Drivers of the opioid crisis: An appraisal of financial conflicts of interest in clinical practice guideline panels at the peak of opioid prescribing


Autoři: Sheryl Spithoff aff001;  Pamela Leece aff002;  Frank Sullivan aff002;  Nav Persaud aff002;  Peter Belesiotis aff007;  Liane Steiner aff008
Působiště autorů: Department of Family and Community Medicine, Women’s College Hospital, Toronto, Canada aff001;  Department of Family and Community Medicine, University of Toronto, Toronto, Canada aff002;  Dalla Lana School of Public Health, University of Toronto, Toronto, Canada aff003;  Public Health Ontario, Toronto, Canada aff004;  Medical School University of St Andrews, St Andrews, Scotland, United Kingdom aff005;  Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Canada aff006;  Faculty of Health Sciences, McMaster University, Hamilton, Canada aff007;  St. Michael’s Hospital Centre for Urban Health Solutions, Toronto, Canada aff008
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article
doi: 10.1371/journal.pone.0227045

Souhrn

Background

Starting in the late 1990s, the pharmaceutical industry sought to increase prescribing of opioids for chronic non-cancer pain. Influencing the content of clinical practice guidelines may have been one strategy industry employed. In this study we assessed potential risk of bias from financial conflicts of interest with the pharmaceutical industry in guidelines for opioid prescribing for chronic non-cancer pain published between 2007 and 2013, the peak of opioid prescribing.

Methods

We used the Guideline Panel Review (GPR) to appraise the guidelines included in the 2014 systematic review and critical appraisal by Nuckols et al. These were English language opioid prescribing guidelines for adults with chronic non-cancer pain published between July 2007 and July 2013, the peak of opioid prescribing. The GPR assigns red flags to items known to introduce potential bias from financial conflicts of interest. We operationalized the GPR by creating specific definitions for each red flag. Two reviewers independently evaluated each guideline. Disagreements were resolved with discussion. We also compared our score to the critical appraisal scores for overall quality from the study by Nuckols et al.

Results

We appraised 13 guidelines, which received 43 red flags in total. Guidelines had 3.3 red flags on average (out of a possible seven) with range from one to six. Four guidelines had missing information, so red flags may be higher than reported. The guidelines with the highest and second highest scores for overall quality in the 2014 critical appraisal by Nuckols et al. had five and three red flags, respectively.

Conclusion

Our findings reveal that the guidelines for opioid prescribing chronic non-cancer pain from 2007 to 2013 were at risk of bias because of pervasive conflicts of interest with the pharmaceutical industry and a paucity of mechanisms to address bias. Even highly-rated guidelines examined in a 2014 systematic review and critical appraisal had many red flags.

Klíčová slova:

Drug discovery – Finance – Industrial organization – Opioids – Pain management – Physicians – Systematic reviews – Treatment guidelines


Zdroje

1. Hadland SE, Rivera-Aguirre A, Marshall BDL, Cerdá M. Association of Pharmaceutical Industry Marketing of Opioid Products With Mortality From Opioid-Related Overdoses. JAMA Netw Open. 2019;2: e186007–e186007. doi: 10.1001/jamanetworkopen.2018.6007 30657529

2. Fischer B, Keates A, Bühringer G, Reimer J, Rehm J. Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world? Addict Abingdon Engl. 2014;109: 177–181. doi: 10.1111/add.12224 23692335

3. Van Zee A. The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy. Am J Public Health. 2009;99: 221–227. doi: 10.2105/AJPH.2007.131714 18799767

4. Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343: d5142. doi: 10.1136/bmj.d5142 21862533

5. Okie S. A Flood of Opioids, a Rising Tide of Deaths. N Engl J Med. 2010;363: 1981–1985. doi: 10.1056/NEJMp1011512 21083382

6. Dhalla IA, Mamdani MM, Sivilotti MLA, Kopp A, Qureshi O, Juurlink DN. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ Can Med Assoc J. 2009;181: 891–896. doi: 10.1503/cmaj.090784 19969578

7. Kolodny A. The opioid epidemic in 6 charts. In: The Conversation [Internet]. [cited 26 Mar 2019]. Available: http://theconversation.com/the-opioid-epidemic-in-6-charts-81601

8. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical Practice Guidelines We Can Trust. Graham R, Mancher M, Miller Wolman D, Greenfield S, Steinberg E, editors. Washington (DC): National Academies Press (US); 2011. Available: http://www.ncbi.nlm.nih.gov/books/NBK209539/

