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Feature Clinical guidelines

Ensuring the integrity of clinical practice guidelines: a tool for protecting patients

BMJ 2013; 347 doi: (Published 17 September 2013) Cite this as: BMJ 2013;347:f5535
  1. Jeanne Lenzer, medical investigative journalist1,
  2. Jerome R Hoffman, professor of medicine emeritus2,
  3. Curt D Furberg, professor of public health sciences emeritus3,
  4. John P A Ioannidis, professor of medicine4
  5. On behalf of the Guideline Panel Review working group
  1. 1NY, USA
  2. 2UCLA School of Medicine, CA, USA
  3. 3Wake Forest School of Medicine, NC, USA
  4. 4Stanford University, CA, USA
  1. Correspondence: Jeanne Lenzer: jeanne.lenzer{at}

Jeanne Lenzer, Jerome Hoffman, Curt Furberg, and John Ioannidis pull together a large expert working group to offer a manifesto for clinical guidelines

Clinical practice guidelines should support doctors by identifying and disseminating the most scientifically sound healthcare practices. When performed rigorosly, this endeavor improves patient care and elevates the profession toward its scientific ideal. However, widespread financial conflicts of interest among the authors and sponsors of clinical practice guidelines have turned many guidelines into marketing tools of industry. Financial conflicts are pervasive, under-reported, influential in marketing, and uncurbed over time.1 2 3 4 5 6 7 Biased guidelines can cause grave harms to patients, while creating a dilemma for doctors, who may face professional or legal consequences when they choose not to follow guidelines they distrust.8 9 Such guidelines fail to place patients’ needs foremost, and instead protect livelihoods and preserve ideologies.

The Institute of Medicine and others10 11 12 13 have recommended that guideline authors should reduce or eliminate financial and professional conflicts. Unfortunately, these admonitions have had little effect.6 Until changes are made in the way panels are constituted, the best defense is an informed readership. Therefore, we address guidelines users and the journals that publish them. The biasing impact of financial conflicts—such as “panel stacking,” which we discuss below—can be invisible to guideline readers. For this reason we have created the Guideline Panel Review (GPR), a short list of questions for guideline authors, which we believe, if published with guidelines, will allow physicians, administrators, policy makers, and patients to better determine which guidelines are likely to offer reliable advice—and which are not.

The special nature of financial conflicts

It has been argued it is unfair to single out financial conflicts of interest because other forms of bias are common.14 We believe, however, the impact …

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