ORIGINAL CONTRIBUTION

Relationships Between Authors

of Clinical Practice Guidelines
and the Pharmaceutical Industry
Niteesh K. Choudhry, MD, FRCPC Context Increasing contact has been reported between physicians and the pharma-
Henry Thomas Stelfox, MD, FRCPC ceutical industry, although no data exist in the literature regarding potential financial
conflicts of interest for authors of clinical practice guidelines (CPGs). These interac-
Allan S. Detsky, MD, PhD, FRCPC
tions may be particularly relevant since CPGs are designed to influence the practice of

I
NTERACTIONS BETWEEN PHYSI - a large number of physicians.
cians and the pharmaceutical in- Objective To quantify the extent and nature of interactions between authors of CPGs
dustry have received increasing and the pharmaceutical industry.
amounts of attention over the last Design, Setting, and Participants Cross-sectional survey of 192 authors of 44
several years. Several authors have de- CPGs endorsed by North American and European societies on common adult diseases
scribed significant contact between the published between 1991 and July 1999. One hundred authors (52%) provided us-
pharmaceutical industry and aca- able responses representing 37 of 44 different CPGs that we identified.
demic researchers, 1 faculty physi- Main Outcome Measures Nature and extent of interactions of authors with drug
cians,2 community physicians,3 resi- manufacturers; disclosure of relationships in published guidelines; prior discussion among
dents,4 and medical students.5 More authors regarding relationships; beliefs regarding whether authors’ own relationships
importantly, these types of interac- or those of their colleagues influenced treatment recommendations in guidelines.
tions have been shown to influence pre- Results Eighty-seven percent of authors had some form of interaction with the phar-
scribing patterns,6 stimulate requests for maceutical industry. Fifty-eight percent had received financial support to perform re-
addition of drugs to hospital formular- search and 38% had served as employees or consultants for a pharmaceutical company.
ies,2 result in favorable publications7 On average, CPG authors interacted with 10.5 different companies. Overall, an average
of 81% (95% confidence interval, 70%-92%) of authors per CPG had interactions. Simi-
and research articles,8,9 and be related
larly, all of the CPGs for 7 of the 10 diseases included in our study had at least 1 author
to the lack of publication of unfavor- who had some interaction. Fifty-nine percent had relationships with companies whose
able articles.10 drugs were considered in the guideline they authored, and of these authors, 96% had
Clinical practice guidelines (CPGs) relationships that predated the guideline creation process. Fifty-five percent of respon-
are intended to present a synthesis of dents indicated that the guideline process with which they were involved had no formal
current evidence and recommenda- process for declaring these relationships. In published versions of the CPGs, specific dec-
tions preformed by expert clinicians and larations regarding the personal financial interactions of individual authors with the phar-
may affect the practice of large num- maceutical industry were made in only 2 cases. Seven percent thought that their own
bers of physicians. As a result, any in- relationships with the pharmaceutical industry influenced the recommendations and 19%
thought that their coauthors’ recommendations were influenced by their relationships.
fluence that the authors of CPGs ex-
perience from their interactions with Conclusions Although the response rate for this survey was low, there appears to be
pharmaceutical companies may be considerable interaction between CPG authors and the pharmaceutical industry. Our study
highlights the need for appropriate disclosure of financial conflicts of interest for authors
transmitted many times over to the
of CPGs and a formal process for discussing these conflicts prior to CPG development.
readers of CPGs. Consequently, if in-
JAMA. 2002;287:612-617 www.jama.com
dividual authors have relationships that
pose a potential conflict of interest, Author Affiliations: Departments of Medicine (Drs attended numerous Department of Medicine educa-
Choudhry, Stelfox, and Detsky) and Health Policy, tional rounds sponsored by the pharmaceutical indus-
readers of these CPGs may wish to Management and Evaluation (Dr Detsky), University try. Dr Detsky has received honoraria for speeches,
know about them to evaluate the merit of Toronto, and Department of Medicine, University consulting fees, and research grants from pharma-
Health Network and Mount Sinai Hospital (Drs ceutical manufacturers.
