Response

We thank Dr Phillips for his letter¹ in response to our article² in the July issue of Canadian Family Physician that recognized the College of Family Physicians of Canada (CFPC), along with many other family medicine organizations and groups, is leading the way in transparency and reduction of bias within clinical practice guidelines (CPGs).²

We also thank Dr Lexchin for his letter³ stressing the important and concerning influence of financial support on CPGs. In drafting these CPG endorsement criteria, this factor was a principal consideration in our deliberation and discussion.

We would like to draw a distinction between guidelines produced by the CFPC and those that the CFPC reviews from other organizations. Clinical practice guidelines produced by the CFPC in collaboration with PEER (Patients, Experience, Evidence, Research) have the highest standards, including the exclusion of anyone with a financial conflict of interest from participating on guideline committees or on the evidence team. No funding from pharmaceutical or medical device industries, directly or indirectly, is accepted for any guideline development itself.

For endorsement of guidelines submitted from outside the CFPC, we recognize that many institutions struggle to completely exclude funding or financial conflicts with industry. The CFPC Guideline and Knowledge Translation Expert Working Group, which approved these criteria, also believed that the presence of a conflict of interest does not mean de facto that bias occurs. The working group did not want to exclude guidelines from consideration without broader assessment of the degree of conflict, the processes used to manage conflict, and the guideline overall.

The appendix to our article² provides the actual endorsement criteria, how they are applied, and a guide of what we look for. While not absolute exclusions, issues like pharmaceutical industry sponsorship of the guideline will strongly tip the balance away from endorsement. Sponsorship includes the indirect methods of financial support mentioned by Dr Lexchin, an element that we did consider and included in the CFPC endorsement criteria for both the applicant and the reviewers.

As to guideline panels with potential financial conflicts, recent Canadian guidance⁴ does not prohibit the inclusion of participants with conflicts. Our criteria allow for careful dissection of conflicts (if acknowledged), including the proportion of participants with potential conflicts, whether the chair had potential conflicts, and how these conflicts were managed. Like Dr Lexchin, we were deeply concerned about any participation of industry employees on guideline panels, so we wanted to make sure that that was specifically identified in our criteria and described. While we did not state that any of these criteria would automatically result in a rejection of endorsement, these factors potentially weigh heavily against endorsement and need to be understood for adequate assessment. To critically evaluate the guideline, these factors must be identified, clear, and transparent. That is why we have included them in our criteria. Without specific mention in our criteria, they could be missed.

While financial conflicts and sponsorship are important, there are many potential biases and limitations that impact practical use and application in primary care. The Guideline and Knowledge Translation Expert Working Group placed high value on several aspects in the guidelines: adequate representation of family physicians and other health professionals, practical application in comprehensive care, involvement of patients and focus on shared decision making, appropriate evidence assessment, and more.

As mentioned from the start, the CFPC criteria and family medicine in general continue to set the standards in expectations of CPG quality and transparency.

• Copyright © 2021 the College of Family Physicians of Canada