Shiffman R N
Center for Medical Informatics, Yale School of Medicine, New Haven, Conn., USA.
Arch Pediatr Adolesc Med. 1995 Jul;149(7):727-32. doi: 10.1001/archpedi.1995.02170200017002.
To understand better the factors that led to revisions of the Jones criteria, a widely used diagnostic guideline for diagnosis of rheumatic fever.
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).
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.
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.
为了更好地理解导致琼斯标准修订的因素，该标准是用于诊断风湿热的广泛使用的诊断指南。
对琼斯标准的原始出版物及四次修订进行审查以确定变化。应用计算机软件维护范式，将修改分类为纠正性（错误纠正）、完善性（根据用户需求进行增强）或适应性（对新知识的响应）。
琼斯标准的修改主要是纠正性和完善性的。最初被列为主要表现的疾病特征，后来被归类为次要表现，反之亦然。首次发布20年后，增加了一项要求以提高特异性（前驱链球菌感染的证据）。随着时间的推移，风湿热表现的描述变得更加详细，以消除模糊定义并提供信息帮助临床医生判断临界病例。这种对纠正性和完善性维护的强调与对适应性变化占主导的预期形成对比，大多数基于知识的系统都是如此。事实上，尽管医学在技术和方法上取得了50年的进步，但只有超声心动图和新的抗体检测带来了与风湿热诊断相关的新知识。
通过有效利用指南发布时已有的知识，可以避免纠正性和完善性维护。尽管琼斯标准显然具有持久性，但精心构建的、基于证据的指南应该需要较少的纠正性和完善性维护。如果明确记录支持每项建议的证据质量或共识水平，则可以预期进行适应性维护。