of those guidelines. Choudhry and Detsky), Toronto, Ontario; and the PhD Corresponding Author and Reprints: Allan S. Detsky,
To date, no published data exists re- Program in Health Care Policy, Harvard University, Bos- MD, PhD, FRCPC, Mount Sinai Hospital, Room 427,
ton, Mass (Drs Choudhry and Stelfox). 600 University Ave, Toronto, Ontario, Canada M5G
garding the extent to which the au- Financial Disclosures: Drs Choudhry and Stelfox have 1X5.

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 CLINICAL PRACTICE GUIDELINE AUTHORS AND PHARMACEUTICAL FIRMS

thors of CPGs interact with the phar- medicine services at our hospitals (ie, nancial interactions, including sup-
maceutical industry. This study seeks pneumonia, congestive heart failure, port for attendance at a symposium (eg,
to provide empirical evidence concern- coronary artery disease, chronic ob- funds for travel expenses), hono-
ing this issue to improve the process of structive pulmonary disease/asthma, rarium for speaking at a symposium,
CPG development in the future. and gastrointestinal bleeding). Fi- support for organization of an educa-
nally, we excluded diseases for which tional program, support for research,
METHODS CPGs did not exist. employment by or consultancy for the
Study Questions Pertinent CPGs were identified company, and equity in the company.
We attempted to compare the amount through the MEDLINE database, ref- The addresses of the corresponding
of financial interaction that authors of erence lists from published articles, and authors were obtained from the ar-
CPGs had with the pharmaceutical in- interviews with expert clinicians. We ticles, a citation index, and other ar-
dustry with the amount of interaction restricted our sample to CPGs that had ticles published by the same authors.
that was disclosed in the published been endorsed by a recognized North All authors were mailed the survey
guidelines that they had authored. We American or European society and had questionnaire with a cover letter ex-
also sought to assess the nature of these identifiable authors. We selected the plaining the purpose of the study. Re-
interactions and the authors’ percep- principal authors and, when indi- minder letters and questionnaires were
tions of the impact of interactions on cated, those who participated in draft- mailed to authors who did not re-
recommendations made by the guide- ing the guideline to be surveyed. spond to the first mailing within 12
line committee. We asked 4 specific The CPGs were reviewed and spe- weeks.
questions: (1) How much interaction cific declarations of potential finan- Second, respondents to the first sur-
do authors of clinical practice guide- cial conflict of interest were recorded. vey were resurveyed to characterize the
lines have with drug manufacturers and Declarations regarding the guideline nature of relationships and the disclo-
what is the nature of this interaction (ie, creation process and individual au- sure process. Authors were asked
do the relationships predate or post- thors were classified as no specific dec- whether their relationships specifi-
date the guideline writing process)? (2) laration made, declaration that no fi- cally involved companies whose drugs
What physician-pharmaceutical inter- nancial interaction existed, declaration were considered or included in the
actions are disclosed in the published that funding was received from a phar- guideline they authored, whether these
guidelines? (3) Prior to beginning the maceutical company, or declaration that relationships predated or postdated the
guideline creation process, was there funding was received from a nonindus- guideline process, whether they believed
any discussion among the guideline au- try source (eg, government agency, pro- their own relationships or those of their
thors regarding relationships with the fessional society/association). State- coparticipants influenced the recom-
pharmaceutical industry? and (4) Do ments indicating that the guidelines had mendations that were put forward,
guideline authors believe that their re- been prepared or approved by the en- whether there was discussion among the
lationships or those of their col- dorsing professional association with- participants prior to beginning the
leagues influence the treatment recom- out explicitly indicating from where guideline process regarding any rela-
mendations that were put forth in the funds had been received were coded as tionships and whether this process was
guidelines? having no specific declaration made. formalized, and how potential con-
flicts of interest were managed.
