text:
Clinical practice guidelines lie at the intersection of medical research, education, and practice. They build on medical research and serve an educational function. In clinical care, they may influence patient and physician decisions about health care interventions, health plan coverage for medical services, and assessments of the performance of individual physicians and institutions that provide health care.
Ideally, clinical practice guidelines are based on valid scientific evidence, critical assessment of that evidence, and objective clinical judgment that relates the evidence to the needs of practitioners and patients. Arguably, the most significant problem in the development of sound clinical practice guidelines is the lack of research that can be used to guide the development of comprehensive recommendations on clinical practice. Clinical trials often exclude children, older adults, and patients with multiple or uncommon diagnoses or complex personal situations. Given the lack of evidence on many clinical topics and patient populations and the frequent lack of consistent research findings, expert judgment based on clinical experience remains a significant element in the development of evidence-based practice guidelines. As the methods manual of the American College of Cardiology and the American Heart Association states, it is not often that there is "an abundance of evidence available that leads directly to an indisputable recommendation" (ACC/AHA, 2009, p. 27).
Financial relationships with pharmaceutical, medical device, and biotechnology companies may create conflicts of interest and a risk of undue influence on judgment both for entities that sponsor the development of clinical practice guidelines and for the individuals who participate in their development. In addition to financial relationships with industry, other potential sources of bias in the development of clinical practice guidelines
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Conflicts of Interest and Development
of Clinical Practice Guidelines
Clinical practice guidelines lie at the intersection of medical research,
education, and practice. They build on medical research and serve an edu-
cational function. In clinical care, they may influence patient and physician
decisions about health care interventions, health plan coverage for medical
services, and assessments of the performance of individual physicians and
institutions that provide health care.
Ideally, clinical practice guidelines are based on valid scientific evidence,
critical assessment of that evidence, and objective clinical judgment that
relates the evidence to the needs of practitioners and patients. Arguably,
the most significant problem in the development of sound clinical practice
guidelines is the lack of research that can be used to guide the development
of comprehensive recommendations on clinical practice. Clinical trials of-
ten exclude children, older adults, and patients with multiple or uncom-
mon diagnoses or complex personal situations. Given the lack of evidence
on many clinical topics and patient populations and the frequent lack of
consistent research findings, expert judgment based on clinical experience
remains a significant element in the development of evidence-based practice
guidelines. As the methods manual of the American College of Cardiology
and the American Heart Association states, it is not often that there is "an
abundance of evidence available that leads directly to an indisputable rec-
ommendation" (ACC/AHA, 2009, p. 27).
Financial relationships with pharmaceutical, medical device, and bio-
technology companies may create conflicts of interest and a risk of undue
influence on judgment both for entities that sponsor the development of
clinical practice guidelines and for the individuals who participate in their
development. In addition to financial relationships with industry, other
potential sources of bias in the development of clinical practice guidelines
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include professional affiliations and practice specialization, reimbursement
incentives, intellectual preconceptions and previously stated positions, and
the desire for recognition and career advancement (see, e.g., Kahan et al.
[1996], Ayanian et al. [1998], Murphy et al. [1998], Fitch et al. [1999],
and Detsky [2006]).
This chapter begins with definitions and a brief historical overview
and description of groups that develop clinical practice guidelines. It then
reviews what the committee learned about the nature and the effects of
sources of funding on the development of clinical practice guidelines, the
financial interests of individual participants, and policies on financial re-
lationships and conflicts of interest. A later section reviews other methods
for promoting objectivity in the development of clinical practice guidelines
and trust in those guidelines. The final section presents recommendations
on how to reduce conflicts of interest in the development of clinical practice
BACKGROUND AND CONTExT
As defined in an earlier Institute of Medicine (IOM) report, clinical
practice guidelines are "systematically developed statements to assist prac-
titioner and patient decisions about appropriate health care for specific
clinical circumstances" (IOM, 1990, p. 8). The IOM report emphasized
the role of formal evaluations of the evidence base for clinical practice
guidelines and the linking of recommendations to those reviews. System-
atic reiews, the common term used today for formal evaluations of the
evidence, are highly structured assessments of the research literature that
use explicit, previously defined methods and tools to identify, select, assess,
and summarize research studies relevant to a technology, treatment of a
clinical condition, or similar topic (see, e.g., OTA [1994] and Cochrane
Collaboration [2005]). A meta-analysis is a quantitative summary of the
data examined in a systematic review. As explained below, various groups
have devised tools for assessing the extent to which a set of guidelines are
based on systematic, evidence-based procedures.
Evolution of Clinical Practice Guidelines
The American College of Cardiology, the American College of Physi-
cians, the National Institutes of Health (NIH) Consensus Development
Program,1 the U.S. Preventive Services Task Force, the Blue Cross and
1 Since 1977, the Consensus Development Program at NIH has sponsored "an unbiased,
independent, evidence-based assessment of complex medical issues" (NIH, undated). It orga-
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Blue Shield Association, ECRI (now the ECRI Institute), and the RAND
Corporation were, among others, leaders in devising systematic methods
for assessing the evidence and developing clinical recommendations for
practitioners, patients, payers, and others (see, e.g., IOM [1985, 1988] for
contemporary descriptions of such activities). In 1989, the U.S. Congress
created the Agency for Healthcare Policy and Research (AHCPR) and gave
it responsibility for creating a public-private partnership to develop, dis-
seminate, and evaluate clinical practice guidelines (P.L. 101-239). In 1995,
the Congress came close to defunding the agency in response to lobbying
by back surgeons who disagreed with the agency's guidelines for the treat-
ment of low back pain developed by an AHCPR Patient Outcomes Re-
search Team (Deyo et al., 1997; Gray et al., 2003; see also Clancy [2003],
Gaus [2003], and Wennberg [2003]). Other government bodies charged
with some aspect of technology assessment have also been defunded under
circumstances that underscore the political sensitivity of this activity (for
example, the National Center for Health Care Technology in 1982 and the
congressional Office of Technology Assessment in 1995) (see, e.g., Bimber
[1996], Rettig [1997], Eisenberg and Zarin [2002], and Keiper [2005]).
After its close call, AHCPR—rechristened the Agency for Healthcare
Quality and Research (AHRQ)—withdrew from the work of developing
clinical practice guidelines. Instead, the agency supports evidence-based
practice centers that conduct systematic reviews that government agencies,
professional societies, and other groups can request and use to develop
guidelines and other recommendations. In 2008, AHRQ supported 14 such
centers, 5 of which focused on assessments for the Centers for Medicare
and Medicaid Services. One evidence review (performed under a grant
from AHRQ) by the RAND Corporation's Evidence-Based Practice Center
concluded that the quality of practice guidelines suffered as a result of the
retreat of the agency from guideline development (Hasenfeld and Shekelle,
2003; see also Grilli et al. [2000]).
The U.S. Preventive Services Task Force, which was created several
years before AHCPR/AHRQ but which is now part of the agency, continues
to develop evidence-based guidelines for preventive services. It is currently
supported by one evidence-based practice center. Other federal agencies,
such as NIH and the Centers for Disease Control and Prevention, also
develop practice guidelines.
To support the dissemination of the clinical practice guidelines devel-
oped and submitted by others, AHRQ sponsors the National Guideline
nizes conferences that are jointly sponsored and administered by one or more NIH institutes
or centers and the Office of Medical Applications of Research, which is located in the Office
of the Director of NIH. Other federal agencies may participate if their expertise is relevant to
the topic. Currently, the Agency for Healthcare Research and Quality provides a systematic
review of the conference topic from one of its Evidence-Based Practice Centers.
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Clearinghouse. The guidelines posted by the clearinghouse are summarized
in a common format that includes headings for information about the
source(s) of funding and about financial disclosures or conflicts of interest.2
Although the clearinghouse is the most comprehensive source of informa-
tion on the funding of guideline development activities and on financial dis-
closures and conflicts of interest, its data have some significant limitations.
