Guideline maintenance and revision. 50 years of the Jones criteria for diagnosis of rheumatic fever.

OBJECTIVE: To understand better the factors that led to revisions of the Jones criteria, a widely used diagnostic guideline for diagnosis of rheumatic fever.
DESIGN: The original publication of the Jones criteria and the four revisions were examined to identify changes. A computer software maintenance paradigm was applied, and modifications were categorized as corrective (error correction), perfective (enhancements in response to user needs), or adaptive (responses to new knowledge).
RESULTS: Modifications of the Jones criteria were primarily corrective and perfective. Disease characteristics, originally characterized as major manifestations, were subsequently categorized as minor manifestations and vice versa. Twenty years after the initial publication, a requirement was added to enhance specificity (evidence for antecedent streptococcal infection). Descriptions of rheumatic manifestations became more detailed over time to eliminate ambiguous definitions and provide information to help clinicians decide about borderline cases. This emphasis on corrective and perfective maintenance contrasts with an expectation that adaptive changes would predominate, as with most knowledge-based systems. In fact, despite 50 years of technologic and methodologic advances in medicine, only echocardiography and new antibody testing contributed new knowledge that bears on the diagnosis of rheumatic fever.
CONCLUSIONS: Corrective and perfective maintenance can be avoided by making effective use of knowledge that exists at the time a guideline is published. Despite the apparent durability of the Jones criteria, carefully structured, evidence-based guidelines should require less corrective and perfective maintenance. Adaptive maintenance can be anticipated if the quality of evidence or the level of consensus that supports each recommendation is explicitly recorded.