Christiana Care Value Institute

Who We Are

The Value Institute at Christiana Care is a diverse team of experts collaborating in the discovery and delivery of value-centered knowledge to improve health.

Who We Serve

To develop, deliver and evaluate innovative solutions impacting population health, patient experience, system performance and policy development.

How We Work

The Value Institute leads the way in conducting real-world research on today’s most pressing health care issues, helping to deliver better health, better care and better value for our neighbors.

Publications

Durability of class I American College of Cardiology/American Heart Association clinical practice guideline recommendations
Durability of class I American College of Cardiology/American Heart Association clinical practice guideline recommendations
Neuman MD, Goldstein JN, Cirullo MA, Schwartz JS

JAMA 2014 May;311(20):2092-100

PMID: 24867012

Abstract

IMPORTANCE: Little is known regarding the durability of clinical practice guideline recommendations over time.
OBJECTIVE: To characterize variations in the durability of class I ("procedure/treatment should be performed/administered") American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations.
DESIGN, SETTING, AND PARTICIPANTS: Textual analysis by 4 independent reviewers of 11 guidelines published between 1998 and 2007 and revised between 2006 and 2013.
MAIN OUTCOMES AND MEASURES: We abstracted all class I recommendations from the first of the 2 most recent versions of each guideline and identified corresponding recommendations in the subsequent version. We classified recommendations replaced by less determinate or contrary recommendations as having been downgraded or reversed; we classified recommendations for which no corresponding item could be identified as having been omitted. We tested for differences in the durability of recommendations according to guideline topic and underlying level of evidence using bivariable hypothesis tests and conditional logistic regression.
RESULTS: Of 619 index recommendations, 495 (80.0%; 95% CI, 76.6%-83.1%) were retained in the subsequent guideline version, 57 (9.2%; 95% CI, 7.0%-11.8%) were downgraded or reversed, and 67 (10.8%; 95% CI, 8.4%-13.3%) were omitted. The percentage of recommendations retained varied across guidelines from 15.4% (95% CI, 1.9%-45.4%) to 94.1% (95% CI, 80.3%-99.3%; P < .001). Among recommendations with available information on level of evidence, 90.5% (95% CI, 83.2%-95.3%) of recommendations supported by multiple randomized studies were retained, vs 81.0% (95% CI, 74.8%-86.3%) of recommendations supported by 1 randomized trial or observational data and 73.7% (95% CI, 65.8%-80.5%) of recommendations supported by opinion (P = .001). After accounting for guideline-level factors, the probability of being downgraded, reversed, or omitted was greater for recommendations based on opinion (odds ratio, 3.14; 95% CI, 1.69-5.85; P < .001) or on 1 trial or observational data (odds ratio, 3.49; 95% CI, 1.45-8.41; P = .005) vs recommendations based on multiple trials.
CONCLUSIONS AND RELEVANCE: The durability of class I cardiology guideline recommendations for procedures and treatments promulgated by the ACC/AHA varied across individual guidelines and levels of evidence. Downgrades, reversals, and omissions were most common among recommendations not supported by multiple randomized studies.
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Frequency of Sale and Reasons for Purchase of Over-the-Counter Insulin in the United States
Frequency of Sale and Reasons for Purchase of Over-the-Counter Insulin in the United States
Goldstein JN, Patel RM, Bland K, Hicks LS

JAMA Intern Med 2019 05;179(5):722-723

PMID: 30776058

Abstract

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Is the Over-the-Counter Availability of Human Insulin in the United States Good or Bad?
Is the Over-the-Counter Availability of Human Insulin in the United States Good or Bad?
Goldstein JN, McCrary M, Lipska KJ

JAMA Intern Med 2018 Sep;178(9):1157-1158

PMID: 30014151

Abstract

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