The analysts who compile the guideline summaries primarily rely on source
documents provided by the guideline sponsor, and those documents may be
incomplete. For example, because the source documents are silent on the
topic, "Not stated" entries for "financial relationships/conflict of interest"
may be found in clearinghouse summaries of guidelines for groups such as
the American College of Physicians and the U.S. Preventive Services Task
Force. These two groups do, in fact, have a process of disclosing, evaluat-
ing, and managing conflicts of interest.3 Given these and other limitations
in the clearinghouse database, the committee used information from the
database on funding sources and disclosures with caution.
The guideline initiatives described above and other initiatives have
gradually but not fully replaced less rigorous guideline development efforts
that lacked formal procedures, clear reporting of the authors involved
with and the methods used for the systematic review of the evidence, and
explicit links between the recommendations and the supporting evidence.
Shortcomings in the processes for the development and reporting of clini-
cal practice guidelines persist. These shortcomings include the incomplete
disclosures of the financial relationships of the participants and the fund-
ing sources and informal procedures, which increase the opportunity for
undue influence and bias (see, e.g., Shaneyfelt et al. [1999], Burgers et al.
[2003], Harpole et al. [2003], Hasenfeld and Shekelle [2003], Shiffman et
al. [2003], Boluyt et al. [2005], Guyatt et al. [2006], Poitras et al. [2007],
Nix [2008], and Nuckols et al. [2008]).
2 The criteria for the inclusion of a guideline in the clearinghouse relate to sponsorship,
evidence of some kind of literature review, adoption of the guideline within the last 5 years,
and print or online availability of the complete text of the guideline.
3 To cite one example of how such omissions may occur, when U.S. Preventive Services
Task Force guidelines are published in journals that require disclosures, they include a state-
ment (compare, e.g., the guidelines on screening for lipid disorders in children as published
in Pediatrics at USPSTF [2007a] and as published online at USPSTF [2007b]). In contrast,
guidelines presented on the agency's website do not routinely include information about the
group's conflict of interest policies and procedures or about the authors' financial relationships
(see, e.g., guidelines on screening for sickle cell disease in newborns at USPSTF [2007c]). The
processes for developing the guidelines were the same, but the information in the clearinghouse
varies because the source documents varied in the information that they provided. A discus-
sion of task force policies can be found online in the procedure manual, but the site does not
highlight it (USPSTF, 2008).
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Systematic Process for Developing Clinical Practice Guidelines
The adoption of explicit, systematic methods for reviewing evidence
and developing and documenting practice guidelines is, as discussed fur-
ther below, an important strategy for reducing the opportunities for bias,
whether the source might be intellectual and professional preconceptions,
financial interests, or something else. Table 7-1 depicts a generic process
for developing evidence-based guidelines that is similar to that used by a
number of government and professional societies. (Sponsor means the entity
developing the guideline.)
At each step in this process, financial relationships may create conflicts
of interest. Any of the responsible parties identified in Table 7-1 could
have financial relationships with industry that could unduly influence rec-
ommendations—even when systematic reviews and other safeguards are
employed. Thus, some groups have conflict of interest policies that apply
not only to the expert panels that develop guidelines but also to some or
all of the other responsible or involved parties. As described in Chapter 4,
the evidence base itself can be biased to the extent that the publication of
TABLE 7-1 Basic Elements of Process for Developing Evidence-Based
Practice Guidelines
Responsible Party Activity
Sponsor Select topic and provide financial and other resources
Sponsor Appoint a panel to develop the guideline that balances
relevant expertise and perspectives and that is subject to
conflict of interest policies throughout the process
Panel Develop a work plan and specify clinical questions and out-
comes of interest
Panel or contractor Conduct a systematic review of the relevant evidence by
using standardized methods for selecting studies, analyz-
ing and rating the evidence, identifying and evaluating
benefits and harms, and presenting conclusions
Panel Develop and agree on a draft guideline with recommen-
dations explicitly linked to the evidence and expert
Panel or sponsor Distribute a draft for internal and external review
Reviewers Review of guideline by external reviewers and internal
reviewers (e.g., the governing board of a professional
Panel Revise a draft and produce the final guideline
Sponsor or journal Publish and disseminate the guideline
Sponsor Monitor new research findings and determine whether a
guideline should be updated
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negative findings or findings unfavorable to a product have been delayed
or suppressed.
Professional societies and other groups sometimes rely on evidence re-
views conducted by AHRQ's Evidence-Based Practice Centers. (Professional
societies and other groups can nominate topics for reviews. In late 2008,
the agency's website listed 11 evidence reports on clinical topics as under
development.) Others groups may use a combination of staff and expert
panel members to conduct reviews. One reason for the latter course is the
expense. Systematic reviews for a complex clinical topic may cost in the
range of $300,000 to $350,000 or more (personal communication, Beth A.
Collins Sharp, director, Evidence-Based Practice Centers Program, Agency
for Healthcare Research and Quality, November 14, 2008). On the basis of
the committee's review of descriptions of the systematic review process for
several professional and patient advocacy groups, groups that rely on staff
or volunteer experts vary considerably in the resources that they devote to
such reviews, the rigor of their evidence review processes, and the products
of these reviews.
Possible Benefits and Risks of Industry
Involvement in Guideline Development
The committee found little systematic information about the funding of
guidelines, the financial relationships of participants, or the effects of both.
In developing this discussion and the recommendations in this chapter, it
drew on testimony at its meeting and a convenience sample of information
available on the Internet, as well as its experience and judgment.
Potential Benefits of Industry Relationships
Industry funding for the development of clinical practice guidelines may
allow some groups to create guidelines on new topics when they otherwise
would not. Groups that develop practice guidelines may also benefit from
presentations by industry employees as part of the evidence consideration
process, and industry employees may be asked to review evaluations of the
evidence for their technical accuracy. Individual panel members who have
financial relationships with industry often have expertise that is pertinent
to the development of a guideline.
Risks of Industry Relationships
As observed above, relationships with industry and conflicts of inter-
est in the development of clinical practice guidelines may exist at both the
individual level (i.e., participants may have industry ties) and the institu-
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tional level (i.e., the sponsoring group may rely on industry funding for
guidelines). These relationships raise the possibility of conflicts of interest
and undue influence at each step in the guidelines development process.
Selection of topics Groups that require industry funding for the develop-
ment of practice guidelines may propose topics that will attract industry
funding (e.g., a guideline on how to use a product but not whether it should
be used). Among the topics proposed to potential funders, companies may
favor topics and questions for which the evidence is most likely to support
conclusions favorable to a particular company.
Review of evidence Studies examining the association between industry ties
and the outcomes of systematic reviews or meta-analyses raise concerns.4
Although these studies do not deal explicitly with the entire process of
developing clinical practice guidelines, they examine a key element. In one
study, industry-sponsored meta-analyses of drug trials were less transparent
about the methods that they used, were much more likely than Cochrane
Collaboration reviews to recommend the experimental drug without res-
ervation, and had fewer reservations about the methodological limitations
of the trials included in the analysis (Jorgensen et al., 2006).5 All of the
industry-sponsored reviews but none of the Cochrane Collaboration re-
views recommended the experimental drug without reservation.
Another study examined review articles on the health effects of second-
hand smoke (Barnes and Bero, 1998). Ninety-four percent of the review ar-
ticles written by individuals affiliated with the tobacco industry concluded
that passive smoking is not harmful to health, whereas 13 percent of the
reviews written by authors without such an affiliation made that conclu-
sion. The association between the conclusion that secondhand smoke is not
harmful and an affiliation with the tobacco industry persisted even after
the analysts took into account the methodological quality of the review, the
year of publication, the clinical topics examined, and whether the review
was subject to peer review.
