Why we can't trust clinical guidelines - BMJ

Clinical guidelines are recommendations on the appropriate treatment and care of people with specific diseases and conditions. They are based on the best available evidence with the aim to help healthcare professionals in their work, but they do not replace their knowledge and skills.


A recent article published in the BMJ, written by a medical investigative journalist, raised the issue that despite repeated calls to limit conflicts of interests among authors and sponsors of clinical guidelines, the problem persists.

The article refers to the drug alteplase, a clot-busting drug given for acute stroke, the guideline recommendation was based on 12 studies, but only two of them found any benefit, and five of them had to be stopped early due to increased risk of brain haemorrhage or increased death rates.

Another example is the conflict between the 1990 guidelines recommending steroids for acute spinal injury and the 2013 cllinical recommendations against using steroids in acute spinal injury.

Based on a poll, the author finds that many doctors know that many guidelines are not supported by research evidence but would continue prescribing the treatment for the fear of "malpractice" or criticism by colleagues if they fail to follow the standard.

Another conflict of interest raised in the article is that many of the guideline committee members and panellists have strong ties with the industry and that their connection would have significant influence in deciding the best guidelines on good medical care and what doctors should prescribe. The author concluded that these problems are wide spread and this is the opportunity that the medical profession takes a long hard look at itself.

According to the BMJ website, this article is one of the most read and has sparkled a lot debate among the readers.

One of the responses came from the Delfini group (US) - saying that large number of physicians and others involved in health care decision-making may not understand that many research studies are not valid or reported sufficiently, they may also lack the skills to be able to critically appraise the research evidence. The remedy is ensuring the transparency in guidelines and that all guideline developers have basic critical appraisal skills.

Source : Jeanne Lenzer. Why we can’t trust clinical guidelines. BMJ 2013;346:f3998 (Published 19 June 2013)  full text via Athens

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