We read with interest the recent analysis of the American Association for the Study of Liver Diseases (AASLD) Clinical Practice Guidelines (CPGs). These guidelines are an important source of information and guidance for clinicians caring for patients with increasingly complex medical conditions. The quality of CPGs and the evidence supporting the recommendations has been challenged in many specialties.[2-4] We recently published a comparison of CPGs issued by the AASLD, the European Association for the Study of the Liver (EASL), and the Asian Pacific Association for Study of the Liver (APASL) and drew similar conclusions to Koh et al. with regard to evidence quality. A recognition that there is a need to improve the evidence base in areas where this is lacking is a consistent message in both studies.
There are several areas in these CPGs, however, where improvements are urgently required. Foremost among these is the issue of editorial independence. It was highlighted by Koh et al. that in this domain of the AGREE tool performance had improved significantly where CPGs had been revised, although scores remained relatively low. A review of current guidelines listed by the AASLD (www.aasld.org/practiceguidelines accessed 1st July 2013) indicates that a significant minority of authors (18/66, 27%) declared a conflict of interest. In one case all the authors of a CPG declared relevant conflicts of interest. This is a critical area that has been highlighted by the Institute of Medicine (IOM) and is a determinant of the trustworthiness of CPGs. Indeed, in a recent analysis of CPGs for treatment options in type 2 diabetes mellitus there was a correlation between the rigor of guideline development and editorial independence. Those guidelines judged to be of greater rigor also contained more recommendations consistent with evidence-based conclusions, further highlighting the importance of editorial independence. The second most pressing concern is frequency of revision. We reported that the median time to formal guideline revision was 5 years. It has been suggested that an interval of 3 years is more appropriate. Using this as a benchmark, as many as 9 of 17 current AASLD guidelines could be considered in urgent need of updating.
Koh et al. highlight that there is room for improvement in CPG development. We suggest that, in line with leading guideline development groups (for example, the UK National Institute for Clinical Excellence [NICE]), the routine involvement of information scientists, nonspecialists, and patient groups will improve the overall quality of CPGs. Furthermore, compliance with the standards issued by the IOM with regard to conflicts of interest through publication of all potential conflicts, and limiting the number of participants with potential conflicts, will improve trustworthiness of these important documents. Developing and writing CPGs is a substantial undertaking and we hope that these studies assessing both the quality of evidence in CPGs in liver disease and the quality of those CPGs will act as a stimulus to further improvements that will positively impact patient care.
Ian A. Rowe, MRCP, Ph.D.1,2
Richard Parker, MRCP1,2
Matthew J. Armstrong, MRCP1,2
Andrew L. King, MRCP1,2
Diarmaid D. Houlihan, MRCPI1,2
David J. Mutimer, FRCP, M.D.1,2
1NIHR Birmingham Liver Biomedical Research Unit University of Birmingham Birmingham, UK
2Liver and Hepatobiliary Unit Queen Elizabeth Hospital Birmingham Birmingham, UK