Selection and Review of Articles Survey Instrument
Authors were identified by reviewing and Data Collection Data Analysis
CPGs endorsed by North American and Two surveys were used in this study. Descriptive statistics were used to ex-
European societies on common adult First, a survey instrument based on that amine the results of both quantitative
diseases published between 1991 and of Chren and Landefeld2 and used by surveys. The results are reported as pro-
July 1999. The list of medical condi- Stelfox et al7 was developed to exam- portions and means with 95% confi-
tions to be included was created using ine authors’ financial interactions with dence intervals (CIs). The rate of re-
the 20 most commonly prescribed pharmaceutical companies. Manufac- sponse to the surveys was similarly
drugs that are paid for by the Ontario turers of drugs used to manage diabe- analyzed. Analyses were conducted
Drug Benefit Program. Drugs that are tes, chronic obstructive pulmonary dis- using STATA, version 7 (STATA Corp,
used symptomatically to treat many po- ease/asthma, hypertension, pneumonia, College Station, Tex).
tentially nonspecific conditions were coronary artery disease, congestive
excluded (eg, acetaminophen with co- heart failure, hyperlipidemia, osteoar- RESULTS
deine, lorazepam). If not already in- thritis, depression, and peptic ulcer dis- One hundred twenty CPGs were iden-
cluded, we added conditions that ac- ease were identified. For each of these tified by our search strategy, of which
counted for the 5 most common manufacturers, authors were asked 35 were excluded because a major
admission diagnoses to the internal whether they had any of 6 types of fi- North American or European society
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 CLINICAL PRACTICE GUIDELINE AUTHORS AND PHARMACEUTICAL FIRMS

served as employees or consultants for

Table 1. Type of Relationship With Pharmaceutical Manufacturers and No. of Companies
With Which Authors Had Relationships pharmaceutical companies did so for a
% of Authors Mean No. of Companies mean of 5.7 companies.
(95% Confidence Interval) (Range) TABLE 2 shows response rates and in-
Relationship (n = 100) (n = 87) teractions categorized by the diseases
Any relationship 87 (80-94) 10.5 (1-37) to which the CPGs included in our
Travel funding/honorarium 53 (43-63) 5.4 (1-16)
sample pertained. All of the CPGs for
Speaker honorarium 64 (54-74) 7.3 (1-20)
7 of the 10 disease states had at least 1
Educational program support 51 (41-61) 4.7 (1-36)
author who had some level of interac-
Research support 58 (48-68) 6.7 (1-26)
tion. Similarly, the average percentage
Employee/consultant 38 (28-48) 5.7 (1-21)
of authors per CPG who had interac-
Equity 6 (1-11) 1.8 (1-4)
tions was 100% for 6 of the 10 disease
states. Overall, an average of 81% (95%
did not endorse the CPG and 38 were percent of authors currently residing in CI, 70%-92%) of authors per guide-
excluded because they were editorials the United States did not respond line had interactions with the pharma-
about CPGs or comparisons of differ- whereas 29% of authors living in Canada ceutical industry.
ent CPGs. Therefore, 47 CPGs were ini- did not respond (P=.001). Fifty-nine percent of authors had re-
tially included.11-57 Subsequently, 1 CPG Twenty-eight (26%) of 107 authors lationships with companies whose
was excluded because the authors could responded with a letter attached to their products were specifically considered
not be identified55 and 2 CPGs were ex- survey. These letters could be inter- or included in the guideline they au-
cluded after the authors had been sur- preted as being supportive (21%), neu- thored (TABLE 3). Of these, 96% and
veyed since these were evaluations of tral (57%), or critical (21%) of our 53% had relationships that predated and
CPGs rather than actual CPGs. 56,57 study. postdated the guideline process, re-
Therefore, 44 CPGs with 192 authors Of the 100 authors who completed spectively.
