For twenty years, the Agency for Healthcare Research and Quality maintained a digital archive of medical guidelines as a resource for clinicians, called the National Guidelines Clearinghouse (NGC). On July 16th, to the chagrin and frustration of doctors and patient advocates, the site shut down as a result of budget cuts at AHRQ.
Clinicians use guidelines regularly to get treatment recommendations from the latest research, and guidelines are being updated all the time. There are hundreds of guidelines published from a variety of different institutions around the world; having a central, searchable repository for guidelines like the NGC made it much easier for clinicians to get the information they need quickly.
This might not seem like a big deal – can’t doctors just google the guidelines they need? But convenient access to guidelines is just a small part of what made the NGC valuable. As Dr. Valerie King, professor at the Center for Evidence-based Policy at Oregon Health & Science University pointed out in The Daily Beast, much of what we called guidelines weren’t actually supported by evidence, they were just expert’s opinions, or “BOGSAT guidelines: ‘bunch of guys sitting around a table’ guidelines.” The NGS sorted through the tangle of low-quality and “BOGSAT” guidelines to find and publish only those with a high quality of evidence.
While BOGSAT guidelines are less prevalent now, that doesn’t mean all guidelines have the same levels of quality. Conflicts of interest are widespread amongst individuals and groups writing or developing practice guidelines. According to a 2011 systematic review, 56-87% of guidelines have authors with a financial connection to industry (although many of the guidelines studied did not include any disclosures of coi). Another study looked at conflicts of interest among guideline panel members; out of 14 guidelines panels with disclosures, the 75% of members had industry ties, on average. Professional societies that create guidelines are often funded by industry, either directly (having an industry sponsor of the guidelines) or indirectly (using money from their general revenue, some of which may come from industry).
The NGS did not weed out all guidelines with author connections to industry, which was a major criticism of the database. However, as Roy Poses writes in Health Care Renewal, AHRQ was committed to changing that, announcing in 2017 that they would be more strict in their evaluation of guidelines that go in the NGS with regards to conflicts of interest. However, they were shut down before this policy was implemented.
So what happens to the guidelines now? A few organizations have stepped up to host the archives of the guideline summaries (check out Guideline Central and CareNet Systems). But will these organizations have the bandwidth and expertise to also screen the guidelines for quality and conflicts of interest? Shutting down the NGC is the government taking an ill-advised step back from evidence-based medicine.