Assessing the Trustworthiness of the Guideline for Management of High Blood Pressure in Adults

The article by James and colleagues1 published in JAMA contains the long-awaited guideline for hypertension issued by the panel members appointed by the National Heart, Lung, and Blood Institute (NHLBI) to the Eighth Joint National Committee (JNC 8). In the past decade, the effect of guidelines on clinical practice has increased because organizations that develop quality measures and make coverage decisions depend on guideline developers to uncover the best evidence and make specific recommendations. Because guidelines matter more, critics have questioned the processes that professional associations have used to develop guidelines. The title of the 2011 Institute of Medicine (IOM) report on quality standards for practice guidelines, Clinical Practice Guidelines We Can Trust,2 captures current concerns. Despite the efforts of the expert panel that developed the new guideline for management of hypertension, some aspects of the external review process may undermine public confidence. The NHLBI convened the JNC 8 panel in 2008. The panel decided to adhere to the standards set by the IOM study committee2 instead of following the practices of earlier JNC panels. The JNC 7 committee produced a comprehensive overview of the management of hypertension. The committee did not commission systematic reviews of the evidence. The report did not state the extent and quality of the evidence for many topics, so that the logical connection between the evidence and some recommendations was not clear. The report described conflicts of interest for committee members but did not say whether members recused themselves from voting when they had a conflict.3 As part of the guideline development process, the present hypertension guideline panel commissioned a systematic review of randomized trial evidence, evaluated the evidence, made recommendations, indicated the level of evidence supporting those recommendations, reported conflicts of interest, and recused conflicted panel members from voting. Because of these changes, this guideline adheres much more closely to the IOM standards than the JNC 7 guideline. The external review process began when the panel submitted the draft guideline to the NHLBI. According to James et al,1 the NHLBI submitted the guideline to 16 federal agencies and to 20 reviewers, all of whom were experts in hypertension. In addition, individual reviewers were expert in cardiology, nephrology, primary care, pharmacology, research (including clinical trials), biostatistics, and other related fields. The authors report that they received responses from 16 individual reviewers and 5 reviewers from federal agencies. The panel revised the guideline, completing its work in June 2013, just as the NHLBI announced that it was turning the guideline development process over to the American Heart Association and the American College of Cardiology, which jointly sponsor a respected guidelines program.4 Rather than submit the hypertension guideline for review by these organizations, the panel members submitted the guideline to JAMA, where it underwent both internal and external peer review. Thus, physicians and other readers are confronted with an important report that, although it has undergone extensive review, has not been evaluated by the specialty societies that the NHLBI designated to take responsibility for the guidelines program. The panel’s departure from usual practice leads to 4 questions. First, what are the key elements of trustworthiness in a guideline? Second, how does this guideline measure up? Third, what is the role of expert review of guidelines? Fourth, what is the pathway to guidelines that the public can trust?