Correspondence  |   January 2015
In Reply
Author Notes
  • Medical University of South Carolina, Charleston, South Carolina (W.R.H.).
  • (Accepted for publication September 23, 2014.)
    (Accepted for publication September 23, 2014.)×
Article Information
Correspondence   |   January 2015
In Reply
Anesthesiology 01 2015, Vol.122, 220-221. doi:
Anesthesiology 01 2015, Vol.122, 220-221. doi:
We thank Dr. Kempen for his interest in our recent study published in Anesthesiology about the effect of a decision support tool (DST) on adherence to published guidelines.1 
Dr. Kempen endorses the importance of evidence-based practice, demonstrated by his thorough reiteration of the narrative related to perioperative β-blockade, and this underlying premise to his letter is very important. Physicians should try to practice with the most up-to-date and clinically-applicable evidence available. The effort of our study was not surrounding the validity of the claims of the 2007 American College of Cardiologists/American Heart Association perioperative guidelines,2  but rather to test the ability of mobile health technology to help physicians apply this guideline to patient scenarios. It is not lost on the authors that evidence will continue to be refined, and, in fact, we have already begun to modify the DST application based on the 2014 update to the American College of Cardiologists/American Heart Association guidelines released this fall.3  This point is perhaps the most important reason we believe a DST to be superior to memory alone. The DST can be updated centrally with push updates sent to end users quickly; and, in theory, practice patterns can be modified almost instantly when this occurs.
However, Dr. Kempen also notes that there may be a “fundamental problem” with assuming that the 2014 practice guidelines are “correct.” To this we would state that we are aware that these guidelines, as the former ones, will almost certainly require amendment in the future. However, the reality of this fact does not negate the validity of the approach to producing a practice guideline founded on a rigorous evidence-based review, as detailed in the guidelines. Additionally, we believe that understanding such guidelines can aid physicians in the very struggles that Dr. Kempen notes concerning patient expectations and responsible testing considerations. Dr. Kempen points out that resources are inconsistently available depending on the location and size of a facility. Regarding the interventions indicated by the 2007 American College of Cardiologists/American Heart Association guidelines discussed, we agree that select patients might be simply better served having surgery only where there is access to echocardiography, stress tests, and perhaps medical management, although we hope this doesnot limit access to care as we expect they are nearly ubiquitous, even outside the “University hospital.”
Concerning Dr. Kempen’s statements about board certification, we make no comment here as that was not the object under consideration in our article.
Dr. Kempen’s concluding remarks should be heeded—revalidation on the premise of our study needs to be published—that a DST will improve adherence to published guidelines, ideally in actual patient care. It then falls upon the practitioner and software developer to ensure the guidelines are internally valid and up to date, representing what is actually published and then allowing the clinical to make the final decision in application.
Competing Interests
The authors declare no competing interests.
William R. Hand, M.D., Matthew D. McEvoy, M.D. Medical University of South Carolina, Charleston, South Carolina (W.R.H.).
Hand, WR, Bridges, KH, Stiegler, MP, Schell, RM, DiLorenzo, AN, Ehrenfeld, JM, Nietert, PJ, McEvoy, MD Effect of a cognitive aid on adherence to perioperative assessment and management guidelines for the cardiac evaluation of noncardiac surgical patients.. Anesthesiology. (2014). 120 1339–53 [Article] [PubMed]
Fleisher, LA, Beckman, JA, Brown, KA, Calkins, H, Chaikof, E, Fleischmann, KE, Freeman, WK, Froehlich, JB, Kasper, EK, Kersten, JR, Riegel, B, Robb, JF, Smith, SCJr, Jacobs, AK, Adams, CD, Anderson, JL, Antman, EM, Buller, CE, Creager, MA, Ettinger, SM, Faxon, DP, Fuster, V, Halperin, JL, Hiratzka, LF, Hunt, SA, Lytle, BW, Nishimura, R, Ornato, JP, Page, RL, Tarkington, LG, Yancy, CW: ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.. Circulation. (2007). 116 1971–96 [Article] [PubMed]
Fleisher, LA, Fleischmann, KE, Auerbach, AD, Barnason, SA, Beckman, JA, Bozkurt, B, Davila-Roman, VG, Gerhard-Herman, MD, Holly, TA, Kane, GC, Marine, JE, Nelson, MT, Spencer, CC, Thompson, A, Ting, HH, Uretsky, BF, Wijeysundera, DN 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.. J Am Coll Cardiol. (2014).