Endorsement of clinical practice guidelines: Criteria from the College of Family Physicians of Canada

G. Michael Allan; Kris Aubrey-Bassler; Michel Cauchon; Noah M. Ivers; Alan Katz; Jessica Kirkwood; Peter James Kuling; Eric J. Mang; Simon Moore; Artem Safarov; Catherine Scrimshaw; Elizabeth Shaw; Penelope Stalker; Robert Woollard

doi:10.46747/cfp.6707499

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RE: Transparent Criteria Expose Potential Bias in Clinical Guidelines
William R. Phillips

Published on: 20 July 2021
RE: Endorsement of clinical practice guidelines: criteria from the College of Family Physicians of Canada
Joel Lexchin

Published on: 20 July 2021

Published on: (20 July 2021)
Page navigation anchor for RE: Transparent Criteria Expose Potential Bias in Clinical Guidelines
RE: Transparent Criteria Expose Potential Bias in Clinical Guidelines
William R. Phillips, Professor Emeritus of Family Medicine, University of Washington, Seattle
With these explicit criteria from the College of Family Physicians of Canada [1], family medicine continues to lead the way in improving the quality, relevance, and usefulness of clinical practice guidelines for practitioners and their patients.[2] The emphasis on transparency and full disclosure of funding sources will help expose potential bias. The American Academy of Family Physicians pioneered these principles in 1994 by publishing the first international call for explicit declaration of conflicts of interest in the development of clinical practice guidelines.[3]

1. Allan GM, Cauchon M, Katz A, Kuling PJ, Moore S, Scrimshaw C, Stalker P. Endorsement of clinical practice guidelines. Criteria from the College of Family Physicians of Canada. Can Fam Physician 2021;67:499-502. DOI: 10.46747/cfp.6707499

2. Phillips WR. General practice leads in transparency of clinical guidelines. Comment on Moore, Ainsley, et al. Financial conflict of interest among clinical practice guideline-producing organisations. British J General Practice 70.700 (2020): 530-531. Web. 30 Oct. 2020. DOI: 10.3399/bjgp20X713177

3. Phillips WR. Clinical policies: making conflicts of interest explicit. JAMA 1994; 272(19):1479. DOI:10.1001/jama.1994.03520190021010.

Competing Interests: None declared.
Published on: (20 July 2021)
Page navigation anchor for RE: Endorsement of clinical practice guidelines: criteria from the College of Family Physicians of Canada
RE: Endorsement of clinical practice guidelines: criteria from the College of Family Physicians of Canada
Joel Lexchin, Emergency physician, University Health Network
The College of Family Physicians of Canada (CFPC) is to be commended for developing criteria for the endorsement of clinical practice guidelines (CPGs) (1), but it’s too bad that those criteria are not bolder when it comes to financial conflict of interest (FCOI).

There is good evidence linking FCOI to biases in guidelines. One study that looked at industry involvement in the production of CPGs for opioid prescribing concluded that “the clinical practice guidelines for opioid prescribing for CNCP [chronic non-cancer pain] from 2007 to 2013 were at risk of bias because of pervasive conflicts of interest with the pharmaceutical industry, and with a paucity of mechanisms to mitigate bias” (2). Industry-sponsored guidelines about the diagnosis and treatment of infants with allergies to cow’s milk protein led to an increase in prescriptions of specialist formula milks in the United Kingdom for infants with cow’s milk protein allergy of nearly 500% despite the lack of any data showing a significant change in the prevalence of the condition (3).

The College criteria rightly require the source of funding for the guidelines to be stated but are silent on the public disclosure of industry funding of the organization that commissioned the guidelines. Among 18 Canadian disease or condition interest groups and medical professional societies that sponsored guidelines, 14 of 15 disclosed organizational funding from industry on their websites (3 did not disclose funding), b...
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The College of Family Physicians of Canada (CFPC) is to be commended for developing criteria for the endorsement of clinical practice guidelines (CPGs) (1), but it’s too bad that those criteria are not bolder when it comes to financial conflict of interest (FCOI).

