Sunday, June 4, 2023

Is a lack of diversity among clinical practice guideline authors contributing to health inequalities for patients?

  1. Julie K. Silver, associate professor, associate chair

  1. Department of Physical Medicine and Rehabilitation, Harvard Medical School

Clinical practice guidelines and other types of guidance documents are among the most important evidence based publications in medicine. Many clinical practice guidelines are disseminated beyond the borders of the country that produced them, and affect access to care, diagnostic work-up, and treatment interventions for billions of people worldwide. This is especially true if they are published or endorsed by influential organisations such as professional societies in the United States, United Kingdom, European Union, and Canada.

Since clinical practice guidelines influence medical care, they are directly tied to the flow of financial resources in healthcare. The World Health Organisation (WHO) examined 190 countries and found global spending on health has continually risen since 2000, and the US has reached more than $8 trillion or 10% of its gross domestic product (GDP).1 An analysis by the Commonwealth Fund reported that despite the US spending more of its GDP on healthcare than other high income countries, it ranked last in access to care, equitable care, and healthcare outcomes.2 The disconnect with high financial spending and low quality outcomes is multifactorial, but clinical practice guidelines clearly influence how money is allocated for care.

Not surprisingly, clinical practice guideline development is under scrutiny and reports show a lack of diversity among contributors. The first study that broadly examined gender equity among authors was published in 2018 and included more than 450 clinical practice guidelines.3 Women were significantly underrepresented, particularly women physicians (25%). Most of the clinical practice guidelines were from the US (59%) or UK (37%), and the majority were produced by American specialty societies. Two recent studies examined the inclusion of people from ethnic minority groups, and both found low inclusion, especially for women physicians.45 One study included 237 guidelines with 3696 panel members and found “most guideline panels exclude racialised women.”4 The other study focused on rehabilitation medicine, and my colleagues and I reached similar conclusions—experts from racial and ethnic minority groups were underrepresented, particularly women.5

A striking example of a clinical practice guideline in our analysis was published by the North American Spine Society (NASS) and focused on low back pain.6 There were 49 authors of which 94% were identified as men (46 men and 3 women). To put the 6% of women experts in context, it is notable that the US and Canada are North American countries with women physicians in the range of 40% or so. Race and gender analysis revealed 10 Asian men versus 1 Asian woman and 2 Black/African American men versus 0 Black/African American women. No Hispanic/Latino authors were identified.

How the diversity of clinical practice guideline panels affects content has not been well studied, but authors exert influence over whether to address topics related to sex as a biologic variable (e.g., pregnancy, menopause), issues related to race and ethnicity, sexual orientation and gender identity and social determinants of health. A report focused on disparities in WHO guidelines stated, “When people from diverse backgrounds—including different genders, cultures, ethnicities, and religions—join forces, they bring with them their own experiential knowledge that enriches discussions and promotes equality.”7

Beyond content, underrepresenting qualified women and people from other marginalised groups is a pattern that contributes to workforce disparities in medicine, because these are prestigious and highly cited publications that may contribute to career opportunities and promotion.

Some strategies to improve diversity of clinical practice guidelines authors include:

● Educate leaders of organisations that produce (e.g., professional societies) and publish (e.g., journals) clinical practice guidelines about the need for diversity among authors and other contributors.

● Implement a process that promotes diversity and track metrics (e.g., participants from underrepresented racial or ethnic minority groups, women chairs, etc).

● Update authoritative guidance documents that inform clinical practice guideline development and ensure they address issues related to diversity among authors and other contributors (e.g., Clinical Practice Guidelines We Can Trust, Appraisal of Guidelines for Research and Evaluation (AGREE) II).8

● Avoid interorganisational structural discrimination—a problem that my colleagues and I recently described when there is a known structural discrimination issue (i.e., operating in a manner that, regardless of intent, results in discrimination) at one organisation and collaborating organisations ignore it and support the offending organisation.9 For example, clinical practice guidelines often list “participating” and “contributing” medical societies. How can societies justify lending their name and support to a clinical practice guideline with very few women authors and exceedingly low proportions of individuals identified with racial and ethnic minority groups? Dismantling interorganisational structural discrimination in medicine and science can lead to more ethical practices in a manner similar to how Fair Trade as a social movement has sought to support ethical practices among businesses and supply chains (i.e., discouraging relationships with organisations that engage in disreputable practices such as child labour and unfair wages).

People trust organisations that produce, endorse, or publish clinical practice guidelines. Trust comes with the responsibility to ensure the evidence base provides the foundation for the work. Part of the evidence base includes growing documentation of inequities among clinical practice guideline authors, and there is an urgent need to address this in order to ensure diversity among qualified people on any given topic. Going forward, no organisation should be involved in clinical practice guideline development or endorsement and no journal should publish them unless they are knowledgeable about the evidence base regarding clinical practice guideline authors and are able to ensure that a diverse group of qualified contributors were included.


  • Competing interests: none declared.

  • Provenance and peer review: not commissioned, not peer reviewed.


  1. 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. PMID: 24983061.

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