were included in the study. the first survey, 1 had died and 1 had Only 7% believed that their own re-
Current addresses of 13 authors could moved and was unreachable, leaving 98 lationships influenced the treatment
not be located and 3 authors had died, potentially contactable authors for the recommendations (Table 3). Nine-
resulting in a total of 176 potentially con- second survey. Of these, 82 (83%) re- teen percent believed that their coau-
tactable authors. Of these, 107 authors sponded. One of these authors re- thors’ recommendations were influ-
(61%) responded representing 37 of the fused to participate and 1 could not re- enced by relationships with the
44 CPGs included in our study. There- call the nature of the disclosure process pharmaceutical industry.
fore, 7 guidelines were not represented and, therefore, left the survey blank.
in our final sample.11,24,32,39,40,42,54 De- Consequently, the response rate for the Guideline Conflict of
spite this, all of the disease states that second survey was 82%. Interest Declarations
were initially included in our study pro- Forty-five percent of authors reported
tocol were still represented by at least 2 CPG Author-Pharmaceutical that prior to beginning the guideline
CPGs, with the exception of depres- Manufacturer Interactions process, discussion occurred among the
sion, for which there was only 1 CPG The nature of the authors’ relation- guideline authors regarding their rela-
included in the sample and for which we ships with pharmaceutical companies tionships with the pharmaceutical in-
received a response. Seven respon- is shown in TABLE 1. Eighty-seven per- dustry. Of these, 61% reported that
dents refused to participate, all of whom cent of the responding authors had there was a formal process for this dis-
were involved with different guide- some form of interaction with the phar- cussion and 75% indicated that all
lines. Three of these 7 authors were from maceutical industry. Fifty-eight per- members of the guideline committee
Europe, 2 were from the United States, cent had received financial support to participated.
and 2 were from Canada. This left 100 perform research and 38% had served In the published versions of the 44
completed surveys, which form the ba- as employees or consultants for a phar- CPGs included in the study, authors de-
sis of our results. Overall, the response maceutical company. clared that they had personal financial
rate was 57% of potentially contactable The mean number of companies with interactions with the pharmaceutical in-
authors and 52% of all authors initially which authors who did have financial dustry in only 1 guideline51 (TABLE 4).
included in our sample. The distribu- relationships interacted is shown in Similarly, only 1 guideline declared that
tion of sex and disease to which the Table 1. On average, CPG authors in- the authors had no conflicts of inter-
guidelines pertained was similar for re- teracted with 10.5 different compa- est.15 In the majority of cases (42 of 44
spondents and nonrespondents; how- nies. Authors who received support for guidelines), no declarations were made
ever, the distribution of current coun- research received this funding from a with respect to the authors’ potential
try of residence was not. Sixty-three mean of 6.7 companies and those who conflicts of interest.
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 CLINICAL PRACTICE GUIDELINE AUTHORS AND PHARMACEUTICAL FIRMS

Table 2. Response Status and Relationship With Pharmaceutical Manufacturers by Disease

No. of Authors No. of Guidelines Average % of Mean No. of
No. of Guidelines With Responding/ in Which at Least No. of Authors Authors per Companies With
Guidelines at Least 1 Authors 1 Respondent Had With Any Guideline With Which Authors Had
Disease Included Respondent (%) Surveyed (%)* Any Interaction (%) Interaction (%) Any Interaction Relationships†
Asthma/chronic obstructive 6 5 (83.3) 6/11 (54.5) 3 (60) 4 (66.7) 60 8.5
pulmonary disease
Coronary artery disease 6 5 (83.3) 20/37 (54.1) 4 (80) 15 (75) 65 13.1
Heart failure 4 2 (50) 8/16 (50) 2 (100) 7 (87.5) 100 8.3
Depression 1 1 (100) 1/5 (20) 1 (100) 1 (100) 100 11.0
Diabetes 5 4 (80) 9/15 (60) 4 (100) 9 (100) 100 8.0
Peptic ulcer disease 3 3 (100) 3/5 (60) 3 (100) 3 (100) 100 11.7
Hypercholesterolemia 3 3 (100) 9/13 (69.2) 3 (100) 9 (100) 100 10.3
Hypertension 6 5 (83.3) 12/27 (44.4) 4 (80) 10 (83.3) 70 16.9
Osteoarthritis 2 2 (100) 3/87 (37.5) 2 (100) 3 (100) 100 4.0
Pneumonia 8 7 (87.5) 44/70 (62.9) 7 (100) 38 (86.4) 76 9.1
*The total number of authors responding equals 115 (not 100) and the total number of authors surveyed equals 207 (not 192) because several authors participated in more than
1 guideline.
