To the Editor: In their systematic review of clinicians' attitudes to clinical practice guidelines, Farquhar et al1 found that, although healthcare providers reported high satisfaction with guidelines, a significant number also expressed concerns about their practicality, their role in cost-cutting and their potential for increasing litigation. The review, however, did not address other potentially significant concerns of clinicians regarding the perceived validity of guidelines and the influence of external agencies (such as the pharmaceutical industry) on treatment recommendations.

In April 2002, I conducted a survey of 155 full-time nephrologists and renal medicine trainees practising in Australia and New Zealand about their attitudes to the Caring for Australians with Renal Insufficiency (CARI) clinical practice guidelines (www.kidney.org.au/cari). The response rate was high (90.3%), with the majority (89%) of doctors agreeing or strongly agreeing that CARI provided a useful evidence summary. However, only 39% indicated that their practice had been significantly influenced by these guidelines, and just 14% felt that patient outcomes were improved as a result of CARI. While a minority expressed concern about the applicability of guidelines to individual patients (16%) and the potential for augmenting litigation (44%), the most significant worry was that 49% did not agree that the treatment recommendations matched the available evidence. Of those who felt that the recommendations were not justified, most believed that erroneous conclusions had been drawn from the evidence and that working parties had been affected by external influences, principally the pharmaceutical industry (74%). This view was significantly more common among nephrologists who were guideline authors (odds ratio, 3.6; 95% CI, 1.5–8.5; P < 0.01).

Choudhry et al2 similarly reported that guideline authors frequently felt that their coauthors' recommendations were influenced by financial relationships with the pharmaceutical industry, despite the fact that only 7% believed that their own recommendations had been influenced by such factors, and that conflicts of interest were disclosed in only a minority (< 5%) of instances. In fact, 47 (59%) of the 80 guideline authors surveyed had financial relationships with companies whose drugs were considered in the guideline they authored.

Other studies have further demonstrated that most clinical practice guidelines published in the peer-reviewed literature in the past decade did not adhere well to established methodological standards of identifying, evaluating and synthesising scientific evidence.3,4 Any review or survey of clinicians' attitudes to clinical practice guidelines should therefore include an assessment of their opinion as to the quality of those guidelines and the extent to which outside agencies (such as drug companies) may have influenced them.