Annals On Call - The Problem of Conflicting Guidelines
Authors: Robert M. Centor, Terrence M. Shaneyfelt
Journal: Annals of Internal Medicine (2021)

Web ExclusivesMay 2021Annals On Call - The Problem of Conflicting GuidelinesFREERobert M. Centor, MD, Terrence M. Shaneyfelt, MDRobert M. Centor, MDHuntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)Search for more papers by this author, Terrence M. Shaneyfelt, MDUniversity of Alabama at Birmingham, Birmingham, Alabama (T.M.S.)Search for more papers by this authorAuthor, Article and Disclosure Informationhttps://doi.org/10.7326/A20-0012 CME/MOC SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In this episode of Annals On Call, Dr. Centor discusses the problem of conflicting guidelines on the same clinical condition with Dr. Terrence M. Shaneyfelt from the University of Alabama at Birmingham.Annals articles discussed include...When Clinical Practice Guidelines Collide: Finding a Way Forward: https://www.acpjournals.org/doi/10.7326/M17-2665Trustworthy Clinical Guidelines: https://www.acpjournals.org/doi/10.7326/0003-4819-154-11-201106070-00011About Annals On CallAnnals On Call focuses on a clinically influential article published in Annals of Internal Medicine. Dr. Robert Centor shares his own perspective on the material and interviews topic area experts to discuss, debate, and share diverse insights about patient care and health care delivery.For more information on Annals On Call and for more episodes, visit go.annals.org/OnCall. Comments0 CommentsSign In to Submit A Comment Dr Robert M CentorUAB Professor-Emeritus10 May 2021 On guideline panels Thanks for your thoughtful comment. You raise the question of doing our best to avoid conflicts of interest in guideline development. The counter argument is that without panelists familar with the clinical question, we might have difficulty finding flaws or strengths in the available studies. I don't think there is an easy answer to this problem. I personally favor having some content experts on a panel along with some generalists and definitely some methodologists. James DickinsonUniversity of Calgary, Departments of Family Medicine and Community Health Sciences3 May 2021 Guideline panels should be jurors, not experts Your thoughtful discussion grapples with the problem of finding experts without conflict of interest, and concludes that it is almost impossible to find such people, so we should try to find balance. There is an alternative approach: the guideline panel should comprise users, clinical and lay, with expertise in methods, NOT in the specific topic, and so can be chosen without conflicts. Then the various experts can provide their information, in the form of systematic reviews, or lower grade evidence if that is the best available. The guideline panel then can assess that evidence, and reach conclusions taking bias of the experts into account. When the panel has reached its conclusions, they can be released for critique and amended if necessary. This approach is similar to a jury in a court of law, and has been used by both the Canadian Task Force on Preventive Care since its inception, and subsequently by the US Preventive Services Taskforce. They are often attacked for making decisions without experts on the panel, but those attackers simply do not understand the model. Expertise is listened to, but must provide evidence not just opinions. When there is no relevant evidence, the panel can say so, and can either stop there or offer guidance that is labelled as based on beliefs of experts. Such an approach does not stop production of dueling guidelines, but sophisticated users can quickly discern which ones follow science, and which ones are commercially based. The explicit identification of evidence-free zones can lead to fruitful new research. Disclosures: I was a member of the Canadian Task Force on Preventive Health Care from 2009 to 2016, and have been involved in Alberta guidelines on Cervical screening. Author, Article and Disclosure InformationAffiliations: Huntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)University of Alabama at Birmingham, Birmingham, Alabama (T.M.S.)Disclosures: Dr. Centor has disclosed the following: Consultancy: DynaMed, MDCalc. Employment: U.S. Department of Veterans Affairs. Dr. Shaneyfelt has reported no disclosures of interest.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Stephanie Chang, MD, MPH, Deputy Editor, reports employment with the Agency for Healthcare Research and Quality, travel compensation from the Guidelines International Network, and participation in the Patient-Centered Outcomes Research Institute methodology committee. Vineet Chopra, MD, MSc, Deputy Editor, reports grants received from the Agency for Healthcare Research and Quality and royalties from UpToDate and Oxford University Press. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he has no financial relationships or interests to disclose. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.This article was published at Annals.org on 4 May 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics May 2021Volume 174, Issue 5Page: OC1 ePublished: 4 May 2021 Issue Published: May 2021 CopyrightCopyright © 2021 by American College of Physicians. All Rights Reserved.Loading ...