4 As described in materials prepared for the Cochrane Collaboration (2002, unpaged),
"meta-analysis is a two-stage process. The first stage is the extraction of data from each indi-
vidual study and the calculation of a result for that study (the 'point estimate' or 'summary
statistic'), with an estimate of the chance variation we would expect with studies like that (the
'confidence interval'). The second stage involves deciding whether it is appropriate to calculate
a pooled average result across studies and, if so, calculating and presenting such a result. Part
of this process is to give greater weight to the results from studies which give us more informa-
tion, because these are likely to be closer to the truth we are trying to estimate."
5 The authors identified 24 Cochrane Collaboration reviews for which another meta-analysis
studied the same two drugs in the same disease and was published within 2 years of the Co-
chrane Collaboration review. (Eight of the 24 comparison guidelines were industry supported;
9 had no declared source of support; 7 reported nonprofit support or self-funding.)
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As discussed in Chapter 4, which describes additional studies, a review
of meta-analyses on hypertensive drugs found that financial ties to a single
pharmaceutical company were not associated with findings that favored
the company but were associated with favorable conclusions (Yank et al.,
2007). The authors further noted that peer reviewers and journal editors
did not prevent the publication of biased conclusions.
Expert panel deliberations The committee found no systematic studies of
the relationship between participant financial relationships and the con-
tent of guidelines. One study did find, however, that only 7 percent of
participants in guideline development surveyed believed that their own
relationships with industry influenced their recommendations, but 19 per-
cent believed that their coauthors' recommendations were influenced by
such relationships (Choudhry et al., 2002). Because more than half of the
participants reported no process for disclosing financial relationships, it is
not clear how well informed the respondents were about their colleagues'
relationships. (The extent of the relationships identified in the study is
discussed below.)
Dissemination of guidelines Even if industry support is limited to the dis-
semination of guidelines, such support could influence the overall strategy
for dissemination in ways that unduly favor a company's product. This is
one interpretation of the controversy over guidelines related to sepsis sum-
marized in Box 7-1 below.
A range of public and private groups develop or collaborate in the de-
velopment of clinical practice guidelines (Table 7-2). On the basis of guide-
lines included in the National Guideline Clearinghouse, medical specialty
societies are the most common developers of the guidelines; they accounted
for almost 40 percent of the guidelines in the clearinghouse database in
April 2008. Professional societies report that practice guidelines are among
the most valued services that they provide (see, e.g., Bennett et al. [2003],
Masur [2007], and Sagsveen [2008]). Evaluations of specialty society guide-
lines have sometimes been critical of their lack of systematic reviews of the
evidence and other characteristics (see, e.g., Grilli et al. [2000]); but the
committee's review indicates that many specialty societies have taken steps
to make their procedures more systematic, transparent, and evidence based
by hiring knowledgeable staff and developing methods, process manuals,
and policies that include conflict of interest policies and procedures. The
committee found less information about the clinical guideline development-
related activities of disease-specific groups.
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TABLE 7-2 Number of Clinical Practice Guidelines in the National
Guideline Clearinghouse by Selected Types of Sponsors, as of March 16,
Type of Sponsor Number of Guidelines
Medical specialty society (U.S. and other) 959
Professional association (U.S. and other; mostly nonphysician or 408
mixed groups)
Government agency (non-U.S.) 214
Federal/state/local government agency 165
Nonprofit organization 142
Independent expert panel 97
Academic institution (U.S. and other) 98
Disease-specific society (U.S. and other) 202
Hospital/medical center (U.S. and other) 26
For-profit organization 21
Managed care organization 11
Total, all guidelines, all sponsors 2,343
NOTE: Some guidelines are developed collaboratively by more than one type of sponsor. For
example, a guideline may list as developers one or more professional societies and one or more
disease-specific societies. The National Guideline Clearinghouse (NGC) search option does not
generate unduplicated counts by category of sponsor. The unduplicated count presented here
was provided by NGC staff. Nineteen of the 26 guidelines from a hospital or medical center
were submitted by a single institution.
SOURCE: Personal communication, Mary Nix, Health Scientist Administrator, National
Guideline Clearinghouse, March 22, 2009.
Public agencies also develop practice guidelines. U.S. federal and state
agencies and public agencies from other countries accounted for more than
500 of the guidelines in the National Guideline Clearinghouse.
Some groups involved in guideline development have sought partners.
For example, the American College of Cardiology and the American Heart
Association have collaborated in their guideline development program
since the 1980s (ACC/AHA, 2009). Several groups are investigating an
international collaboration to develop guidelines for the care of respira-
tory diseases (personal communication, Holger Schunemann, M.D., Ph.D.,
chair, Department of Clinical Epidemiology and Biostatistics, McMaster
University, February 19, 2009). Compared with the complexity of simply
adding individuals with different professional and other backgrounds to a
guideline development panel, the management of partnerships between and
among agencies tends to be more complicated because each partner usu-
ally has, for example, its own policies and procedures. Nevertheless, the
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potential benefits of collaboration include the sharing of costs, broadening
of the scope of the questions examined, and reductions in the number of
dueling guidelines that may undermine the credibility and acceptance of
Sources of Funding for Guidelines and Systematic Reviews
The committee found no systematic assessment of the public or private
sources of funding for the development of clinical practice guidelines (see,
e.g., Boyd [2008]) or systematic reviews of funding sources (Jorgensen et
al., 2006). Nearly all (98 percent) of the summaries of more than 2,000
guidelines included in the National Guideline Clearinghouse as of April 21,
2008, contained a statement about the funding source, usually indicating
that the group that developed the guideline had funded it (Nix, 2008). Some
information is inconsistent. For example, in the summary statement for
guidelines on bronchial intraepithelial neoplasia/early central airways lung
cancer, the section on the source of funding states that a professional society
funded it, whereas the section on financial disclosures/conflict of interest
states that funding came from five pharmaceutical or biotechnology compa-
nies (NGC, 2009c; see also Kennedy et al. [2007]). Similarly, a guideline on
the prevention and treatment of mucositis listed the two authoring groups
as the source of funding, but the information on financial disclosures/con-
flicts of interest referred to unrestricted grants from unnamed companies
(NGC, 2009h; see also Keefe et al. [2007]).
Some professional societies, such as the American College of Physicians,
the American Academy of Neurology, the American Society of Hematol-
ogy, and the American Society for Clinical Oncology, fund their guide-
line development programs from general revenues and, in some instances,
grants from independent nonprofit organizations (ASCO, 2008; Sagsveen,
2008; personal communication, Martha Liggett, executive director, Ameri-
can Society of Hematology, February 24, 2008; personal communication,
Vincenza Snow, director, Clinical Programs and Quality of Care, American
College of Physicians, February 23, 2009). As discussed in Chapter 6, a
society's general revenues may include a significant share from industry, for
example, income generated by journal advertising or by pharmaceutical or
device company exhibits at professional society meetings.
The committee is aware that some smaller professional societies that
have sought to fund clinical guideline development and systematic re-
views without industry support have found it difficult to do so (personal
communication, Roger Chou, assistant professor of medicine and medical
informatics and clinical epidemiology, Oregon Health Sciences University,
April 2, 2008). Professional societies can, however, nominate topics for
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AHRQ-supported systematic reviews, and if such a topic is selected, even
a resource-limited society will have an evidence-based review with which
to work.
Most, if not all, guidelines developed by government agencies in the
United States (e.g., the U.S. Preventive Services Task Force) and elsewhere
(e.g., the National Institute for Health and Clinical Excellence in the United
Kingdom) are publicly funded. One controversial exception involving a
Texas state agency is described in Box 7-1, which cites several controversies
involving financial relationships in practice guidelines.
Practice guidelines are sometimes developed by ad hoc groups, which
by their nature are not likely to have a well-developed infrastructure for
the performance of evidence-based reviews and other activities, including
procedures for identifying and managing conflicts of interest. Box 7-1 de-
scribed one ad hoc initiative related to heart disease screening guidelines
that provoked concerns about bias and conflict of interest.