9. Qaseem A. Guidelines International Network: Toward International Standards for Clinical Practice Guidelines. Ann Intern Med. 2012;156: 525. doi: 10.7326/0003-4819-156-7-201204030-00009 22473437

10. Kredo T, Bernhardsson S, Machingaidze S, Young T, Louw Q, Ochodo E, et al. Guide to clinical practice guidelines: the current state of play. Int J Qual Health Care. 2016;28: 122–128. doi: 10.1093/intqhc/mzv115 26796486

11. Lugtenberg M, Burgers JS, Westert GP. Effects of evidence-based clinical practice guidelines on quality of care: a systematic review. Qual Saf Health Care. 2009;18: 385–392. doi: 10.1136/qshc.2008.028043 19812102

12. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. The Lancet. 1993;342: 1317–1322. doi: 10.1016/0140-6736(93)92244-N

13. Spooner L, Fernandes K, Martins D, Juurlink D, Mamdani M, Paterson JM, et al. High-Dose Opioid Prescribing and Opioid-Related Hospitalization: A Population-Based Study. PLOS ONE. 2016;11: e0167479. doi: 10.1371/journal.pone.0167479 27973601

14. Bohnert ASB, Guy GP, Losby JL. Opioid Prescribing in the United States Before and After the Centers for Disease Control and Prevention’s 2016 Opioid Guideline. Ann Intern Med. 2018;169: 367. doi: 10.7326/M18-1243 30167651

15. Institute of Medicine. Conflict of Interest in Medical Research, Education, and Practice. 2009 [cited 18 Sep 2019]. Available: http://www.nationalacademies.org/hmd/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx

16. Choudhry NK, Stelfox HT, Detsky AS. Relationships Between Authors of Clinical Practice Guidelines and the Pharmaceutical Industry. JAMA. 2002;287: 612–617. doi: 10.1001/jama.287.5.612 11829700

17. Shnier A, Lexchin J, Romero M, Brown K. Reporting of financial conflicts of interest in clinical practice guidelines: a case study analysis of guidelines from the Canadian Medical Association Infobase. BMC Health Serv Res. 2016;16: 383. doi: 10.1186/s12913-016-1646-5 27528247

18. Lashner BA, Cominelli F. Conflicts of Interest in Clinical Practice Guidelines. Inflamm Bowel Dis. 2019;25: 646–646. doi: 10.1093/ibd/izy317 30295815

19. Campsall P, Colizza K, Straus S, Stelfox HT. Financial Relationships between Organizations That Produce Clinical Practice Guidelines and the Biomedical Industry: A Cross-Sectional Study. PLoS Med. 2016;13: e1002029. doi: 10.1371/journal.pmed.1002029 27244653

20. Canadian Institute for Health Information. Pan-Canadian Trends in the Prescribing of Opioids, 2012 to 2016. 2017. Available: https://secure.cihi.ca/free_products/pan-canadian-trends-opioid-prescribing-2017-en-web.pdf

21. Gomes T, Mamdani MM, Paterson JM, Dhalla IA, Juurlink DN. Trends in high-dose opioid prescribing in Canada. Can Fam Physician. 2014;60: 826–832. 25217680

22. Kuo Y-F, Raji MA, Chen N-W, Hasan H, Goodwin JS. Trends in Opioid Prescriptions Among Part D Medicare Recipients From 2007 to 2012. Am J Med. 2016;129: 221.e21–30. doi: 10.1016/j.amjmed.2015.10.002 26522794

23. Foy R, Leaman B, McCrorie C, Petty D, House A, Bennett M, et al. Prescribed opioids in primary care: cross-sectional and longitudinal analyses of influence of patient and practice characteristics. BMJ Open. 2016;6: e010276. doi: 10.1136/bmjopen-2015-010276 27178970

24. Guy GP. Vital Signs: Changes in Opioid Prescribing in the United States, 2006–2015. MMWR Morb Mortal Wkly Rep. 2017;66. doi: 10.15585/mmwr.mm6626a4 28683056

25. Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, Di Capua P, et al. Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med. 2014;160: 38–47. doi: 10.7326/0003-4819-160-1-201401070-00732 24217469

26. American Coll of Occupational and Environmental Medicine. ACOEM Guidelines for Chronic Use of Opioids. American Coll of Occupational and Environmental Medicine; 2011. Available: https://www.nhms.org/sites/default/files/Pdfs/ACOEM%202011-Chronic%20Pain%20Opioid%20.pdf

27. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57: 1331–1346. doi: 10.1111/j.1532-5415.2009.02376.x 19573219

28. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50: S205–224. doi: 10.1046/j.1532-5415.50.6s.1.x 12067390

29. Chou R. 2009 Clinical Guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain: what are the key messages for clinical practice? Pol Arch Med Wewn. 2009;119: 469–477. 19776687

30. American Pain Society, American Academy of Pain Medicine. Guideline for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: Evidence Review. American Pain Society, American Academy of Pain Medicine; 2009. Available: http://americanpainsociety.org/uploads/education/guidelines/chronic-opioid-therapy-cncp.pdf

31. Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain. 2009;10: 113–130.e22. doi: 10.1016/j.jpain.2008.10.008 19187889

32. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112: 810–833. doi: 10.1097/ALN.0b013e3181c43103 20124882

33. Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I—evidence assessment. Pain Physician. 2012;15: S1–65. 22786448

34. Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2—guidance. Pain Physician. 2012;15: S67–116. 22786449

35. Furlan AD, Reardon R, Weppler C, National Opioid Use Guideline Group. Opioids for chronic noncancer pain: a new Canadian practice guideline. CMAJ Can Med Assoc J J Assoc Medicale Can. 2010;182: 923–930. doi: 10.1503/cmaj.100187 20439443

36. National Opioid Use Guideline Group. Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. National Pain Centre; 2010. Available: http://nationalpaincentre.mcmaster.ca/opioid_2010/

37. Kahan M, Mailis-Gagnon A, Wilson L, Srivastava A, National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians. Part 1: general population. Can Fam Physician Med Fam Can. 2011;57: 1257–1266, e407-418.

38. Kahan M, Wilson L, Mailis-Gagnon A, Srivastava A, National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians. Part 2: special populations. Can Fam Physician Med Fam Can. 2011;57: 1269–1276, e419-428.

39. Colorado Division of Workers’ Compensation. Chronic Pain Disorder Medical Treatment Guidelines. Colorado Division of Workers’ Compensation; 2011.

40. Fine PG, Portenoy RK, Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation. Establishing “best practices” for opioid rotation: conclusions of an expert panel. J Pain Symptom Manage. 2009;38: 418–425. doi: 10.1016/j.jpainsymman.2009.06.002 19735902

41. Institute for Clinical Systems Improvement. Assessment and Management of Chronic Pain. Bloomington, MN: Institute for Clinical Systems Improvement; 2011. Institute for Clinical Systems Improvement; 2011.

42. University of Michigan. Managing Chronic Non-Terminal Pain in Adults Including Prescribing Controlled Substances. University of Michigan; 2009.

43. Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. Utah Department of Health; 2009.

44. Rolfs RT, Johnson E, Williams NJ, Sundwall DN, Utah Department of Health. Utah clinical guidelines on prescribing opioids for treatment of pain. J Pain Palliat Care Pharmacother. 2010;24: 219–235. doi: 10.3109/15360288.2010.503265 20718642

45. Department of Veterans Affairs, Department of Defense. Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Department of Defense; 2010. Available: http://www.healthquality.va.gov/guidelines/Pain/cot/COT_312_Full-er.pdf

46. Work Loss Data Institute. Pain (chronic). Work Loss Data Institute; 2011. doi: 10.1007/s00586-011-1931-2

47. Shekelle P, Woolf S, Grimshaw JM, Schünemann HJ, Eccles MP. Developing clinical practice guidelines: reviewing, reporting, and publishing guidelines; updating guidelines; and the emerging issues of enhancing guideline implementability and accounting for comorbid conditions in guideline development. Implement Sci. 2012;7: 62. doi: 10.1186/1748-5908-7-62 22762242

48. Joanna Briggs Institute. The Joanna Briggs Institute Critical Appraisal tools for use in JBI Systematic Reviews Checklist for Systematic Reviews and Research Syntheses. 2017.

49. American College of Occupational and Environmental Medicine. Methodology for ACOEMʼs Occupational Medicine Practice Guidelines, 2011 revision. 2011. Available: https://www.acoem.org/gmc.aspx

50. Department of Veteran Affairs and Department of Defense. Guidelines for guidelines. 2013.

51. Bindslev JB, Schroll J, Gøtzsche PC, Lundh A. Underreporting of conflicts of interest in clinical practice guidelines: cross sectional study. BMC Med Ethics. 2013;14: 19. doi: 10.1186/1472-6939-14-19 23642105