†Among authors with relationships.

In 11 of the 44 CPGs, a declaration Table 3. Nature and Author Perceptions of Relationship With Pharmaceutical Manufacturers
was made that a pharmaceutical com- No. of Authors (%)
[95% Confidence Interval]
pany had sponsored the guideline cre-
Had relationship with companies whose drugs were 47/80 (59) [48-70]
ation and writing process.* Nonindus- considered in the guideline process
try organizations sponsored 9 CPGs.† Relationship predated guideline process 45/47 (96) [92-100]
Two of these guidelines were sup- Relationship postdated guideline process 25/47 (53) [39-67]
ported by both industry and govern- Believed that relationships influenced personal recommendations 5/68 (7) [1-9]*
mental sources.21,27 Believed that relationships influenced recommendations 13/67 (19) [8-30]†
of colleagues
COMMENT *Only 68 of the 80 respondents provided answers to these questions.
†Only 67 of the 80 respondents provided answers to these questions.
Although the results of this study must
be interpreted cautiously in light of the
Table 4. Declarations Contained Within Published Guidelines
relatively low response rate, our re-
No. of Guidelines No. of Guidelines
sults appear to indicate that most CPG Making Declarations Making Declarations
authors have interactions with phar- Regarding Authors’ Regarding Guideline
Financial Interactions Creation Process
maceutical companies and that a sig- Type of Declaration (n = 44) (n = 44)*
nificant proportion work as employees/ No declaration made 42 26
consultants for drug manufacturers. Declared that no sponsorship received 1 0
Moreover, a majority of our respon- Received nonpharmaceutical industry support 0 9
dents indicated that they had relation- Received pharmaceutical industry support 1 11
ships with companies whose products *Column values total more than 44 because 2 guidelines received funding from both industry and government.
were considered in the guideline that
they authored, and of these, almost all those guidelines authored by individu- over, almost 20% of the respondents be-
had relationships that predated the als without relationships. Unfortu- lieved that their colleagues’ relation-
guideline creation process. nately, most authors had relation- ships influenced the recommendations
The majority of responding authors ships and virtually all guidelines that they put forward.
believed that their relationships had no permitted use of a wide range of drugs We wonder whether academicians
influence on the recommendations that as first-line agents “if clinically indi- and physicians underestimate the im-
they put forward. Ideally, we would cated,” thereby making any differen- pact of relationships on their actions be-
have liked to have objectively as- tiation impossible. cause the nature of their professions is
sessed whether this was true by evalu- Nevertheless, the authors’ percep- the pursuit of objective unbiased in-
ating whether guidelines authored by tions of the influence of their relation- formation. Unfortunately, bias may oc-
individuals with relationships recom- ships are in stark contrast with the large cur both consciously and subcon-
mended use of different therapies than body of literature that indicates that sciously, and therefore, its influence
*References 14, 16, 21-24, 27, 32, 43, 46, 47.
these types of relationships are indeed may go unrecognized. In fact, pharma-
†References 15, 17, 18, 21, 27, 30, 40, 41, 51. significant in other domains.2-10 More- ceutical marketing or “detailing” may
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 CLINICAL PRACTICE GUIDELINE AUTHORS AND PHARMACEUTICAL FIRMS

rely on the impact of these more subtle ences, especially for CPGs that were au- aged. Participants should be sensitive
forms of influence.58 Concern about bias thored more than 5 years ago. In con- to the possibility that the influence
in interpretation of outcomes in ran- trast, the interviewees thought that it of these relationships may subcon-
domized trials led to the practice of may be neither possible nor desirable sciously affect their judgments.
