April 02, 2019
6 min read

Clinical guidelines from North American specialty societies often biased, have conflicts of interest

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Ismail Jatoi

Clinical practice guidelines issued by specialty societies in North America often call for greater use of services associated to their own specialties, and at times contradict European guidelines and those from independent North American groups, according to a commentary published in the Canadian Medical Association Journal.

In addition, the authors wrote that specialty organizations from nations with fee-for-service health care systems, such as the United States, often recommend more intensive diagnostic and treatment guidelines. This constitutes a conflict of interest that, along with specialty bias, is rarely disclosed in the guidelines, they wrote.

“Regardless of country of origin, physicians often recommend procedures and treatments that they are trained to provide, a phenomenon known as ‘specialty bias,’” Ismail Jatoi, MD, PhD, of the University of Texas Health, and Sunita Sah, MD, PhD, of Cornell University, wrote. “This may explain why medical specialty societies frequently issue guidelines calling for greater use of health care services linked to their specialties, thereby exacerbating overdiagnosis, overtreatment and increasing health care costs.”

Clinical practice guidelines issued by specialty societies in North America often call for greater use of services associated to their own specialties, according to a commentary.
Source: Adobe

In their commentary, the authors included four examples of such biases and conflicts. In one example, the National Comprehensive Cancer Network, which is based in the United States, included 25 urologists in its 32-member panel to draft clinical guidelines for prostate cancer. According to Jatoi and Sah, the guidelines recommend prostate-specific antigen screening for healthy men aged 45 years and older.

This is at odds with the guidelines issued by the Canadian Task Force on Preventative Health Care and the European Society of Medical Oncology, both of which recommend against prostate-specific antigen screening for men of all ages. The Canadian Task Force on Preventative Health Care included zero urologists on its nine-member panel, while the European Society of Medical Oncology had one urologist out of four members.

“Evidence-based clinical practice guidelines can improve health care delivery,” Jatoi and Sah wrote. “Yet specialty bias and fee-for-service conflicts of interest threaten their validity and may lead to unnecessary overuse of health care services. More is not necessarily better in medicine; if anything, patient outcomes may be worse the more ‘care’ they receive. Every medical test, procedure and treatment adds risk against potential benefit, and some may lead to more harm than good.”

According to the authors, organizations that issue clinical guidelines should disclose specialty biases and fee-for-service conflicts of interest as “an important first step.”

“Clinical practice guideline panels should be multidisciplinary in composition, independent of the governing bodies of medical specialty societies, and strive to reduce fee-for-service conflicts of interest, Jatoi told Healio Rheumatology.

Specialty societies should also acknowledge “that they serve the interests of their memberships, which are not always aligned with the public’s interests,” Jatoi and Sah added.

“Guideline panels should ideally contain individuals with expertise in epidemiology, biostatistics and clinical trial methodology, along the lines of those assembled by the Canadian task force, United States Preventive Services Task Force and [the UK’s National Institute for Health and Care Excellence],” Jatoi and Sah wrote. “Specialty societies should do the same lest guidelines from independent bodies become the only ones deemed to meet adequate standards.” – by Jason Laday

Disclosure: Jatoi and Sah report no relevant financial disclosures.