I have great joy today as the co-author of a JAMA editorial.  This link will only work for subscribers – Shaneyfelt T, Centor R "Reassessment of clinical practice guidelines: Go gently into that good night" JAMA 2009; 301: 868-869.

Two major medicine sites have included quotes from our editorial – Cardio Care Guidelines Backed by Weak Evidence and ACC/AHA Guidelines Largely Based on Weak Evidence and Expert Opinion.  Some quotes from those articles:

In an accompanying editorial, Terrence Shaneyfelt, M.D., M.P.H., and Robert Centor, M.D., of the University of Alabama School of Medicine in Birmingham, said that practice guidelines "are actually expert consensus reports."

They expressed concern about the influence potential bias could have on the writing of guidelines, both financial and organizational.

"Guidelines often have become marketing tools for device and pharmaceutical manufacturers," they said. "Financial ties between guideline panel members and industry are common. "Experts" on guideline panels are more likely to receive industry funding for research, consulting fees, and speakers’ honoraria."

They also criticized guidelines for focusing on single diseases, failing to address the complexity of most patients’ conditions. They pointed out that most guidelines become outdated after 5 years.

"Most guidelines have a one-size-fits-all mentality and do not build flexibility or contextualization into the recommendations," they said.

As a result of these problems, they said that "many clinicians do not use guidelines. An even greater concern, however, is that some of these consensus statements are being turned into performance measures and other tools to critique the quality of physician care."

They called for major changes in guideline writing, including centralizing all guideline writing under a single agency, for example, under the guidance of the Agency for Healthcare Research and Quality or a similar group. They also advocated reducing or eliminating all potential conflicts of interest, prioritizing guideline development for the most important issues, and adding flexibility to account for the complexities of individual patients.

They remained skeptical that such changes would occur, however, "because many guideline developers seem set in their ways."

"If all that can be produced are biased, minimally applicable consensus statements, perhaps guidelines should be avoided completely. Unless there is evidence of appropriate changes in the guideline process, clinicians and policymakers must reject calls for adherence to guidelines," they said.

and

In an editorial accompanying the published study [2], Drs Terrence Shaneyfelt and Robert Centor (University of Alabama School of Medicine, Birmingham) write that the "overreliance on expert opinion in guidelines is problematic," particularly since the guideline committees come to the table with implicit biases, values, and goals that aren’t typically disclosed. Moreover, too many current guidelines are marketing- and opinion-based pieces, "delivering directive rather than assistive statements," they add.

In addition, they argue that guidelines are not patient-specific enough to be useful and do not allow for individualization of care, instead adopting a one-size-fits-all mentality. Moreover, there are simply too many guidelines on the same topic. The editorialists write that if the guidelines continue to exist, they need to undergo major changes, including limiting committee members with financial ties to industry or other potential conflicts of interest. Guideline development should also be centralized under a governing body to reduce bias and redundancy, something that might be achieved by allowing the US Department of Health and Human Services to oversee their drafting.

"However, it seems unlikely that substantial change will occur because many guideline developers seem set in their ways," write Shaneyfelt and Centor. "If all that can be produced are biased, minimally applicable consensus statements, perhaps guidelines should be avoided completely. Unless there is evidence of appropriate changes in the guideline process, clinicians and policy makers must reject calls for adherence to guidelines."

Speaking with heartwire, Tricoci, rather than fault the guideline committees, said the findings represent a failure of the current research system. With clinical trials performed predominantly by industry, unaddressed clinical questions are overlooked, as these companies are interested primarily in bringing new products to market.

Excuse me if I have a grin plastered on my face all day.  Dr. Shaneyfelt (a frequent commenter on this blog) originally published the classic article criticizing the guideline process.  He and I have discussed this issue often over the past 5 years.  Those discussions led to this editorial.

We must also thank the blog readers.  This blog gives me the opportunity to explore ideas, some of which lead to articles and editorials.  Readers will recognize many concepts that I have explored here in the past.

Back to smiling.

Related posts:

1. Dr. RW and the JAMA editorial
2. Another performance measure challenged – BP goal
3. Caution – guidelines have biases
4. Can expert panels improve health care?
5. Guidelines as goals

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