blinding subjects, their caregivers, and to exclude authors who are involved Second, authors who have relation-
outcome assessors to the knowledge of with industry since the “experts” who ships with the pharmaceutical industry
which treatment the subject received. write guidelines are the same individu- need not necessarily be excluded from
Is the situation regarding CPG author- als who are most likely to receive fi- participating in the guideline creation
ship not analogous? nancial support to conduct research. process. However, authors with signifi-
Unlike relationships that individual Moreover, our interviewees suggested cant conflicts of interest should likely be
authors or physicians have with the that an author’s objectivity might ac- excluded. What level of conflict is sig-
pharmaceutical industry, financial con- tually be maintained by having mul- nificant is clearly a contentious issue. Is
flicts of interest for authors of CPGs are tiple small relationships with different there a threshold below which authors
of particular importance since they may pharmaceutical companies as op- will not perceive subconscious influ-
not only influence the specific practice posed to large relationships with a few ences from their relationships with phar-
of these authors but also those of the companies. The authors also sug- maceutical companies? The only thresh-
physicians following the recommenda- gested that relationships with pharma- old that is not arbitrary is zero, implying
tions contained within the guidelines. ceutical industries are not the only type that all authors with any relationships
There are several possible explana- of potential conflicts of interest that ex- would be excluded. This standard, how-
tions for our low response rate. First, ist. Concerns regarding obtaining con- ever, is both impractical and likely too
physicians’ interactions with the phar- tinued funding from governmental strict. Thus, groups will have to decide
maceutical industry have received in- agencies (eg, by ensuring that one’s gov- on this issue for themselves. However,
creasing amounts of attention in the ernment-funded research is included in we do think that authors who hold eq-
medical literature1-10 and popular press. the studies cited by a CPG) or of indi- uity in a company whose products are
As a consequence, physicians may have vidual academic promotion (eg, by en- being considered in the guideline pro-
been reluctant to disclose their rela- suring that one’s own research is in- cess should be disqualified. This is con-
tionships. Second, the cover letter that cluded in the studies cited by a CPG) sistent with the current practices of most
we sent to our survey participants made may also influence the guideline pro- governmental granting agencies in North
no promise of anonymity. Rather, we cess and may serve as forms of “dual America and the editorial policies of most
indicated that participation in our sur- commitment.” major medical journals.
vey was voluntary. Although we have Third, there must be complete dis-
presented our results in aggregate and Recommendations closure to the readers of CPGs of indi-
never intended to identify individual Based on our results and the consider- vidual authors’ financial relationships
physicians, it is possible that some au- able debate that has taken place about with the pharmaceutical industry. Ide-
thors may have been concerned about the relationships between clinical ally, this should occur in the printed
being recognized and therefore pre- researchers and the pharmaceutical version of the guideline. However, if this
ferred to not respond. Therefore, based industry, we propose the following is not feasible given the large number
on these factors, it is possible that non- recommendations for the manage- of authors who may participate in a
respondents actually had a higher de- ment of potential financial conflicts of CPG and practical limitations on space,
gree of interaction with the pharma- interest for authors of clinical practice alternative forms of disclosure, such as
ceutical industry than respondents. guidelines. the journal’s Web site, could be used.