The Cochrane Collaboration (an independent, nonprofit, international
organization that produces systematic reviews, among other activities) does
not allow industry funding for a review. It does, however, allow commercial
contributions to a central pool of funds to be used for certain other activi-
ties, such as the translation of reviews into different languages (Cochrane
Collaboration, 2006).
Although the committee found no systematic information, industry
involvement in the dissemination of guidelines appears to be fairly com-
mon. For example, companies may buy copies of the journal issue in which
a guideline is published. They may also develop derivative materials (e.g.,
summaries for lay audiences) based on the guideline. The committee was
unable to systematically investigate whether dissemination activities re-
sulted in materials that altered or elaborated on a guideline in ways that
departed from the conclusions in the guideline itself.
Nature and Extent of Individual Relationships with Industry
The committee found little systematic study and documentation of fi-
nancial relationships between industry and the individuals who author clin-
ical practice guidelines. A 2002 study reported that the authors of practice
guidelines had widespread financial relationships with the pharmaceutical
industry (Choudhry et al., 2002).6 Of 44 practice guidelines that Choudhry
et al. initially reviewed, only 2 included disclosures of the authors' financial
relationships with industry. A follow-up survey of 100 authors involved
with 37 of the guidelines found that 87 percent of the authors had some
6 The study covered guidelines that were published between 1991 and 1999, that had iden-
tifiable authors, and that had been endorsed by a "recognized" North American or European
professional society.
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and discussions with staff or members of organizations involved with guide-
line development. It found no systematic information on the conflict of
interest policies of groups that develop clinical practice guidelines. Reviews
by Boyd and Bero (2006) and Boyd (2008) likewise found no systematic
descriptions or assessments of these policies.
The availability, representativeness, and quality of the available in-
formation are limited in several important ways. As noted above, even if
the developers of guidelines have conflict of interest policies, they may not
refer to them in individual guideline documents. This in turn means that
the summaries in the National Guideline Clearinghouse are likely to have
no information either. A number of groups have recently revised aspects of
their policies, and the committee is aware of other groups that are consider-
ing changes. In some cases, these changes may not be reflected on websites
or in publications.
From the policies examined, the committee identified several variations
in organization conflict of interest policies and procedures. They vary in
• information required for disclosure, including how detailed the
information disclosed must be, how often disclosure is requested, and
whether a panel member needs to explicitly state that he or she has no
relationships to disclose;
• management of disclosed information, including who reviews it
and whether other panel members are told of conflicts;
• procedures for managing the relationships disclosed, including limi-
tations of participation by members with conflicts (such as serving as chair
or cochair or voting);
• provisions for public disclosure of conflict of interest policies, fund-
ing sources, and individual financial relationships;
• procedures for managing relationships with companies that provide
funding for guidelines development; and
• assignment of explicit responsibility for monitoring whether insti-
tutional policies are followed.
The frequent lack of transparency of conflict of interest policies lim-
its the ability of guideline readers to consider financial relationships and
conflicts of interest as part of their assessment of the credibility of a set of
guidelines. To give a sense of what readers of guidelines may encounter, Box
7-3 includes additional examples of the range of summary statements in the
National Guideline Clearinghouse. (See also Box 7-2.)
The committee found few descriptions of the policies used to manage
the relationship between guideline developers and industry for groups that
accept industry funding for guideline development. One exception is the
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Examples of Conflict of Interest Policy Descriptions Excerpted
from Summaries in the National Guideline Clearinghouse
Example A
Not stated. [This is the most common entry for the period from 1999 to 2006.]
Example B
To assure the integrity of the Advisory Committee on Immunization Practices
(ACIP), the U.S. Department of Health and Human Services has taken steps to
assure that there is technical compliance with ethics statutes and regulations
regarding financial conflicts of interest. Concerns regarding the potential for the
appearance of a conflict are addressed, or avoided altogether, through both pre-
and postappointment considerations. Individuals with particular vaccine-related
interests will not be considered for appointment to the committee. Potential nomi-
nees are screened for conflicts of interest, and if any are found, they are asked
to divest or forgo certain vaccine-related activities. In addition, at the beginning
of each ACIP meeting, each member is asked to declare his or her conflicts.
Members with conflicts are not permitted to vote if a conflict involves the vaccine
or biologic being voted upon. [NGC, 2009g; see also ACIP, 2007]
Example C
The American Academy of Neurology (AAN) is committed to producing indepen-
dent, critical and truthful clinical practice guidelines (CPGs). Significant efforts
are made to minimize the potential for conflicts of interest to influence the recom-
mendations of this CPG. To the extent possible, the AAN keeps separate those
who have a financial stake in the success or failure of the products appraised in
the CPGs and the developers of the guidelines. Conflict of interest forms were
American College of Chest Physicians, whose policies are summarized in
Box 7-4.
Effectiveness of Policies
The committee identified no evaluations of the impact of conflict of
interest policies on the content of guidelines or other outcomes. The review
by Boyd and Bero (2006) also found no rigorous assessments of conflict of
interest policies for guideline development and no evaluations of different
strategies for implementing or enforcing them.
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obtained from all authors and reviewed by an oversight committee prior to project
initiation. AAN limits the participation of authors with substantial conflicts of inter-
est. The AAN forbids commercial participation in, or funding of, guideline projects.
Drafts of the guideline have been reviewed by at least three AAN committees,
a network of neurologists, Neurology peer reviewers, and representatives from
related fields. The AAN Guideline Author Conflict of Interest Policy can be viewed
at www.aan.com. With regards to this specific report, all authors have stated that
they have nothing to disclose. One of the authors performs epidural steroid injec-
tions. [NGC, 2009b; see also Armon et al., 2007]
Example D
Standards and guidelines are to insure that individuals participating in professional
activities are aware of author relationships with commercial companies that could
potentially affect the information presented. The American Thyroid Association has
endorsed the requirement that authors disclose any significant financial interest
or affiliations they may have with the manufacturers of products or devices that
may be discussed in the development of guidelines. In compliance with this policy,
a superscript number placed by the name of an author denotes an author who
has indicated an affiliation with organizations which have interests related to the
content of these guidelines. The intent of this policy is to openly identify potential
conflicts of interest so that physicians may form their own judgments about the
guidelines with full disclosure of the facts; it remains for the audience to determine
whether an author's outside interest may reflect a possible bias in either the expo-
sition or the conclusions presented. [NGC, 2009f; see also Cooper et al., 2006a]
NOTE: As explained in the text of this chapter, the documents on which guideline summaries
are based may not include references to organizational policies that have governed the de-
velopment of the guideline. Thus, a "Not stated" response does not necessarily indicate that
a group has no policy.
Other Strategies to Limit Bias in the Development
of Clinical Practice Guidelines
Those committed to the development and implementation of sound,
credible, and useful guidelines have devised a number of methods and tools
that can be used to support the creation of such guidelines. Several are
listed in Box 7-5, roughly according to the step in the process of guideline
development described in Table 7-1. Arguably, the most important steps
are the conduct of a systematic review of the evidence and the linking of
recommendations to the evidence in an explicit fashion. The strategies—and
continuing areas of debate and methodological refinement—are described
in depth elsewhere (see, e.g., Higgins and Green [2008] and IOM [2008]).
OCR for page 189
Policies of American College of Chest Physicians
on Industry Funding of Guideline Development
• Fund development activities are undertaken by the organization's executive
office without the involvement or knowledge by the organizational unit responsible
for guideline development, and each guideline ideally is either self-funded or
funded by at least three to five outside sources.
• Names of sponsoring companies are not revealed to staff, society mem-
bers, and other participants in guideline development until the information is
disclosed in the final publication.
• Sponsors do not nominate topics, participate in meetings, or review drafts.
They see the guideline only upon publication.
• The organization does not inform sponsors of the participants involved in
developing a guideline, the specific questions investigated, the methodologists or
evidence-based practice center involved in the evidence review, the reviewers, or
meeting times or places.
• Guidelines refer to pharmaceuticals only by their generic names and not
by their brand names.
