To the Editor,
Dr Jiménez-Navarro et al propose additional reasons for why Dr Ruiz Nodar's study found that guideline adherence was not associated with improvement in clinical outcomes. The authors raise two interesting issues: a) the use of adherence to clinical practice guidelines as a "gold standard" for good practice; and b) publication bias in existing available evidence.
The authors correctly highlight that guidelines are based on varying levels of evidence. In fact, the majority of recommendations are not based on adequate randomized trial data.1 Professional organizations such as the American College of Cardiology and the American Heart Association have recognized this inadequacy and have made great efforts to provide timely updates to practice guidelines as the evidence base changes2. Other alliances including the World Health Organization and the European Society of Thoracic Surgeons, have adopted a new grading system that more accurately reflects the evidence behind the guidelines (http://gradeworkinggroup.org) Concurrently, investigators globally are implementing clinical studies to address the void in existing knowledge (clinicaltrials.gov).
As suggested, adherence to guidelines as a benchmark of good clinical care is an imperfect paradigm. Nevertheless, guideline-based therapy is in the best interest of our patients. In an analysis of acute coronary syndrome (ACS) patients, we found that the composite adherence guideline rate was significantly associated with lower in-hospital mortality.3 Variation in practice existed even for therapies such as beta-blockers, whose role in ACS is generally well-established.3 Therefore, we believe that the data support guideline-based process measures as a means of assessing quality of care. We agree that publication bias is a significant problem. We advocate holding ourselves to the highest ethical standards, allowing for dissemination of all scientifically sound evidence—whether positive or negative.
However imperfect, evidence-based therapy is still associated with improved clinical outcomes. Our obligation is to provide the highest standard of care possible. As the guideline evidence evolves, so should the standards that we hold ourselves to.