Guideline development seems to have lost some of its grounding as a medical
science. At their best, guidelines should be a constructive response to assist practicing
physicians in applying the exponentially expanding body of medical knowledge.
In fact, guideline development seems to be evolving into a cottage industry with
multiple, frequently discordant guidance on the same subject. Evidence Based
Medicine does not always provide for conclusive opinions. With competing interests
of payers, practitioners, health policy makers, and third parties benefiting from
development of the guidelines as cost saving measures, guideline preparation has
been described as based on pre-possession, vagary, rationalization, or congeniality
of conclusion.
Beyond legitimate differences in opinions regarding the evidence that could yield
different guidelines there are potentials for conflicts of interest and various other
issues play a major role in guideline development. As is always the case, conflicts of
interest in guideline preparation must be evaluated and considered.
Following the development of American Pain Society (APS) guidelines there has been
an uproar in interventional pain management communities on various issues related
to not only the evidence synthesis, but conflicts of interest. A recent manuscript
published by Chou et al, in addition to previous publications appear to have limited
clinician involvement in the development of APS guidelines, demonstrates some of
these challenges clearly.
This manuscript illustrates the deficiencies of Chou et al’s criticisms, and demonstrates
their significant conflicts of interest, and use a lack of appropriate evaluations in
interventional pain management as a straw man to support their argument. Further,
this review will attempt to demonstrate that excessive focus on this straw man has
inhibited critique of what we believe to be flaws in the approach.
Key words: Guidelines, interventional pain management, professionalism,
discourse, disclosure, conflicts of interest, evidence-based medicine, comparative
effectiveness research, Patient-Centered Outcomes Research Institute
Forefront of medical science and medical care.Procedure and significance of evidence-based medicine.