SOURCE: Baumann et al., 2007; Lever and Lewis, 2008.
In general, they reinforce conflict of interest policies by limiting the op-
portunity for secondary financial interests to exert undue influence on the
primary interest of developing sound guidelines.
Unfortunately, as Steinberg and Luce (2005) have observed, rigorous
methods for clinical practice guideline development and reviews of the clini-
cal evidence are not applied consistently, and the conclusions of evidence
reviews are not always interpreted appropriately. Furthermore, given that
the evidence base is weak in many areas, they advise, "physicians, policy-
makers, and others acting on the basis of judgments, recommendations,
or measures . . . should not blindly assume that the label [evidence-based]
truly applies" (p. 91).
As noted earlier, in addition to developing methods to limit bias, in-
dividuals and groups have been developing tools for standardizing the
presentation of guidelines and assessing the quality of guidelines across
several domains (see, e.g., IOM [1992], the AGREE Collaboration [2003],
and Shiffman et al. [2003]). Methodologists have also developed tools
that can be used to assess the quality of systematic reviews (Shea et al.,
2007; see also Oxman et al. [2006a]). The 23-item AGREE instrument,
which was developed by experts from 13 countries with funding from the
European Union, includes two elements that relate to conflict of interest,
specifically, that the "guideline is editorially independent from the funding
OCR for page 189
Other Strategies for Limiting Bias in
Clinical Practice Guideline Development
Using an explicit process to select topics for clinical practice guideline develop-
ment. Various groups and individuals have recommended a formal process and
the use of explicit criteria for the selection of topics for guideline development (see,
e.g., Battista and Hodge [1995], IOM [1995], and Oxman et al. [2006a]). Although
the primary rationale is to use limited resources to evaluate areas that offer the
greatest potential to improve the quality or effectiveness of health care, another
potential benefit is a reduction in the opportunity for financial relationships and
other sources of bias to influence the selection of topics.
Creating a diverse expert panel. The inclusion of individuals with a range of rel-
evant professional and other backgrounds on guideline development panels can
help check financial, professional, and other sources of bias; promote the fuller
consideration of potential outcomes, relevant evidence, and aspects of implemen-
tation; and help win broader acceptance by professionals, consumers or patients,
health care plans, and others who play roles in the successful implementation of
guidelines (see, e.g., IOM [1990, 1992, 2008] and AGREE Collaboration [2003]).
Systematically reviewing relevant evidence. As summarized by Higgins and Green
Higgins and Green
(2008, Section 1.2.2) for the Cochrane Collaboration, key elements of this critical
elements of this critical
step include
• "a clearly stated set of objectives with pre-defined eligibility criteria for
• an explicit, reproducible methodology;
• a systematic search that attempts to identify all studies that would meet the
eligibility criteria;
• an assessment of the validity of the findings of the included studies, for
example, through the assessment of risk of bias; and and
• a systematic presentation, and synthesis, of the characteristics and findings
of the included studies."
Using systematic procedures to evaluate the evidence, employing expert judg-
ment, and linking recommendations to the evidence. Methodologists have de-
veloped and tested formal processes for developing consensus and otherwise
structuring the expert judgment process (see, e.g., Fink et al. [1984], Murphy et al.
[1984], Murphy et al.
[1998], Verkerk et al. [2006], and Renfrew et al. [2008]). In addition, considerable
effort has been invested in developing and testing explicit methods for reporting
and rating the evidence relevant to guidelines and for rating the strength of the
recommendations (see, e.g., Guyatt et al. [1995], Lohr [2004], and Schünemann
et al. [2006], and Schünemann [2008]).
Obtaining expert reviews. An independent, expert review of the guidelines and
related documents is an important tool that can be used to improve the identifi-
cation, evaluation, and use of the evidence. The process used to select expert
reviewers should explicitly identify and assess reviewer ties with potentially af-
fected companies.
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body" (Item 22) and that "[c]onflicts of interest of guideline development
members have been recorded" (Item 23). In addition, the Conference on
Guideline Standardization (COG) proposed a somewhat similar 18-item
checklist for reporting (documenting) guidelines (Shiffman et al., 2003).
The COG list includes the identification of the funding source or spon-
sor, its role in developing or reporting the guideline, and the disclosure of
conflicts of interest.
These and other instruments are not intended to be used to assess the
full substance of the guidelines. In and of themselves, they will not identify,
for example, whether key evidence has been overlooked or incorrectly as-
sessed, whether relevant benefits or harms have been ignored or improperly
weighed, or whether critical barriers to implementation have been missed.
Notwithstanding some shortcomings of guideline assessment tools, their
development and application underscore that it is important for documents
containing clinical practice guidelines to provide potential users of the
guidelines with informative descriptions of the development process, the
evidence base, the participants, and the applicable conflict of interest poli-
cies. When users of guidelines confront guidelines that lack such descrip-
tions, they would be prudent to treat the guidelines with caution and search
for other guidelines that provide appropriate documentation.
Even when the developers of clinical practice guidelines use sound
methods, they are often limited by shortcomings in the evidence base. A
review of the guidelines in the National Guideline Clearinghouse reveals
recommendation after recommendation that is supported by weak, mixed,
or no evidence. Both to support the development of practice guidelines and
for other purposes, many groups in the United States and elsewhere have
called for greatly increased public investments in comparative effectiveness
research and analysis for at least two decades (for a small sampling, see
IOM [1985, 2007, 2008], OTA [1994], CBO [2007], and MedPAC [2007]).
At the end of the next section, the committee endorses the recommenda-
tions for such investments that another IOM committee made recently.
Overall, the combination of a better evidence base for clinical practice
guidelines and better tools for assessing that evidence not only strengthens
the usefulness of practice guidelines but also reduces the potential for con-
flicts of interest to bias guidelines.
Given the important role that clinical practice guidelines play in many
aspects of health care, it is important that these guidelines be free of indus-
try influence and be viewed by clinicians, policy makers, patients, and oth-
ers as objective and trustworthy. The committee found substantial variation
in the extent to which different groups disclosed their conflict of interest
OCR for page 189
policies and the financial ties to industry of the sponsoring group and the
members of the guideline panel. It also found little systematic descriptions
or assessments in the literature. On the basis of its judgment and experience
(including experience with conflicting guidelines and guidelines not based
on formal reviews of the evidence), the committee believes that the risk of
undue industry influence on clinical practice guidelines is significant, and
that risk justifies that strong steps be taken to strengthen conflict of inter-
est policies governing the development of guidelines. Recommendation 7.1
proposes several such steps.
RECOMMENDATION 7.1 Groups that develop clinical practice
guidelines should generally exclude as panel members individuals with
conflicts of interest and should not accept direct funding for clini-
cal practice guideline development from medical product companies
or company foundations. Groups should publicly disclose with each
guideline their conflict of interest policies and procedures and the
sources and amounts of indirect or direct funding received for develop-
ment of the guideline. In the exceptional situation in which avoidance
of panel members with conflicts of interest is impossible because of the
critical need for their expertise, then groups should
• publicly document that they made a good-faith effort to find
experts without conflicts of interest by issuing a public call for members
and other recruitment measures;
• appoint a chair without a conflict of interest;
• limit members with conflicting interests to a distinct minority of
the panel;
• exclude individuals who have a fiduciary or promotional rela-
tionship with a company that makes a product that may be affected by
the guidelines;
• exclude panel members with conflicts from deliberating, draft-
ing, or voting on specific recommendations; and
• publicly disclose the relevant conflicts of interest of panel
Transparency is one key element of Recommendation 7.1. Groups
should disclose their conflict of interest policies and their process for seek-
ing members without conflicts of interest and its results. The disclosure of
the relevant financial interests of members of guideline development panels
should be sufficiently specific and comprehensive that it helps others judge
the severity of the conflicts of interest, including allowing the identification
of fiduciary interests (e.g., membership on company boards) and promo-
tional relationships (e.g., participation in industry speakers bureaus).
