Improved Recommendations of Deintensification in Clinical Guidelines Is Needed

Most healthcare services involve ongoing testing or treatment for chronic diseases. While clinical guidelines are useful to balance overuse and underuse, they need to be updated to specify when physicians should deintensify care, according to authors of a letter in JAMA Internal Medicine.

Adam A. Markovitz, BS, and colleagues at the VA Center for Clinical Management and Research in Ann Arbor, Michigan, examined current clinical guidelines for diabetes and cardiovascular disease in an attempt to understand the balance between overuse and underuse in current guidelines and whether guidelines recommend intensification more than deintensification.

Of the 361 recommendations identified, 71% were for intensification and only 29% were for deintensification. One example of intensification that the authors noted was from the American Diabetes Association Standards of Medical Care in Diabetes—2016, which recommended that people with diabetes and hypertension be treated to a systolic blood pressure goal of less than 140 mm Hg. An example of deintensification was the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes recommendation that there is potential harm in lowering systolic blood pressure to less than 120 mm Hg in older adults with type 2 diabetes.

The analysis also found that there was a large variation in how frequently guideline developers recommend deintensification.

The reason for so many more recommendation for intensification may be as simple as the fact that there is more evidence regarding intensification. Randomized clinical trials focus on evidence for initiating or intensifying treatment.

“The large variation detected across guideline developers underscores a second explanation—developers’ inconsistent engagement with existing evidence on benefit and harm,” the authors wrote.

When results from homogenous trial populations are generalized to the broader population, developers tend to provide “unqualified intensification recommendations,” while using vague statements to note deintensification recommendations.

Without deintensification trials, existing trials should document harms more reliably, the authors suggested. They added that guideline developers should better account for treatment heterogeneity.

“Given guidelines’ potential impact on clinical practice and performance measurement, appropriate attention to deintensification is critical,” the authors wrote.