Poor quality of Indian clinical practice guidelines : academic elitism, capacity gaps and poor governance key factors

Guideline development has changed internationally with greater stress on the use of rigorous, transparent and evidence-based methods. Guideline development in India has come under increased scrutiny with a growing interest in the use of evidence for guideline development. The National Health Policy 2017 lays stress on the use of evidence in clinical practice guidelines. Quality guidelines are also a prerequisite for Clinical Establishment Act to be implemented too.
Last week we published a study in the Journal of Evidence Based Medicine which explored the issue of guideline quality in India.  (Link)
In the study , we first searched for   all guidelines for four diseases with highest overall burden in India (ischemic heart disease, lower respiratory infections, chronic obstructive pulmonary diseases, tuberculosis) and appraised their quality using an internationally validated tool called AGREE II(WHO also uses it ensuring quality in the guidelines they make). This tool evaluates the guideline quality in six domains and overall domain.
In general we found was that overall Indian guidelines were rated very poorly in 4 of the 6 domains – stakeholder involvement , editorial independence(conflict of interest and funding management), methodological riguor of development, and applicability (pertains to the likely barriers and facilitators to implementation, strategies to improve uptake, and resource implications of applying the guideline) .
We then set out to interview people who developed this guidelines to understand why this was happening and found :
that the key reasons were ;
  • Guideline development was seen as an academic activity and hence restricted to elite academic institutions . The academic elitism meant doctors from non-elite institutions,other healthcare professionals were excluded and there was poor consideration of actual implementation issues
  • There was inadequate capacity on methods for guideline development and no governance structure in place for the purpose.
  • There were mixed views on involving patients (which is standard internationally since they are the ultimate stakeholders) but in general it was negative.
  • People did not understand what conflict of interest meant and declaring it was seen as a taboo

In terms of policy implications the study implies that a lot of concerted efforts are needed by issuing agencies and the government to ensure development of guidelines in transparent, evidence-based and a systematic manner with high quality in India.

Read the full study here .

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