Clinical practice guidelines typically include ratings or categorizations that reflect the objective quality of the evidence supporting the guideline recommendations—often designated as level of evidence—and an assessment of the certainty or strength of the recommendation—often designated as class of recommendation. Tricoci and colleagues Article reviewed the cardiovascular practice guidelines issued jointly by the American College of Cardiology and the American Heart Association (ACC/AHA) from 1984 to September 2008 to assess the evolution of the guidelines and the distribution of recommendations across class and levels of evidence. In their analysis of the subset of guidelines with at least 1 revision or update by September 2008, the authors found that current recommendations were largely based on lower levels of evidence or expert opinion and reflected a lower level of certainty (class) compared with earlier guideline versions. In an editorial, Shaneyfelt and Centor Article discuss potential bias and other limitations in the guideline development process and in the utility of practice guidelines in clinical practice.
Individuals with diabetes have an increased risk of depression compared with the general population. In a retrospective cohort study of low-income women who gave birth in 2004-2006, Kozhimannil and colleagues examined the association between preexisting diabetes and perinatal and postpartum depression. In this sample of low-income women who were continuously enrolled in Medicaid for 6 months prior to delivery and through the first postpartum year, the authors found that compared with women without diabetes, women with prepregnancy or gestational diabetes had a significantly increased risk of experiencing depression during pregnancy and postpartum.
The US prison system may offer the first opportunity for some individuals at high risk of human immunodeficiency virus infection to receive screening and treatment. However, the likelihood that treatment will continue after prison release is not known. To address this question, Baillargeon and colleagues reviewed medical and drug assistance program records for 2115 Texas prison system inmates who received antiretroviral therapy (ART) while incarcerated and who were released between January 2004 and December 2007. The authors found that only 5.4% of inmates filled a prescription for ART within 10 days of release—potentially averting a clinically significant treatment interruption—and only 30% filled a prescription within 60 days.
It is well known that patients may be at risk of medication-related harm if physicians do not adhere to appropriate prescribing practices; however, guidelines for effective, evidence-based prescribing are lacking. To address this deficiency, Schiff and Galanter present a set of principles that may guide clinicians in evidence-based prescribing. These principles include consideration of alternatives to pharmaceutical treatment of disease, heightened vigilance for adverse effects, a cautious embrace of new drugs, rational drug utilization, and addressing barriers that interfere with conservative prescribing.
“It is hard to believe that in this modern age, when there are seemingly inexhaustible ways of achieving a given outcome, we all draw a blank at Mr V.” From “Dying to Talk.”
Although the US Food and Drug Administration stood by its approval of ezetimibe/simvastatin after reviewing data showing it reduces levels of low-density lipoprotein cholesterol, whether the drug actually improves clinical outcomes remains unknown.
Professional monopolies in medicine
Defining and improving cardiac arrest survival rates
Feminization of medicine and population health
Appreciation for JAMA's peer reviewers and authors.
Join Steven A. Schroeder, MD, March 18, from 2 to 3 PM eastern time to discuss smoking cessation in patients with psychiatric illness. To register, go to http://www.ihi.org/AuthorintheRoom.
For your patients: Information about evidence-based medicine.
This Week in JAMA . JAMA. 2009;301(8):801. doi:10.1001/jama.2009.226