It is encouraging to read that CMAJ is going to adopt the Guidelines International Network (GIN) principles for disclosure of interests in guidelines.1 However, it is important to recognize the limitations of the principles underlying the GIN recommendations.2
One of the main sources of concern is the use of terms such as “make all possible efforts” (principle 1) and “should” (principles 2–9). These terms are vague and open to a wide variety of interpretations by guideline developers as to how they should be applied depending on their resources and expertise.
Principle 4, for example, requires the public disclosure of interests of members of guideline development groups, but this does not apply to the organizations or societies that may be sponsoring the guidelines. A cross-sectional survey and review of websites of 95 national and international medical organizations that produced 290 clinical practice guidelines published on the US National Guideline Clearinghouse found that only 1% of guidelines (4/290) contained a statement about the financial relationships with biomedical companies of the organizations producing the guidelines.3
Principle 6 refers to situations in which “direct or indirect COIs [conflicts of interest] of a chair are unavoidable,” but what does “unavoidable” mean in practice? At a minimum, the committee should be required to explain in detail why COIs are unavoidable.
Principle 7 calls for “an appropriate balance of opinion” of experts with relevant COIs, but what constitutes an appropriate balance is not defined, nor is there a requirement to explain how an appropriate balance was sought or why one could not be achieved.
Finally, there are no recommendations about the oversight committee required in principle 9. The members of the independent oversight committee that reviewed the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Major Depressive Disorder declared that they had “no current relationships with industry.” However, one member of this committee had undeclared relationships to pharmaceutical manufacturers of antidepressants in the 3 years before publication of the guidelines, and 2 others had financial relationships, although it could not be determined whether they fell outside the 3-year window.4
Conflicts of interest are a serious danger to the credibility of guidelines. CMAJ needs to continue to strengthen its efforts to ensure that guidelines are free of bias by adopting standards that are more stringent than those recommended by GIN.
Footnotes
Competing interests: In 2016–2019, Joel Lexchin was a paid consultant on 2 projects: one looking at developing principles for conservative diagnosis (Gordon and Betty Moore Foundation) and a second deciding what drugs should be provided free of charge by general practitioners (Government of Canada, Ontario Supporting Patient Oriented Research Support Unit and the St. Michael’s Hospital Foundation). He also received payment for being on a panel at the American Diabetes Association, for a talk at the Toronto Reference Library, for writing a brief for a law firm, and from the Canadian Institutes of Health Research (CIHR) for presenting at a workshop on conflict of interest in clinical practice guidelines. He is currently a member of research groups that are receiving money from CIHR and the Australian National Health and Medical Research Council. He is a member of the Foundation Board of Health Action International and on the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written.
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