There is good evidence linking FCOI to biases in guidelines. One study that looked at industry involvement in the production of CPGs for opioid prescribing concluded that “the clinical practice guidelines for opioid prescribing for CNCP [chronic non-cancer pain] from 2007 to 2013 were at risk of bias because of pervasive conflicts of interest with the pharmaceutical industry, and with a paucity of mechanisms to mitigate bias” (2). Industry-sponsored guidelines about the diagnosis and treatment of infants with allergies to cow’s milk protein led to an increase in prescriptions of specialist formula milks in the United Kingdom for infants with cow’s milk protein allergy of nearly 500% despite the lack of any data showing a significant change in the prevalence of the condition (3).

The College criteria rightly require the source of funding for the guidelines to be stated but are silent on the public disclosure of industry funding of the organization that commissioned the guidelines. Among 18 Canadian disease or condition interest groups and medical professional societies that sponsored guidelines, 14 of 15 disclosed organizational funding from industry on their websites (3 did not disclose funding), but none disclosed this information in the CPGs themselves (4).

The 2011 report from the United States Institute of Medicine (now the National Academy of Medicine) recommended that the chairs and co-chairs of guidelines committees have no FCOI and that committee members with FCOIs should represent not more than a minority of the committee (5). The College’s criteria ignore those recommendations and even allow industry employees to be members of guideline committees provided there is an explanation about how FCOI was managed.

Clinicians rely on CPGs for guidance when making treatment decisions for patients. In 2016, 8 of the 15 most-cited articles across all science were medical guidelines, disease definitions, or disease statistics (6). Well done, evidence-based CPGs enhance the clinical care that physicians deliver (7, 8), but the CFPC needs to recognize the corrosive effect of industry involvement in the generation of guidelines and take decisive action.

References

1. Allan G, Aubrey-Bassier K, Cauchon M, Ivers N, Katz A, Kirkwood J, et al. Endorsement of clinical practice guidelines: criteria from the College of Family Physicians of Canada. Canadian Family Physician. 2021;67:499-502.
2. Spithoff S, Leece P, Sullivan F, Persaud N, Belesiotis P, Steiner L. Drivers of the opioid crisis: an appraisal of financial conflicts of interest in clinical practice guideline panels at the peak of opioid prescribing. PLoS ONE. 2020;15:e0227045.
3. van Tulleken C. Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers. BMJ. 2018;363:k5056.
4. Elder K, Turner K, Cosgrove L, Lexchin J, Shnier A, Moore A, et al. Reporting of financial conflicts of interest by Canadian clinical practice guideline producers: a descriptive study. CMAJ. 2020;192.
5. Institute of Medicine. Clinical practice guidelines we can trust. Washington, DC; 2011.
6. Ioannidis J. Professional societies should abstain from authorship of guidelines and disease definition statements. Circulation: Cardiovascual Quality and Outcomes. 2018;11:e004889.
7. Lugtenberg M, Burgers J, Westert G. Effects of evidence-based clinical practice guidelines on quality of care: a systematic review. Quality and Safety in Health Care. 2009;18:385-92.
8. Corriere M, Minang L, Sisson S, Brancati F, Kalyani R. The use of clinical guidelines highlights ongoing educational gaps in physicians’ knowledge and decision making related to diabetes. BMC Medical Education. 2014;14:186.
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Competing Interests: In 2017-2020, Joel Lexchin received payments for being on a panel at the American Diabetes Association, for talks at the Toronto Reference Library, for writing a brief in an action for side effects of a drug for Michael F. Smith, Lawyer and a second brief on the role of promotion in generating prescriptions for Goodmans LLP and from the Canadian Institutes of Health Research for presenting at a workshop on conflict-of-interest in clinical practice guidelines. He is currently a member of research groups that are receiving money from the Canadian Institutes of Health Research and the Australian National Health and Medical Research Council. He is a member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written.