52. Thompson JC, Volpe KA, Bridgewater LK, Qeadan F, Dunivan GC, Komesu YM, et al. Sunshine Act: shedding light on inaccurate disclosures at a gynecologic annual meeting. Am J Obstet Gynecol. 2016;215: 661.e1–661.e7. doi: 10.1016/j.ajog.2016.06.015 27319366

53. Checketts JX, Sims MT, Vassar M. Evaluating Industry Payments Among Dermatology Clinical Practice Guidelines Authors. JAMA Dermatol. 2017;153: 1229–1235. doi: 10.1001/jamadermatol.2017.3109 29049553

54. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ Can Med Assoc J. 2010;182: E839–E842. doi: 10.1503/cmaj.090449 20603348

55. Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E, Grimshaw J, et al. AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. J Clin Epidemiol. 2009;62: 1013–1020. doi: 10.1016/j.jclinepi.2008.10.009 19230606

56. Brouwers MC, Florez ID, McNair SA, Vella ET, Yao X. Clinical Practice Guidelines: Tools to Support High Quality Patient Care. Semin Nucl Med. 2019;49: 145–152. doi: 10.1053/j.semnuclmed.2018.11.001 30819394

57. Lenzer J, Hoffman JR, Furberg CD, Ioannidis JPA. Ensuring the integrity of clinical practice guidelines: a tool for protecting patients. BMJ. 2013;347: f5535. doi: 10.1136/bmj.f5535 24046286

58. Bero LA, Grundy Q. Why Having a (Nonfinancial) Interest Is Not a Conflict of Interest. PLOS Biol. 2016;14: e2001221. doi: 10.1371/journal.pbio.2001221 28002462

59. Norris SL, Holmer HK, Ogden LA, Burda BU. Conflict of Interest in Clinical Practice Guideline Development: A Systematic Review. PLoS ONE. 2011;6. doi: 10.1371/journal.pone.0025153 22039406

60. Allan GM, Kraut R, Crawshay A, Korownyk C, Vandermeer B, Kolber MR. Contributors to primary care guidelines What are their professions and how many of them have conflicts of interest? Can Fam Physician. 2015;61: 52–58. 25609522

61. Wang AT, McCoy CP, Murad MH, Montori VM. Association between industry affiliation and position on cardiovascular risk with rosiglitazone: cross sectional systematic review. BMJ. 2010;340: c1344–c1344. doi: 10.1136/bmj.c1344 20299696

62. Fickweiler F, Fickweiler W, Urbach E. Interactions between physicians and the pharmaceutical industry generally and sales representatives specifically and their association with physicians’ attitudes and prescribing habits: a systematic review. BMJ Open. 2017;7: e016408. doi: 10.1136/bmjopen-2017-016408 28963287

63. Lexchin J. Interactions between physicians and the pharmaceutical industry: what does the literature say? CMAJ Can Med Assoc J J Assoc Medicale Can. 1993;149: 1401–1407.

64. Schott G, Dünnweber C, Mühlbauer B, Niebling W, Pachl H, Ludwig W-D. Does the Pharmaceutical Industry Influence Guidelines? Dtsch Ärztebl Int. 2013;110: 575–583. doi: 10.3238/arztebl.2013.0575 24078837

65. Lin DH, Lucas E, Murimi IB, Kolodny A, Alexander GC. Financial Conflicts of Interest and the Centers for Disease Control and Prevention’s 2016 Guideline for Prescribing Opioids for Chronic Pain. JAMA Intern Med. 2017;177: 427–428. doi: 10.1001/jamainternmed.2016.8471 28114444

66. Government of Canada CI of HR. CIHR Assessment of the Canadian Guideline for Opioids for Chronic Non-Cancer Pain—CIHR. 29 Aug 2017 [cited 31 May 2019]. Available: http://www.cihr-irsc.gc.ca/e/50544.html

67. Howlett K. Doctor’s pharma links raise fears of bias on opioid panel. 14 May 2017. Available: https://www.theglobeandmail.com/news/national/doctors-pharma-links-raise-fears-of-bias-on-opioid-panel/article34984781/. Accessed 31 May 2019.