Consequently, our low response rate First, the process whereby authors
may have actually biased our results by disclose their potential conflicts of in- Conclusions
underestimating the already high de- terest must be made more formal. In In conclusion, there appears to be a high
gree of interaction that we observed. particular, authors must disclose rela- degree of interaction between authors
To put our results in perspective tionships with the pharmaceutical in- of clinical practice guidelines and the
without unduly biasing our respon- dustry before guideline meetings are pharmaceutical industry. These spe-
dents, we conducted semistructured in- held. A full discussion must occur cific interactions may influence the
terviews with 5 guideline authors af- among the participants before the start practice of a very large number of phy-
ter the second survey had been of the writing process about each per- sicians. We believe that our study high-
completed. These authors under- son’s relationships and how signifi- lights the need for appropriate disclo-
scored the lack of formal process for cant relationships (eg, those that pre- sure of financial conflicts of interest for
CPG authors to declare potential con- date the guideline process, involve large authors of CPGs and a formal process
flicts of interest and to sensitize each sums of money, or involve equity po- for discussing these conflicts prior to
other to subtle or subconscious influ- sitions in companies) will be man- CPG development.
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Author Contributions: Study concept and design: 18. Holbrook AM, Sabharwal M, Trepanier EF. Medi- 38. ACC/AHA Task Force. Guidelines for the evalu-
Choudhry, Stelfox, Detsky. cal Treatment Guidelines for the Treatment of Os- ation and management of heart failure. Circulation.
Acquisition of data: Choudhry, Detsky. teoarthritis, Rheumatoid Arthritis, and Acute Mus- 1995;92:2764-2784.
Analysis and interpretation of data: Stelfox, Choudhry. culoskeletal Injury. Toronto: Queen’s Printer for 39. Johnstone DE, Abdulla A, Arnold JM, et al. Di-
Drafting of the manuscript: Choudhry, Detsky. Ontario; 1999. agnosis and management of heart failure. Can J Car-
Critical revision of the manuscript for important in- 19. American Psychiatric Association. Practice guide- diol. 1994;10:613-631.
tellectual content: Choudhry, Stelfox, Detsky. line for major depressive disorder in adults. Am J Psy- 40. Agency for Health Care Policy and Research. Heart
Statistical expertise: Stelfox. chiatry. 1993;150:S1-S26. Failure: Evaluation and Care of Patients With Left-
Obtained funding: Detsky. 20. British Diabetic Association, Royal College of Phy- Ventricular Systolic Dysfunction. Rockville, Md: US
Administrative, technical, or material support: sicians, and Royal College of General Practitioners. Dept of Health and Human Services; June 1994.
Choudhry, Detsky. Guidelines for good practice in the diagnosis and treat- 41. Ontario Anti-infective Review Panel. Anti-
Study supervision: Detsky. ment of non-insulin-dependent diabetes mellitus. J R infective guidelines for community-acquired infec-
Disclaimer: This study received no financial support Coll Physicians Lond. 1993;27:259-266. tions. 2nd ed. Toronto: Queen’s Printer for Ontario;
from the pharmaceutical industry. 21. Expert Committee of the Canadian Diabetes Ad- 1997.
Acknowledgment: We thank the guideline authors, in visory Board. Clinical practice guidelines for treatment 42. British Thoracic Society. Guidelines for the man-
particular those who responded to 2 surveys and those of diabetes mellitus. CMAJ. 1992;147:697-712. agement of community-acquired pneumonia in adults
who participated in interviews, for their assistance and 22. Meltzer S, Leiter L, Daneman D, et al. 1998 Clini- admitted to hospital. Br J Hosp Med. March 1993:
honesty. We are also indebted to Darren Merker, Kevin cal practice guidelines for the management of diabe- 3-16.
Lumb, Kevin Schwartz, Heather Smith-St. Kitts, and Kim- tes in Canada. CMAJ. 1998;159:S1-S29. 43. American Thoracic Society. Hospital-acquired
berley Britnell for their invaluable assistance with data 23. European IDDM Policy Group 1993. Consensus pneumonia in adults: diagnosis, assessment of sever-
collection and survey administration. guidelines for the management of insulin-dependent ity, initial antimicrobial therapy, and preventative strat-
(type 1) diabetes. Diabet Med. 1993;10:990-1005. egies. Am J Respir Crit Care Med. 1996;153:1711-
24. AACE guidelines for the management of diabe- 1725.
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