockers. UNCOMPLICATED MILD HYPERTENSION: Conventional guidelines all emphasize the importance of long-term blood pressure, measured over some months, for treatment decisions. However the blood pressure for routine treatment varies from 160/100 mmHg (British Hypertension Society) to 140/90 mmHg (Joint National Committee V). This dictates very large differences in the number of patients to be treated to prevent a cardiovascular disease event and in the proportion of the population to be treated, yet the reasons for these differences are not explicit. None of the conventional guidelines is entirely satisfactory. The more conservative British Hypertension Society policy may leave untreated some middle-aged men who ought to be treated. The more aggressive Joint National Committee V policy will lead to treatment of some young subjects who have only a remote chance of benefit, at very high cost, and possibly with adverse harm-benefit consequences. RISK-BASED GUIDELINES: Guidelines developed in New Zealand target absolute cardiovascular disease risk in mild hypertension and have the potential to correct this shortcoming of conventional guidelines. However they require further consideration as regards the number needed to treat which is acceptable to well-informed patients, the appropriate estimate of relative cardiovascular disease risk reduction by treatment in mild hypertension, the pattern of treatment which will emerge and their acceptability in ordinary practice. CONCLUSION: Comparative evaluation will be needed to determine whether the outcome is better with conventional guidelines, which are simple but at the expense of accuracy, or with risk-targeted guidelines, which are more accurate but at the expense of simplicity.

Blood Pressure↗