Guidelines and other statements from professional societies have become increasingly influential. These documents shape how disease should be prevented and treated and what should come within the remit of medical care.
Changes in definition of illness can easily increase overnight by millions the number of people who deserve specialist care. This has been seen repeatedly in conditions as diverse as hypertension, diabetes mellitus, composite cardiovascular risk, depression, rheumatoid arthritis, or gastroesophageal reflux.
Similarly, changes in prevention or treatment options may escalate overnight the required cost of care by billions of dollars.
For example, if we accept PROP’s argument that we’re all addicted to our “heroin pills”, we’d all suddenly need “addiction-recovery programs/clinics/residential treatment centers/resorts” for our “substance abuse” instead of “chronic pain”.
Should the specialists of the respective field be the developers for such influential articles?
Many influential professional society documents are written exclusively by insiders. Joining such guideline panels is considered highly prestigious and allocation of writing positions is a unique means to advance an expert’s visibility and career within the specific medical specialty
Hundreds and thousands of designated guideline coauthors share in the society-wide power game across a large portfolio of guidelines and statements that improve, fine tune, or manipulate disease definition and management.
Tens of thousands of society members then cite these articles. This creates a massive, clan-like, group self-citation network.
Eight of the 15 most-cited articles across all science published in 2016 are medical guidelines, disease definitions, or disease statistics.
Most (not all) citation superstars get bulk citations by coauthoring guidelines, industry trials, and nonsystematic expert reviews.
Stardom is the interwoven product of guidelines and industry links (Table). Industry trials nurture opinion leaders who then solidify their clan power authoring guidelines that serve the industry.
these guidelines writing activities are particularly helpful in:
- promoting the careers of specialists,
- building recognizable and sustainable hierarchies of clan power,
- boosting the impact factors of specialty journals and in
- elevating the visibility of the sponsoring organizations and their conferences that massively promote society products to attendees.
However, do they improve medicine or do they homogenize biased, collective, and organized ignorance?
Well-conducted unbiased guidelines can be useful. However, most published guidelines have one or more red flags that either make them overtly unreliable or should at least raise suspicion among potential users.
The CDC opioid prescribing guideline is a case study of special-interest corrupted guidelines:
The list of red flags includes
- sponsoring by a professional society with substantial industry funding, [recovery industry, medication for addiction treatment]
- conflicts of interest for chairs and panel members, [recovery and anti-addiction industries are interested in classifying more people as addicted and needing their product]
- stacking, [many guideline writers are PROP memebers]
- insufficient methodologist involvement, [used low quality evidence to generate “strong” recommendations]
- inadequate external review, and [no time was given for external review]
- noninclusion of nonphysicians, patients, and community members. [no pain specialists or patients were included]
Prioritizing more the role of methodologists with expertise on evidence assessment and biostatistics and excluding content experts with conflicts (both financial and nonfinancial)7 is still uncommon across medical specialties. Moreover, stacking of the panels with specialists who have overt preferences (even without overt conflicts) is more difficult to avoid
Some professional societies are behemoth financial enterprises. Efforts are made to minimize the influence of this funding.
However, securing objectivity is difficult when industry-manufactured interventions also procure much of the specialty income. Would a society advise its members to change jobs, if evidence proved their medical services a waste?
An overspecialized worldview is a major disadvantage in making sound recommendations. Specialists cannot compare their merchandise against the merchandise of other healthcare providers. However, diverse specialists and societies compete for the same pie of healthcare resources.
Proponents of evidence-based medicine have recognized early the need to be critical toward guidelines.
Yet evidence-based medicine and professional societies have had a mutually suspicious relationship.
Grading of Recommendations Assessment, Development and Evaluation (http://ww.gradeworkinggroup.org and http://www.gradeworkinggroup.org/#pub), an important initiative on evidence appraisal, has tried to improve standards of guidelines and secure their objectivity and methodological strength
Especially when guideline authors choose to give strong recommendations on the basis of the week evidence, as we see in the cc guidelines
Guideline development also needs to consider the sociopolitical context.
The CDC guidelines are a special case of guidelines that bow to the demands of the cultural moment. Such biased guidelines would never have passed muster before the drug war focused on prescription opioids.
in the United States, the US Preventive Services Task Force is convened by the Agency for Health Research and Quality, but most powerful guidelines are issued by professional societies; these typically place less attention on cost containment. With skyrocketing healthcare expenditures, largely cost-unconscious guidelines make little sense.
This makes it sound like all these groups create “Guidelines to Generate the Most Profit for our Speciality”.
This is certainly happened when anti-opioid zealots wrote a guideline to restrict opioids for pain management, blaming prescription opioids for the increasing numbers of opioid overdose deaths, even though those are usually from illicit fentanyl supplementation.
An alternative approach to the current situation would be to avoid having specialists assume any major role in guidelines that pertain to their own fields
Especially when they are writing guidelines outside of their field of expertise.
A more realistic solution would be to have professional societies and their members abstain specifically from writing their own guidelines.
Another good idea that will never be implemented. There’s too much money at stake when some drug or device is “recommended” in one of these guidelines.
Instead of having mostly or exclusively specialists write the guidelines and occasional nonspecialists consult or comment on them, guidelines could be written by methodologists and patients, with content experts consulted and invited to comment. This approach has been proposed also for systematic reviews and meta-analyses that synthesize the evidence feeding into guideline development
What may seem crucially important to a field expert, may appear as minutiae to a less personally involved outsider.
Like the pain levels associated with the opioid use that’s being studied: Opioids Blamed for Consequences of Chronic Pain
Methodologists, patients, and different field specialists add to guideline teams more methodological rigor, patient-centeredness, and impartiality.
Professional societies should consider disentangling their specialists from guidelines and disease definitions and listen to what more impartial stakeholders think about their practices. Professional societies could still fund these efforts without their own experts authoring them.
Author: John P.A. Ioannidis MD, DScStanford Prevention Research Center, Meta-Research Innovation Center at Stanford (METRICS), and Departments of Medicine, Health Research and Policy, Biomedical Data Science, and Statistics, Stanford University, CA. E-mail Address: firstname.lastname@example.org
Here’s another article about this, pointing out that it’s always about the *people* and what those people want.
The influence of the team in conducting a systematic review – August 2017 – Lesley Uttley and Paul Montgomery
There is an increasing body of research documenting flaws in many published systematic reviews’ methodological and reporting conduct.
When good systematic review practice is questioned, attention is rarely turned to the composition of the team that conducted the systematic review.
This commentary highlights a number of relevant articles indicating how the composition of the review team could jeopardise the integrity of the systematic review study and its conclusions.
Key biases require closer attention such as sponsorship bias and researcher allegiance, but there may also be less obvious affiliations in teams conducting secondary evidence-syntheses.
The importance of transparency and disclosure are now firmly on the agenda for clinical trials and primary research, but the meta-biases that systematic reviews may be at risk from now require further scrutiny.