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Groups that develop guidelines should also disclose the sources and
the amounts of funding provided for guideline development, including un-
restricted company grants. Some committee members also wanted groups
that develop guidelines to report publicly all their sources, amounts, and
purposes of funding because industry contributions to general revenues
(e.g., from journal advertising or unrestricted grants) could also create un-
due influence. The committee did not reach a consensus on this point. Other
committee members were also concerned about the overall reliance of some
professional and patient groups on industry funding, but they believed
that this reporting of all sources and purposes of funding is not necessary,
provided that groups developing guidelines adopt and implement rigorous
evidence-based procedures, report indirect and direct funding sources for
each guideline, and institute the conflict of interest policies and procedures
recommended in this report. Another safeguard would be the continued
development of processes for rating guidelines development processes, as
described above. Moreover, if the U.S. Congress requires companies to
report payments not only to individuals but also to a range of medical
organizations, that information, in combination with the annual reports
that many professional society and patient groups issue, should allow the
calculation of industry funding as a share of total revenues.
Transparency also involves the inclusion of the specified information
with each guideline that a group sponsors. Preferably, the information
would accompany the written text, but it could—particularly if it is very
lengthy—be provided by an Internet link that is maintained through the
life of the guideline.
In addition to expanded disclosure about funding, the committee rec-
ommends an end to direct industry funding of clinical practice guidelines.
It recognizes that this step might have the undesirable effect of reducing the
involvement of professional societies in guideline development but believes
that it is necessary to avoid the conflicts that come from industry financing.
It is also likely that an increase in public support for systematic reviews of
the evidence would buffer such effects because these reviews are an expen-
sive part of the process of developing evidence-based guidelines. Profes-
sional societies and other groups with a shared interest in certain clinical
problems could also collaborate on the development of guidelines and
spread the costs. In addition, a pooling mechanism might be created—as
has been suggested by some for continuing medical education—to support
indirect industry funding of the development of clinical guidelines in certain
broad categories.
Another important step is to exclude or substantially limit the partici-
pation of individuals with conflicts of interest on panels that develop clini-
cal practice guidelines. As more academic institutions and other groups as
well as individual professionals take the steps recommended in Chapters 5
OCR for page 189
and 6 of this report, it should be easier to find individuals who are free of
conflicts of interest involving promotional relationships (e.g., participation
in speakers bureaus). If groups conclude that participants with conflicts of
interest are essential to provide the necessary expertise, they should demon-
strate to the public that they have made a good faith but unsuccessful effort
to find individuals with the required expertise and without conflicts of in-
terest. They should also preclude individuals with conflicts of interest from
chairing guideline development panels, restrict the number of individuals
with conflicts of interest on panels to a distinct minority (e.g., to 25 to 30
percent of the membership), and prohibit members with conflicts of interest
from drafting and deciding specific recommendations.
In addition to actions by the institutions directly involved in the de-
velopment of guidelines, organizations with an interest in unbiased clinical
practice guidelines can create incentives for groups that develop guidelines
to adopt the recommendations presented in this report. The committee
understands that the National Guideline Clearinghouse will be phasing in
a requirement for the disclosure of conflicts of interest, but the committee
recommends that it extend the requirement to include the disclosure of
funding and policy information, consistent with Recommendation 7.1. It
would also be desirable for the clearinghouse or some other entity to begin
substantive assessments of the quality of clinical practice guidelines.
RECOMMENDATION 7.2 Accrediting and certification bodies, health
insurers, public agencies, and other similar organizations should en-
courage institutions that develop clinical practice guidelines to adopt
conflict of interest policies consistent with the recommendations in this
report. Three desirable steps are for
• journals to require that all clinical practice guidelines accepted
for publication describe (or provide an Internet link to) the developer's
conflict of interest policies, the sources and amounts of funding for the
guideline, and the relevant financial interests of guideline panel mem-
bers, if any;
• the National Guideline Clearinghouse to require that all clinical
practice guidelines accepted for posting describe (or provide an Inter-
net link to) the developer's conflict of interest policies, the sources and
amounts of funding for development of the guideline, and the relevant
financial interests of guideline panel members, if any; and
• accrediting and certification organizations, public and pri-
vate health plans, and similar groups to avoid using clinical practice
guidelines for performance measures, coverage decisions, and similar
purposes if the guideline developers do not follow the practices recom-
mended in this report.
OCR for page 189
The committee expects that the adoption of the committee's recom-
mendations will reduce the probability of undue influence from industry
funding and may also reduce the number of conflicting and competing clini-
cal practice guidelines. Some groups that have operated with undisclosed
industry support or that have been unwilling to disclose the financial rela-
tionships of guideline development panel members may remove themselves
from the guideline development process. Other groups may collaborate to
share the costs of developing guidelines on topics of common interest.
Although the committee believes that an expanded role for public-sector
sponsorship of the development of systematic reviews and clinical practice
guidelines would be desirable, an examination of this issue is beyond its
scope. The committee endorses the recommendation in a recent IOM report
for expanded federal support for assessments of the effectiveness of clinical
services (IOM, 2008). That report called for the U.S. Congress to direct the
U.S. Department of Health and Human Services to designate a single entity
with the responsibility and capacity to "to ensure production of credible,
unbiased information about what is known and not known about clini-
cal effectiveness" (p. 171). That entity would establish priorities for and
manage the development of systematic reviews of clinical effectiveness,
develop standards for such reviews and for clinical guidelines, and address
conflicting guidelines. The report also recommended that accreditation
organizations and other groups preferentially use guidelines developed by
using the standards described in the report. In addition, it recommended
that guideline development panels minimize bias by including a balance of
competing interests, prohibit voting by participants with conflicts of inter-
est, and publish conflicts that have been disclosed.
Other Relevant Recommendations in This Report
In addition to the two recommendations in this chapter, recommen-
dations elsewhere in this report are relevant to institutions that develop
clinical practice guidelines. Consensus standards on disclosure elements
and procedures would make disclosures more informative as well as less
burdensome for those making disclosures to multiple institutions (Recom-
mendation 3.2). A national system for public reporting by companies of
their payments to individuals and organizations would allow the easier
verification of certain disclosures (Recommendation 3.4). Limitations on
certain industry ties and practices (e.g., the receipt of gifts and participation
in speakers bureaus) should reduce conflicts of interest among the pool of
experts considered for participation in clinical practice guideline develop-
ment (Recommendations 5.1, 6.1, and 6.2).
The adoption of explicit policies and procedures on institutional conflict
OCR for page 189
of interest would challenge professional societies, patient advocacy groups,
and other entities that develop clinical practice guidelines to confront the
scope and appropriateness of their financial ties with industry, eliminate
questionable ties, and prudently manage others (Recommendation 8.1). The
next chapter discusses conflicts of interest at the level of institutions.


text:
Tickets for BlizzCon Go on Sale April 24, 27
By Chris Holzworth, Reporter
Posted on April 4, 2013 AT 02:32pm
Posted on April 4, 2013 AT 02:32pm
Tickets for Blizzard's seventh BlizzCon—being held at the Anaheim Convention Center November 8 and 9—will go on sale April 24 and April 27.
Said tickets cost $175 a pop. The first round on April 24 go on sale at 7pm PT, while the second round on April 27 starts at 10am PT.
This year's BlizzCon will also holist the Starcraft 2 World Championship Series Global Finals.
Blizzard promises "tons of other exciting events and activities" during BlizzCon, as well as hands-on access to their games (Diablo 3 on PS3, possibly PS4, no doubt).
Today's Top 10 Stories
Partner Pages
Top Partner Stories
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Website Interface © 2012 EGM Digital Media, LLC.
Website Interface © 2012 EGM Digital Media, LLC.

