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Conflict of Interest in Medical Research, Education, and Practice
Blue Shield Association, ECRI (now the ECRI Institute), and the RAND Corporation were, among others, leaders in devising systematic methods for assessing the evidence and developing clinical recommendations for practitioners, patients, payers, and others (see, e.g., IOM [1985, 1988] for contemporary descriptions of such activities). In 1989, the U.S. Congress created the Agency for Healthcare Policy and Research (AHCPR) and gave it responsibility for creating a public-private partnership to develop, disseminate, and evaluate clinical practice guidelines (P.L. 101-239). In 1995, the Congress came close to defunding the agency in response to lobbying by back surgeons who disagreed with the agency’s guidelines for the treatment of low back pain developed by an AHCPR Patient Outcomes Research Team (Deyo et al., 1997; Gray et al., 2003; see also Clancy , Gaus , and Wennberg ). Other government bodies charged with some aspect of technology assessment have also been defunded under circumstances that underscore the political sensitivity of this activity (for example, the National Center for Health Care Technology in 1982 and the congressional Office of Technology Assessment in 1995) (see, e.g., Bimber , Rettig , Eisenberg and Zarin , and Keiper ).
After its close call, AHCPR—rechristened the Agency for Healthcare Quality and Research (AHRQ)—withdrew from the work of developing clinical practice guidelines. Instead, the agency supports evidence-based practice centers that conduct systematic reviews that government agencies, professional societies, and other groups can request and use to develop guidelines and other recommendations. In 2008, AHRQ supported 14 such centers, 5 of which focused on assessments for the Centers for Medicare and Medicaid Services. One evidence review (performed under a grant from AHRQ) by the RAND Corporation’s Evidence-Based Practice Center concluded that the quality of practice guidelines suffered as a result of the retreat of the agency from guideline development (Hasenfeld and Shekelle, 2003; see also Grilli et al. ).
The U.S. Preventive Services Task Force, which was created several years before AHCPR/AHRQ but which is now part of the agency, continues to develop evidence-based guidelines for preventive services. It is currently supported by one evidence-based practice center. Other federal agencies, such as NIH and the Centers for Disease Control and Prevention, also develop practice guidelines.
To support the dissemination of the clinical practice guidelines developed and submitted by others, AHRQ sponsors the National Guideline
nizes conferences that are jointly sponsored and administered by one or more NIH institutes or centers and the Office of Medical Applications of Research, which is located in the Office of the Director of NIH. Other federal agencies may participate if their expertise is relevant to the topic. Currently, the Agency for Healthcare Research and Quality provides a systematic review of the conference topic from one of its Evidence-Based Practice Centers.