DOCTORS should use the same level of scrutiny when reading clinical practice guidelines as they do for medical research studies, according to an expert who has developed strategies to improve the transparency and credibility of guidelines.

Professor Ian Scott, director of internal medicine and clinical epidemiology at Princess Alexandra Hospital, Brisbane, has outlined several solutions to potential problems in guideline development in the latest MJA. (1)

The strategies, cowritten by Professor Gordon Guyatt of the department of clinical epidemiology and biostatistics at McMaster University, Canada, call for nominated guideline panellists to disclose all industry-related professional activities and divest themselves of financial interests in relevant companies.

Only panellists without conflicts of interest should be involved in drafting the recommendations within guidelines, the authors said.

The strategies come in response to recently published claims of bias in Australian acute coronary syndromes guidelines. (2)

Additionally, a recent review of American cardiovascular guidelines found that 56% of authors reported conflicts of interest. (3)

Suggestions in the new strategies for improving the credibility of guidelines include ensuring the recommendations are rated according to their level of evidence.

The authors suggest guideline panels use the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to rate the quality of evidence for each recommendation. (4)

“People need to be aware that some guideline recommendations are pretty weak, and others are very strong. It’s not one size fits all”, Professor Scott told MJA InSight.

He said doctors were fatigued by the proliferation of guidelines, particularly when different guidelines on the same topic made conflicting recommendations.

“In that sense we would like clinicians to be a little more critical of guidelines … we’re not saying that you need to be a content expert. What we are asking is that perhaps we should look more closely at the methodology of how the recommendations have been developed.”

Professor Scott acknowledged the strategies would increase the time and resources required to develop guidelines, but he said this was justified given the enormous impact of clinical guidelines.

“Guidelines are not only used as a reference source for clinicians, but are also used to determine benchmarks and standards of practice used in performance measures. They have taken on more importance and authority so we need to make sure the recommendations contained within them are based on good evidence.”

Other strategies for improving the quality of guidelines included engaging separate methodologists to work with content experts to interpret evidence, and ensuring that the end users of the guidelines were able to provide feedback on their practical implementation.

– Sophie McNamara

1. MJA 2011; 195: 29-33
2. MJA 2010; 192: 696-699

3. Arch Intern Med 2011; 171: 577-585

4. GRADE working group

Posted 4 July 2011

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