68. Eady EA, Layton AM, Sprakel J, Arents BWM, Fedorowicz Z, Zuuren EJ van. AGREE II assessments of recent acne treatment guidelines: how well do they reveal trustworthiness as defined by the U.S. Institute of Medicine criteria? Br J Dermatol. 2017;177: 1716–1725. doi: 10.1111/bjd.15777 28667760

69. Wilson M. Is transparency really a panacea? J R Soc Med. 2014;107: 216–217. doi: 10.1177/0141076814532744 24912788

70. Wilson M. The Sunshine Act: Commercial conflicts of interest and the limits of transparency. Open Med. 2014;8: e10–e13. 25009680

71. Loewenstein G SS. The unintended consequences of conflict of interest disclosure. JAMA. 2012;307: 669–670. doi: 10.1001/jama.2012.154 22337676

72. Melo-Martín I de, Intemann K. How do disclosure policies fail? Let us count the ways. FASEB J. 2009;23: 1638–1642. doi: 10.1096/fj.08-125963 19176877

73. Panagiotou OA, Ioannidis JPA. Primary study authors of significant studies are more likely to believe that a strong association exists in a heterogeneous meta-analysis compared with methodologists. J Clin Epidemiol. 2012;65: 740–747. doi: 10.1016/j.jclinepi.2012.01.008 22537426

74. Oxman AD, Guyatt GH. The science of reviewing research. Ann N Y Acad Sci. 1993;703: 125–133; discussion 133–134. doi: 10.1111/j.1749-6632.1993.tb26342.x 8192290

75. Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts. Treatments for myocardial infarction. JAMA. 1992;268: 240–248. 1535110

76. Bauchner H, Fontanarosa PB, Flanagin A. Conflicts of Interests, Authors, and Journals: New Challenges for a Persistent Problem. JAMA. 2018;320: 2315–2318. doi: 10.1001/jama.2018.17593 30422174

77. Boddapati V, Fu MC, Nwachukwu BU, Ranawat AS, Zhen WY, Dines JS. Accuracy Between AJSM Author-Reported Disclosures and the Centers for Medicare and Medicaid Services Open Payments Database. Am J Sports Med. 2018;46: 969–976. doi: 10.1177/0363546517750124 29382212

78. Horn J, Checketts JX, Jawhar O, Vassar M. Evaluation of Industry Relationships Among Authors of Otolaryngology Clinical Practice Guidelines. JAMA Otolaryngol—Head Neck Surg. 2018;144: 194–201. doi: 10.1001/jamaoto.2017.2741 29270633

79. Lopez J, Samaha G, Purvis TE, Siegel G, Jabbari J, Ahmed R, et al. The Accuracy of Conflict-of-Interest Disclosures Reported by Plastic Surgeons and Industry. Plast Reconstr Surg. 2018;141: 1592–1599. doi: 10.1097/PRS.0000000000004380 29794718

80. Ziai K, Pigazzi A, Smith BR, Nouri-Nikbakht R, Nepomuceno H, Carmichael JC, et al. Association of Compensation From the Surgical and Medical Device Industry to Physicians and Self-declared Conflict of Interest. JAMA Surg. 2018;153: 997–1002. doi: 10.1001/jamasurg.2018.2576 30140910

81. Ornstein C, Thomas K. Top Cancer Researcher Fails to Disclose Corporate Financial Ties in Major Research Journals. The New York Times. 12 Jan 2019. Available: https://www.nytimes.com/2018/09/08/health/jose-baselga-cancer-memorial-sloan-kettering.html. Accessed 13 May 2019.

82. Boyd EA, Bero LA. Improving the use of research evidence in guideline development: 4. Managing conflicts of interests. Health Res Policy Syst. 2006;4: 16. doi: 10.1186/1478-4505-4-16 17140441

83. Rohwer A, Young T, Wager E, Garner P. Authorship, plagiarism and conflict of interest: views and practices from low/middle-income country health researchers. BMJ Open. 2017;7. doi: 10.1136/bmjopen-2017-018467 29170291

84. Baethge C. The effect of a conflict of interest disclosure form using closed questions on the number of positive conflicts of interest declared–a controlled study. PeerJ. 2013;1. doi: 10.7717/peerj.128 24024081

85. Weinfurt KP, Friedman JY, Dinan MA, Allsbrook JS, Hall MA, Dhillon JK, et al. Disclosing Conflicts of Interest in Clinical Research: Views of Institutional Review Boards, Conflict of Interest Committees, and Investigators. J Law Med Ethics J Am Soc Law Med Ethics. 2006;34: 581–481.

86. Owens B. Ontario delays implementation of pharma transparency rules. CMAJ. 2019;191: E241–E242. doi: 10.1503/cmaj.109-5718 30803958

87. Norris SL, Burda BU, Holmer HK, Ogden LA, Fu R, Bero L, et al. Author’s specialty and conflicts of interest contribute to conflicting guidelines for screening mammography. J Clin Epidemiol. 2012;65: 725–733. doi: 10.1016/j.jclinepi.2011.12.011 22498428


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