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Invited Commentary |

Can We Trust Cardiovascular Practice Guidelines?  Comment on “Conflicts of Interest in Cardiovascular Clinical Practice Guidelines”

Steven E. Nissen, MD
Arch Intern Med. 2011;171(6):584-585. doi:10.1001/archinternmed.2011.94.
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Clinical practice guidelines play an enormously important role in society and the practice of medicine. Individual physicians use CPGs to determine which diagnostic tests and therapeutic strategies are most appropriate for their patients. Government and third-party payers use CPGs to determine which procedures and drugs should receive reimbursement. Hospitals and clinics use these CPGs to decide when innovative, but expensive, therapies are sufficiently mature to warrant a major investment. Increasingly, government, the public and the media use CPGs as a benchmark to gauge the quality of medical practice for both hospitals and individual physicians.13 Accordingly, protecting the integrity and reliability of CPGs is essential to society and fundamental to the practice of evidence-based medicine.4

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Disclosure of only "skin deep" conflicts of interest is not enough
Posted on March 28, 2011
Adam G. Dunn, PhD
Australian Institute of Health Innovation
Conflict of Interest: None Declared
Mendelson et al. and the above commentary from Nissen are excellent and thought-provoking pieces that teach us more about the disclosure of conflicts of interest (COIs) in clinical practice guidelines (CPGs) and the potential consequences for the clinicians that rely on these guidelines to make informed decisions. My curiosity about conflicts of interests was piqued on the 16th of this month, when I saw Roseman et al.1 publish an interesting article in JAMA about reporting COIs in meta-analyses. Should the same argument not be applied when investigating COIs in clinical practice guidelines? Whether or not the 56% of CPG authors managed to leverage their social power in the development of CPGs or not, they were still basing their writing on Level 1 and Level 2 evidence that may have been written by authors with COIs. That evidence comes from clinical trials that may have been funded by big pharma, and were designed and implemented within a system backed by 900 billion dollars of "more pills = more profit".
In order to really examine what influence industry has over what ends up in a CPG, I propose that we need to investigate the flow of COIs throughout the process, rather than measuring only at the faucet. If we follow one trail of evidence from clinical trial design, publication bias, meta-analysis, review and then guideline, we may be able to create a unified picture of the potential for industry influence in the evidence pipeline.
1. Roseman M, Milette K, Bero LA, et al. Reporting of Conflicts of Interest in Meta-analyses of Trials of Pharmacological Treatments. JAMA: The Journal of the American Medical Association;305:1008-17.

Conflict of Interest: None declared
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