include professional affiliations and practice specialization, reimbursement incentives, intellectual preconceptions and previously stated positions, and the desire for recognition and career advancement (see, e.g., Kahan et al. [1996], Ayanian et al. [1998], Murphy et al. [1998], Fitch et al. [1999], and Detsky [2006]).

This chapter begins with definitions and a brief historical overview and description of groups that develop clinical practice guidelines. It then reviews what the committee learned about the nature and the effects of sources of funding on the development of clinical practice guidelines, the financial interests of individual participants, and policies on financial relationships and conflicts of interest. A later section reviews other methods for promoting objectivity in the development of clinical practice guidelines and trust in those guidelines. The final section presents recommendations on how to reduce conflicts of interest in the development of clinical practice guidelines.



As defined in an earlier Institute of Medicine (IOM) report, clinical practice guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (IOM, 1990, p. 8). The IOM report emphasized the role of formal evaluations of the evidence base for clinical practice guidelines and the linking of recommendations to those reviews. Systematic reviews, the common term used today for formal evaluations of the evidence, are highly structured assessments of the research literature that use explicit, previously defined methods and tools to identify, select, assess, and summarize research studies relevant to a technology, treatment of a clinical condition, or similar topic (see, e.g., OTA [1994] and Cochrane Collaboration [2005]). A meta-analysis is a quantitative summary of the data examined in a systematic review. As explained below, various groups have devised tools for assessing the extent to which a set of guidelines are based on systematic, evidence-based procedures.

Evolution of Clinical Practice Guidelines

The American College of Cardiology, the American College of Physicians, the National Institutes of Health (NIH) Consensus Development Program,1 the U.S. Preventive Services Task Force, the Blue Cross and


Since 1977, the Consensus Development Program at NIH has sponsored “an unbiased, independent, evidence-based assessment of complex medical issues” (NIH, undated). It orga

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