Several underemphasised limitations of guidelines need proactive remediation in meeting the contemporary needs of clinicians

Clinical practice guideline (CPG) panels are expected to abide by standards that ensure their processes are multidisciplinary, systematic and unbiased.1 Unfortunately, many CPGs fail to satisfy these standards. Only a third of 130 US guidelines produced by subspecialty societies between 2006 and 2011,2 satisfied more than 50% of standards set by the Institute of Medicine (IOM—see table 1),1 relating to panel composition, conflicts of interest, evidence synthesis, reconciliation of different interpretations of evidence and enumeration of treatment harms. Guidelines from other countries demonstrate similar deficiencies.3 Editorialists have identified the need for transparent measures of guideline trustworthiness,4 and some professional societies have issued rigorous standards for their guideline development panels.5 The fact that comparative studies have identified guidelines that more consistently meet most IOM standards6 ,7 suggests that it is possible for more guideline panels to improve the quality and rigour of their processes.

In an era when clinicians are increasingly using CPGs to inform their care and guidelines are being increasingly used as reference standards for clinical audits, pay for performance schemes, public scorecards and medical litigation, guidelines must be both rigorously developed and mindful of challenges in implementing their recommendations. In this article, we explore problematic issues that have received limited attention to date in guideline appraisal tools and commentaries.

Recommendations that conflict

A medical defence organisation in Australia recently warned doctors that conflicting guideline recommendations around prostate cancer screening using prostatic-specific antigen (PSA) testing may render them individually liable to claims of delayed diagnosis.8 In this case, CPG issued from the Royal Australasian College of General Practitioners9 stated that men aged 55–69 years should not be offered PSA testing routinely whereas CPG from the Urological Society of Australia and New …