From the Journals

Guideline authors inconsistently disclose conflicts


Financial conflicts are often underreported by authors of clinical practice guidelines (CPGs) in several specialties including oncology, rheumatology, and gastroenterology, according to a pair of research letters published in JAMA Internal Medicine. The Institute of Medicine recommends that guideline authors include no more than 50% individuals with financial conflicts.

In one research letter, Rishad Khan, BSc, of the University of Toronto in Ontario and his colleagues reviewed data on undeclared financial conflicts of interest among authors of guidelines related to high-revenue medications.

The researchers identified CPGs via the National Guideline Clearinghouse and selected 18 CPGs for 10 high-revenue medications published between 2013 and 2017. Financial conflicts of interest were based on the Centers for Medicare & Medicaid Services Open Payments.

Of the 160 authors involved in the various guidelines, 79 (49.4%) disclosed a payment in the CPG or supplemental materials, and 50 (31.3%) disclosed payments from companies marketing 1 of the 10 high-revenue medications in the related guidelines.

Another 41 authors (25.6%) received but did not disclose payments from companies marketing 1 of the 10 high-revenue medications in CPGs.

Overall, 91 authors (56.9%) were found to have financial conflicts of interest that involved 1 of the 10 high-revenue medications, and “the median value of undeclared payments from companies marketing 1 of the 10 high-revenue medications recommended in the CPGs was $522 (interquartile range, $0-$40,444) from two companies,” the researchers said.

The study findings were limited by several factors including “potential inaccuracies in CMS-OP reporting, which are rarely corrected, and lack of generalizability outside the United States” and by the limited time frame for data collection, which may have led to underestimation of conflicts for the guidelines, the researchers noted. In addition, “we did not have access to guideline voting records and thus did not know when conflicted panel members recommended against a medication or recused themselves from voting,” they said.

Mr. Khan disclosed research funding from AbbVie and Ferring Pharmaceuticals.

In a second research letter, half of the authors of gastroenterology guidelines received payments from industry, wrote Tyler Combs, BS, of Oklahoma State University, Tulsa, and his colleagues. Previous studies have reviewed the financial conflicts of interest in specialties including oncology, dermatology, and otolaryngology, but financial conflicts of interest among authors of gastroenterology guidelines have not been examined, the researchers said.

Mr. Combs and his colleagues identified 15 CPGs published by the American College of Gastroenterology between 2014 and 2016. They identified 83 authors, with an average of 4 authors for each guideline. Overall, 53% of the authors received industry payments, according to based on data from the 2014 to 2016 Centers for Medicare & Medicaid Services Open Payments database (OPD).

However, OPD information was not always consistent with information published with the guidelines, the researchers noted. They found that 16 (19%) of the 83 authors both disclosed financial conflicts of interests in the CPGs and had received payments according to OPD or had disclosed no financial conflicts of interest and had received no payments according to OPD. In addition, 49 (34%) of 146 cumulative financial conflicts of interest disclosed in the CPGs and 148 relationships identified on OPD were both disclosed as financial conflicts of interest and evidenced by OPD payment records. In this review, the median total payment was $1,000, with an interquartile range from $0 to $39,938.

The study findings were limited by a relatively short 12-month time frame, the researchers noted. However, “our finding that FCOI [financial conflicts of interest] disclosure only corroborates with OPD payment records between 19% and 34% of the time also suggests that guidance from the ACG [American College of Gastroenterology] may be needed to improve FCOI disclosure efforts in future iterations of gastroenterology CPGs,” they said.

The researchers had no financial conflicts to disclose.

SOURCE: Combs T et al. JAMA Intern Med. 2018 Oct 29. doi: 10.1001/jamainternmed.2018.4730; Khan R et al. JAMA Intern Med. 2018 Oct 29. doi: 10.1001/jamainternmed.2018.5106.

Statement from the AGA on the integrity of AGA’s clinical guideline process

The American Gastroenterological Association (AGA) understands how important it is for AGA members, patients, and the public at large to have access to the most trustworthy, actionable, and evidence-based guidelines in order to achieve the highest possible quality of patient care. In developing guidelines, our goal is to maintain a high level of methodologic rigor through the utilization of an evidence-based approach that is very transparent.

However, not all clinical guidelines are created with equal rigor. Clinicians should examine guidelines closely and consider whether or not they follow the Academy of Medicine’s (formerly the Institute of Medicine’s) standards for trustworthy clinical guidelines. The guideline should be based on a systematic review of the evidence, focus on transparency, have a rigorous conflict of interest system in place, include the involvement of an unconflicted Grading of Recommendations Assessment, Development and Evaluation (GRADE) system-trained methodologist, ideally as a cochair, and the recommendations should be concise and actionable. AGA follows a transparent, independent guideline development process that is not subject to company influence or bias and fully complies with the Academy of Medicine’s criteria for trustworthy guidelines.

AGA has been proactive in developing policies to minimize bias in our guidelines. AGA requires that the Chair of the Guideline Development Group, and a majority of Guideline (and other clinical practice documents) Development Group members are free of conflicts of interest relevant to the subject matter of the guideline. At the time of invitation, we ask our panel members to disclose any and all potential conflicts. Furthermore, all author disclosures are verified by means of accessing publicly available sources (such as the Centers for Medicare and Medicaid Services’ Open Payment database) prior to their involvement on the panel.

AGA strives to be transparent in reporting commercial bias and independent of any industry influence in the development of our clinical practice documents. Our goal is to produce the most trustworthy, actionable, and evidence-based guidelines possible for our members.

Learn more about AGA’s clinical guideline process (

Yngve T. Falck-Ytter, MD, AGAF, is chair, and Shahnaz Sultan, MD, MHSc, AGAF, is chair-elect, AGA Institute Clinical Guidelines Committee.

Next Article: