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Editor's Note
February 18, 2019

On the Need for (Only) High-Quality Clinical Practice Guidelines

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco
  • 2Editorial Fellow, JAMA Internal Medicine
  • 3Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
  • 4Associate Editor, JAMA Internal Medicine
JAMA Intern Med. 2019;179(4):561. doi:10.1001/jamainternmed.2018.7471

Health care practitioners rely on clinical practice guidelines to provide evidence-based, unbiased recommendations for patient care. Ideally, guidelines are as definitive as possible, developed through a rigorous and systematic review of the most current and relevant evidence, followed by formal consensus building among a diverse and unconflicted group of stakeholders and experts. In reality, clinicians are faced with a surplus of clinical practice guidelines of widely variable quality, many based primarily on the opinions of a self-selected group of experts whose work is not sufficiently transparent with respect to principles for guideline development, evidence review, or potential conflicts of interest. In 2011, the Institute of Medicine (IOM) released its report Clinical Practice Guidelines We Can Trust,1 establishing best practices and quality standards to inform the development of clinical practice guidelines, including managing conflicts of interest, engaging a diverse set of stakeholders, conducting systematic reviews, rating evidence (eg, the GRADE [Grading of Recommendations, Assessment, Development and Evaluations] framework), and articulating recommendations. Implementing these IOM standards led to the removal of nearly 50% of the 2619 guidelines on the now-defunded National Guideline Clearinghouse between 2014 and 2018.2

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    1 Comment for this article
    A (relatively) simple solution to bad guidelines
    Barry Saver, MD, MPH | Swedish Family Medicine Residency Cherry Hill
    There is an answer for how we can get higher quality, more evidence-based guidelines. The model used by the USPSTF has produced the highest quality guidelines we have. After the IOM issued a call for guideline groups to essentially follow this model, those groups that had issued guidelines conflicting with USPSTF guidelines and then follow a process more like the USPSTF (e.g., the ACS and AUA) have issued guidelines much closer to USPSTF recommendations. However, I don't think just trying to follow the process is sufficient. Where evidence is not overwhelming - i.e., most of the time - judgment calls must be made. Even with the best of intentions, experts and advocates will allow their biases to enter at this point. If we want high quality guidelines, we should either expand the mission of the USPSTF and, guidelines generated in the US, only recognize those issued by them. Organizations wanting a guideline on a topic would then issue a request, be quoted a price, and could then fund the USPSTF (or a similar group created to make treatment guidelines) to do the work. This would both minimize bias and allow for some economies of scale. Other countries could use a similar process or contract out the work to recognized, certified guideline development organizations. This might be a natural next step for the Cochrane collaboration.

    Would this be perfect? Of course not. Do I think the USPSTF sometimes goes the wrong way on close judgment calls? Yes. Has Cochrane had to retract reviews not because evidence has changed but because of errors? Certainly. But would this approach be far better than the situation we have today, with a plenitude of conflicting guidelines, many with significant bias, and large numbers of strong recommendations based on weak to very weak evidence? Absolutely. Currently, anyone can create a guideline. But most, even with the best of intentions, should not.