subset: commoncrawl


text:
March 21, 2011
Jerry Meyer Rivals.com Basketball Recruiting
Tennessee fired coach Bruce Pearl on Monday. And soon, the Volunteers will lose two of their top recruits. Rivals.com has learned that Kevin Ware and Chris Jones will look elsewhere. ...More... To continue reading this article you must be a member. Sign Up Now!
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text:
Tue Mar 25 2003 16:45:
From various sources, so I'll just pick toastedkitten. The Smoking Gun used to do one-off exposes of the backstage riders of various musical groups. Now they've gone overboard with Backstage Pass, a collation of over 100 backstage riders, full of both universal "We need towels and fresh socks because we sweat like purebred hogs under the stage lights" moments, and artist-specific "this bad thing happened once and so help us we will WRITE ITS ABSENCE INTO THE CONTRACT so that it will NEVER HAPPEN AGAIN" moments ("IF THERE IS AN ANIMAL BACKSTAGE, ALABAMA WILL NOT PERFORM."--a convenient general escape clause, since humans are animals).
TSG has their own commentary on each rider, and how can you not agree with the analysis "All hail Foo Fighters"? FF's rider is Berendian in parts: "**Dearest reader-This rider is comprised of the things that make the band rock you like a proverbial hurricane!".
The common-denominator corporate beneficiary of all these riders: the Solo Cup Company.


text:
Optimize Your Culture and Achieve Exceptional Results
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text:
Welcome to OM Industrial Products
OM offers 20+ years of experience in sourcing, and delivers high quality OEM parts produced domestically and overseas. Our global procurement and production teams work to bring you the lowest costs while our strict Quality Assurance process works to provide consistent results.
Find out more about our capabilities


text:
Staff Reporter
Delhi branch of Truth Labs to be operational by June
To provide scientific investigation and detection services using modern techniques
To make available free service to the poor and also in cases of public interest
NEW DELHI: Truth Labs, a unique initiative to provide private and independent forensic laboratory services at nominal rates to help victims of crime and injustice, will open its branch in the Capital soon.
Conceived by K.P.C. Gandhi, former director of the Andhra Pradesh Forensic Science Laboratory, Truth Labs was first established in Hyderabad in 2007 with the aim of providing scientific investigation and detection services using modern tools and techniques. "It has been set up to cater to the demands of the common man requiring scientific services to resolve a number of civil, criminal, regulatory or non-litigious disputes," said Dr. Gandhi.
Truth Labs promises to provide free service to the poor and the under-privileged and also in cases of public interest.
A subsidiary of non-profit and non-government organisation Truth Foundation, Truth Labs offers services like DNA sampling analysis, lie-detection and examination of disputed speech and visuals.
The services include investigations into authenticity of documents through various techniques like examination of handwriting and signatures. The lab carries out fingerprint analysis, investigates cyber crime offences and does psychological evaluation and behavioural profiling. It also offers "failure analysis" service that involves investigation of the premature failure of any structure resulting in loss of life or damage to public property.
"The opinion and reports given by the experts of Truth Labs are valid in the court of law as per Section 45 of the Indian Evidence Act," said Dr. Gandhi, adding that the lab had roped in highly qualified, experienced, certified and skilled professionals in their area of expertise. They include experts who retired from the Central and State government forensic laboratories.
The Delhi branch at Bhikaji Cama Place is scheduled to become functional in June. It will be headed by S. R. Singh, former director of the Central Forensic Science Laboratory of the Central Bureau of Investigation.
Dr. Gandhi said the Hyderabad-based Truth Labs had received over 300 cases so far and even courts were referring cases to the lab. "The lab has received over 100 cases from courts and about 50 from the police. In fact, several cases have been reopened on the basis of our reports," he said, adding that a large number of individuals and reputed companies had also availed of its services. "In urgent and deserving cases Truth Labs can furnish reports within 24 hours," said Dr. Gandhi.


text:
Indias foreign
panel opposes govt Money transfer
service by Yahoo! |
Optra variant to
cost 7.3 lakh WTC design to be
unveiled on Friday
TV Today IPO on
Dec 18
Volvo plans
R&D centre in India
i-flex buys out US company
Indias foreign currency outlook revised
New Delhi, December 16 However, the outlook on Indias BB+ long-term local currency rating remains negative because of slow economic reforms and fiscal deficit. Both foreign and local currency short-term ratings on the sovereign were affirmed at B. Rapidly increasing external liquidity, sustained by growing foreign exchange reserves and modest debt service payments sparked the revision in the foreign currency outlook, S & Ps Credit Analyst Takahira Ogawa, Director in the Asia-Pacific Sovereign Ratings Group, said in a statement. Indias stable economic prospects is another factor supporting the sovereign ratings. India is expected to achieve 5-6 per cent GDP growth in the medium term, which should help cushion the impact of its high fiscal deficit. The outlook on Indias local currency ratings can be revised to stable if the government manages to reverse its fiscal trajectory by reducing the deficit and accelerating structural reform. This will also improve prospects for the foreign currency rating, Mr Ogawa said. The consolidated direct debt of Indias state and Central Government is expected to be 84 per cent of GDP in fiscal, 2003, which is high for the rating category. Moreover, this level is expected to rise steadily because of the high consolidated general government deficit, which, at more than 9 per cent, is one of the highest of all sovereigns rated by Standard & Poors. The government must also accelerate progress in structural reform. Resistance from vested interests, including bureaucrats and politicians, has hindered government efforts to reduce restrictions such as land ownership and labour markets, he added.
Re gains on rating revision
The rupee closed two-and-half paise stronger against the US Dollar at 45.53/54 today on improved dollar inflows after the fresh weakness in greenback in the global markets and the Standard & Poors revised Indias long-term foreign currency rating outlook to stable from negative.
Parliamentary panel opposes govt
New Delhi, December 16 The Parliamentary Standing Committee on Petroleum, in its report tabled in Parliament today, said the government ignored its unanimous view which called for sanction of Parliament before going in for disinvestment in HPCL and BPCL. This amounts to dilution of the legislature which forced judiciary to step in and remind the executive of the authority of Parliament, it said. The Supreme Court had asked the government to seek the Parliamentary approval before privatising the two oil refiners which were nationalised through an act of Parliament. Noting that the government has again moved the Supreme Court for a review of its judgement, the Committee reiterated its earlier stand that sanction of Parliament is mandatory before a decision to disinvest HPCL and BPCL is taken. The report said the Committee was also not convinced by the reply of the government that ownership of one PSU by another PSU did not serve the purpose of disinvestment. If any PSU is allowed to bid for HPCL, it will fulfil the objective of facilitating vertical integration of business and also enhance the capacity of public sector oil companies to compete with the private companies and MNCs, it said.
Money transfer service by
Yahoo! Washington, December 16 The service, called Yahoo PayDirect International, revolutionises current Internet person-to-person payment methods, Dickson Chu, General Manager of Yahoo PayDirect, said yesterday. Foreign born nationals living and working in the United States that need to send money home can make their money go even farther, with rates well below many other money transfer methods. The new venture puts Yahoo head-to-head with money transfer firms like the Western Union. The new service will allow users to obtain cash through some 8,00,000 ATMs around the world through the Cirrus network.
