In a recent letter to National Heart, Lung and Blood Institute (NHLBI) director Gary Gibbons, M.D., AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash., voiced concern regarding the NHLBI's decision to stop issuing clinical practice guidelines(www.nhlbi.nih.gov) and focus instead only on developing evidence reviews. The decision leaves uncertain the fate of long-awaited recommendations on hypertension(www.nhlbi.nih.gov), high blood cholesterol(www.nhlbi.nih.gov), and overweight and obesity in adults(www.nhlbi.nih.gov).
Specifically, the much-anticipated guidelines are The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8); Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel [APT] IV); and Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, respectively. The AAFP has played an integral role in creating NHLBI guidelines for many years.
"I am writing to express the Academy's concern regarding the recent announcement from your institute to publish the integrated cardiovascular guidelines as evidentiary reviews instead of publishing the final JNC 8, ATP 4 and Obesity guidelines, which have been in development for over five years and repeatedly delayed," Stream said in the letter.
Under its new "collaborative partnership" model(www.nhlbi.nih.gov), the NHLBI has handed the evidence reviews and recommendations generated by the three expert panels originally convened to produce these guidelines over to the American Heart Association and the American College of Cardiology, who now will spearhead the development of all three cardiovascular disease prevention guidelines with an as-yet-undefined level of input from other organizations such as the AAFP.
Stream noted that the Academy has been involved with the National Program to Reduce Cardiovascular Risk (NPRCR) and has had an official representative on the NPRCR's coordinating committee. The NPRCR has worked collaboratively with the cardiovascular guideline writing groups for several years, he added, "and these guidelines are pivotal in providing evidence-based recommendations for the NPRCR."
"The AAFP feels strongly that these guidelines, as developed by the JNC 8 and ATP 4 writing groups, should be published as soon as possible and should not be left to organizations that are only focused on one aspect of cardiovascular disease," said Stream.
He suggested that if the NHLBI, in fact, is getting out of the business of issuing guidelines but will continue to develop evidence reviews, the organization should
- adhere to the Institute of Medicine Standards for Systematic Reviews to ensure a rigorous methodology is used in their development;
- coordinate topics for review with the Agency for Healthcare Research and Quality to avoid duplication of effort; and
- develop a topic nomination process to allow specialty societies to nominate key clinical topics for review.
Stream concluded by stating that the "AAFP has a long history of developing evidence-based guidelines, alone and with other medical specialty organizations, and would welcome the opportunity to explore the development of guidelines based on the NHLBI's evidence reviews."