Many ‘strong’ IDSA recommendations based on lower-quality evidence, analysis finds
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Almost half of the recommendations graded as “strong” in 17 current Infectious Diseases Society of America clinical practice guidelines are based on lower-quality evidence, an analysis found.
Still, “Clinicians should continue to trust IDSA guidelines as they always have,” Ryan Rodriguez, PharmD, BCPS, clinical associate professor at the University of Illinois at Chicago Department of Pharmacy Practice, told Healio.
“The IDSA guideline panelists are clinical experts and GRADE methodology is an international standard in guideline production. However, when reviewing and applying guideline recommendations, clinicians should consider the level of evidence that supports each recommendation,” he said.
Rodriguez and colleagues noted that the IDSA adopted the GRADE system — the acronym stands for Grading of Recommendations Assessment, Development, and Evaluation — in 2008 and has used it since 2010 to produce guidelines that note the strength of the recommendations (SOR) and the quality of evidence (QOE).
In their paper, they said one of the determinants of SOR is the QOE behind it — “classified as high, moderate, low, or very low based on the confidence in the effects estimate.”
“GRADE initially designates a body of evidence as high or low QOE when it is composed of randomized controlled trials or observational studies, respectively,” they wrote. “This initial classification of QOE can then be upgraded by one or two levels based on factors such as a large magnitude of effect, dose-response gradient, or an effect of residual confounding that further supports a treatment’s effect. The QOE classification may also be downgraded by one or two levels due to risk of bias, inconsistency, indirectness, imprecision, or publication bias.”
Rodriguez and colleagues assessed the relationship between recommendation strength (SOR) and quality of evidence (QOE) for 17 current IDSA guidelines published since 2010 that used the GRADE methodology, including guidelines for candidiasis, infectious diarrhea, aspergillosis and implementing an antimicrobial stewardship program. Among other things, they analyzed the frequency of discordance between SOR and QOE pairings.
In total, their analysis included 1,042 recommendations. The most frequent SOR was strong (71.8%; n = 748), whereas the most common QOE was determined to be low (48.6%; n = 506). Within the strong recommendations 47.1% (n = 352) were discordant with QOE.
IDSA Immediate Past President and Infectious Disease News Editorial Board Member Thomas File Jr., MD, MSc, FIDSA, told Healio that IDSA welcomes feedback on its guidelines, and said that guideline development, as well as the GRADE methodology itself, is “an evolving process.”
“To me, what this indicates is not so much criticism but acknowledgement that when we make decisions about the treatment of patients, we try to make it on the best available evidence,” he said. “What this paper acknowledges is that often the best evidence available is not robust or high level. Nevertheless, we do what is best for the patient under the circumstances.”
File said the IDSA will prioritize improving its guideline development over the next 5 years and has hired new staff, including methodologists, to help.
Rodriguez said the researchers were surprised to find that treatment recommendations for infectious diseases were more often discordant than prevention or diagnosis recommendations, and noted that treatment recommendations are often the decisions that physicians spend the most time making with their patients.
“These results may underscore the importance for clinicians to be familiar with the underlying evidence for guideline recommendations that they are acting upon,” Rodriguez said.
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