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When is a guideline not a guideline? The devil is in the details
  1. Lisa Cosgrove1,
  2. Allen F Shaughnessy2,
  3. Terrence Shaneyfelt3
  1. 1 Department of Counseling and School Psychology, University of Massachusetts Boston, Boston, Massachusetts, USA
  2. 2 Department of Family Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
  3. 3 Division of General Internal Medicine, University of Alabama, Birmingham, Alabama, USA
  1. Correspondence to Lisa Cosgrove, Department of Counseling and School Psychology, University of Massachusetts Boston, Boston, MA 02125-3393, USA; Lisa.Cosgrove{at}

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Clinical practice guidelines (CPGs) are intended to enhance the practice of evidence-based medicine by streamlining healthcare delivery and improving the process and outcomes of patient care. Because guidelines are believed to represent the best evidence and best judgements, they are adopted as standards of care by payers and have a powerful influence on medical practice. However, because guideline development, like all areas of medicine, is vulnerable to biased judgements,1–3 commercial sponsorship of guidelines and conflicts of interest (COI) of panel members remains an important public health issue. There also are increasing concerns that common medical practices, often codified in CPGs, are not evidence based and may be drivers of overtreatment, raising questions about the quality and trustworthiness of guidelines.4–9

Certainly, some progress has been made in the last few years in terms of increased transparency, enhanced guideline development methods and requirements, and improved dissemination standards. For example, in 2011, the Institute of Medicine (IOM, now the National Academy of Medicine) published standards for enhancing the integrity of the guideline development process. The U.S. Agency for Healthcare Research and Quality (AHRQ) recently required stricter standards (eg, a systematic literature search of the evidence base must be conducted) for CPGs to be included on the National Guideline Clearinghouse (NGC).10 The stricter inclusion criteria provided another signal that more safeguards are needed to ensure the trustworthiness of guidelines. Similarly, the Guideline International Network (G-I-N) developed a minimal criteria set for high-quality guidelines.11Last year a new BMJ collaboration, ‘Rapid Recommendations’, was initiated.12 Using The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, this multidisciplinary team evaluates emerging evidence and conducts systematic reviews in order to produce trustworthy practice recommendations. Additionally, a number of checklists have been developed that can be used to assist guideline developers, clinicians and journal …

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