Paradox, process and perception: the role of organizations in clinical practice guidelines development

The role of organizations in the development of clinical practice guidelines (CPGs) has received virtually no analytic attention. In a strictly rational and disinterested world, CPGs would be assessed on the basis of the supporting evidence and applicability to practice. However, factors that have more to do with medical sociology play a key role in CPG acceptance and, in some cases, development. The entire concept of CPGs entails troubling paradoxes, many of which turn on the distinction between scientific evidence and the sociologic determinants of validation and implementation. At the root of the question of organizational roles is the issue of values: Whose values should be at the table? What values are legitimate? From what perspectives should the utility of a procedure or technology be addressed? The Canadian health care system is a largely public creature, and CPG development is part of the public policy process. In this context, decisions about organizational roles must be sensitive to conflict of interest and a diversity of values. A provisional model for participation in CPG processes would minimize the role of organizations per se, although individual participants would no doubt reflect the legitimate interests of their affiliations without representing them formally.