Clinical Practice Guidelines Establish Norms of Practice But Must Reduce Risk for Bias

Clinical practice guidelines are an important part of medical practice, but scarce funding for updates; competing organizations issuing their own, sometimes conflicting, guidelines; and the risk for bias have raised challenges, according to an opinion piece published in JAMA.¹

Paul G. Shekelle, MD, PhD, from the Veterans Affairs Greater Los Angeles Healthcare System in California, details the challenges facing guidelines and the positive steps that have been taken to remediate the situation. He details the importance of guidelines, as they not only constitute important reviews and assessments of medical literature but also establish practice norms.

The Grading of Recommendation Assessment, Development and Evaluation (GRADE) working group published an article on improving guidelines in 2004, but Dr Shekelle noted that it was not until the release of the 2011 Institute of Medicine (now National Academy of Medicine) report Clinical Practice Guidelines We Can Trust² that an important step was taken toward better, clearer guidelines. This was the first time an authoritative body had stepped into the fray to establish guidelines for guidelines. Since that time, clinical practice guidelines have been defined as statements that include recommendations intended to optimize patient care that are based on a systematic review of evidence and an assessment of the benefits and harms of treatment options. This change in definition resulted in an approximately 50% reduction in the number of guidelines listed on the National Guideline Clearinghouse, from 2619 guidelines in 2014 to 1440 in 2018.

However, Dr Shekelle notes, some operational issues still need to be addressed. On July 16, 2018, free access to the National Guideline Clearinghouse website was inactivated because of a lack of funding, despite its having 2.6 million annual visitors. This limits the access to summaries of 1385 guidelines for medical professionals and patients.

Dr Shekelle also recommended that to increase trust in guidelines, guideline committee members with conflicts of interest should be in the minority. The need for regular updating of guidelines is another important issue, but funding is often lacking. He argues that different organizations should pool their resources to develop 1 set of guidelines, rather than each seeking to publish their own guidelines on the same topic. The result would be fewer, more regularly updated guidelines, he said.

1. Shekelle PG. Clinical practice guidelines. What’s next? JAMA. 2018;320:757-758.
2. Greenfield S, Steinberg EP, Auerbach A, Avorn J, Galvin R, Gibbons R. Clinical Practice Guidelines We Can Trust. Washington, DC: Institute of Medicine; 2011.