Optra variant to cost 7.3 lakh
New Delhi, December 16 GMI Vice-President (marketing) Amit Dutta said the new car is expected to help the company boost its market share in the overall mid-size segment to 30-35 per cent next year from the present 23 per cent in the upper-end mid-size segment. The 1.6-litre Optra, which has 104 brake horse power, will compete with cars like Honda City and Hyundai Accent Tornado in the segment which accounts for about 1,00,000 units annually. The 1.8-litre model is positioned against cars like Toyota Corolla and Skoda Octavia in the upper-end of the mid-size segment, which are about 16,000 units annually. Mr Dutta said GMI plans to introduce a new multi-utility vehicle Isuzu Panther, rechristened as Chevrolet Tavera, by September 2004, which it hopes would double its market share to 2.4 per cent next year in the total Indian automobile industry of over 1.5 million
vehicles. UNI |
WTC design to be unveiled on Friday
New York, December 16 The Lower Manhattan Development Corp., which oversees the rebuilding, issued a statement yesterday saying the new design would be unveiled on Friday by Pataki and Mayor Michael Bloomberg. According to the statement, a centerpiece tower will rise 1,776 feet, culminating in a spire and evoking the Statue of Liberty, as Daniel Libeskind, the architect who won the design competition for the 16-acre sites redevelopment, had proposed. The Freedom Tower also will incorporate windmill technology that will generate much of the towers electricity, a proposal put forth by David Childs, the Skidmore Owings and Merrill architect hired by leaseholder Larry Silverstein. The design includes 1,100 feet of commercial space topped with a sloping roof, a redevelopment official said. Childs energy-generating structure will extend 400 feet from the roof, and Libeskinds spire will rise another 276 feet. The compromise seemed to put at least a temporary end to the disagreements between the architects, who have had a stormy relationship that libeskind has likened to a forced marriage.
Stop using groundwater, HC to Coke
Kochi, December 16 The court also directed the Perumatty gram panchayat, under the jurisdiction of which the cola plant is located, and the state government to ensure that the plant does not extract groundwater after the specified time limit. Extraction of the groundwater, even up to the admitted limit by the company, was illegal, the court held. The company had no legal right to extract this much natural wealth and the Panchayat and the government were bound to prevent it.
Volvo plans R&D centre in India New Delhi, December 16 Volvo India Managing Director Ulf Nordqvist said India occupied an important position in the Swedish automakers overall operations. This year we expect the sourcing to be in the region of £ 15 million and with quality manufacturing here on the increase, it is expected to grow exponentially, the Volvo India chief said in an interview.
Jet Air offers special fares Auto Summit ICICI Lombard Debt-swapping Hind Sanitary Fund for HP Oil unions strike Return rate cut |
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Hardness of approximation of the discrete time-cost tradeoff problem
Deineko, Vladimir G. and Woeginger, Gerhard J. (2001) Hardness of approximation of the discrete time-cost tradeoff problem. Operations Research Letters, 29 (5). pp. 207-210. ISSN 0167-6377
Restricted to UT campus only : Request a copy 76kB |
Abstract: | We consider the discrete version of the well-known time-cost tradeoff problem for project networks, which has been extensively studied in the project management literature. We prove a strong in-approximability result with respect to polynomial time bicriteria approximation algorithms for this problem. |
Item Type: | Article |
Copyright: | © 2001 Elsevier |
Faculty: | Electrical Engineering, Mathematics and Computer Science (EEMCS) |
Research Group: | |
Link to this item: | http://purl.utwente.nl/publications/74416 |
Official URL: | http://dx.doi.org/10.1016/S0167-6377(01)00102-X |
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Metis ID: 203191


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The Fallen-Angel, JOSHUA... from "November's End".
Congratulations on the Daily Inspiration! .. this is very well deserved.
Apr 30th, 2012 Reply SubscriberCongratulations!
Your art is very inspirational to all of us artists and at Shadowness we like to thank our amazing artists for all they do, to show our appreciation for you, your artwork has been featured in todays Daily Inspiration #420
Strong use of colour...nice concept...
Apr 27th, 2012 ReplyThanks for taking a look... glad you like it! :D And, thanks for the fave too.
Apr 27th, 2012 Reply


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CITY LANDING: About Hobe Sound
Learn more about the city of Hobe Sound by reading about the specific demographics and lifestyle that is unique to this city area. This includes local information such as age ranges, population, income, households, schools, search tips, restaurants, shopping, local flavor and more. Knowing the area of Hobe Sound will be essential if you are going to consider renting in Hobe Sound. You can also view apartments for rent in Hobe Sound, FL by clicking the link and search box below.
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Comments (3)
louislieberman37 wrote:
sanding sealer dries faster &is cheaper than topcoats. apolyethurine sealer will dry to a hardness for sanding in 20-40 min. depending on temperature-it's also used as primer coat for mdf -otherwise the first coaat is absorbed almost completely/
6/20/2013 01:28:36 PM Report Abuse
jreid03 wrote:
Hi: I believe you left out one important use of a dewaxed shellac sanding sealer and that is its use as a means to eliminate or diminish the blotchiness of some woods (cherry, alder, etc.)
6/7/2012 09:50:50 AM Report AbuseAdd your comment
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Making quick decisions is easy when it's the Blowfish Quick Natural Faux Straw Smoking Slipper Flats that you're choosing! There's no going back once you've slipped on these round-toe flats with their beige straw pattern printed over a faux leather upper. Canvas piping trims the notched opening. Embroidered logo along heel. 1/2" rubber heel. Lightly padded insole. Rubber sole has non-skid markings. Available in whole and half sizes. Fit is true to size. Measurements are for a size 6. Man made materials. Imported.
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Old Landing Golf Course
- 300 Old Landing Rd, Rehoboth Beach, DE 19971
- (302)227-3131
18 total holes at facility |
Green fees - $30 to $49 (estimate) |
Designed by Russell Roberts |
Built in 1962 |
Bermuda Grass |
Driving Range: Yes |
Public golf course |
Old Landing Golf Course is an 18-hole regulation length golf course in Rehoboth Beach, Delaware. This short layout has 3 sets of teeboxes for a fun, but challenging golfing experience. Online tee times may be available at Old Landing Golf Course or at nearby golf courses, usually offered at a discount from the normal rate.
Tees | Par | Yardage | Course Rating | Slope |
Back | 71 | 6097 | 68.2 | 108 |
Golf Pro: Willis Johnson | Course Superintendent: Jay Scot Anderson | Manager: Robert Marshall |
Remember, in some cases there will be errors, even though the data about these courses is generally correct. If you stumble upon something that should be updated, please let us know.
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Fr. Stan Fortuna: what works for Catholic schools.
Toronto -- At a time when the existence of Ontario Catholic schools is being questioned, and in a place where many students have barriers to learning, Fr. Stan Fortuna, C.F.R. drilled home the basics of "Faith and Family" with a three-day high school mission to students, parents, and teachers on May 16-18, 2007.Thanks especially to the efforts of dedicated staff, the internationally-known "Rapping Reverend" from the South Bronx was welcomed back to Dante Alighieri Academy, a Catholic secondary school in northwest Toronto, for an expanded follow-up to a concert the previous year.
Dante students frequently come from families struggling to pay their bills, settle into a new country following recent immigration, and adjust to tragedies, separations and/or divorces. Disproportionate numbers of students speak languages other than English at home, and/or require special education. Just 72 percent of Dante's grade nine students passed the Ontario Secondary School Literacy Test (OSSLT) this year, compared to 84 percent in the province as a whole (www.tcdsb.org, Mar. 2007).
On top of these burdens, the students are immersed in media which disparage the values that had traditionally been conveyed through the cooperative efforts of home, school, and parish. But by regularly 'switching channels' in his delivery, Fr. Stan kept the attention of students used to constant change with their electronic devices. He was well-received as he interspersed serious messages from Scripture, the lives of the Saints, and papal teachings with a wide range of music and comedy. Throughout his visit, he exhorted his audience to faith and morality through conversion to Christ.
The mission got underway with an evening talk for parents and teachers on "Reaching Youth in a Media Culture." On the second day, Fr. Start gave a school assembly for the students, on the search for authentic love. He used an acronym for F.A.M.I.L.Y. also found in his lyrics: "Forget About Me, I Love You." On the third day he offered an Instructional Mass--in which he meticulously explained each part of the liturgy, beginning with the vestments he wore. Later on, he concluded his visit with a concert demonstrating his eclectic style and reverence for Truth. "He has challenged students to really think about life's most important questions and the answers, religion teacher Robert Quaglia told Catholic Insight.
Taken as a whole, the mission attested to the importance of strong Catholic schools. Ticket prices were offset by grassroots fundraisers and by support from the both the CSAC (Catholic School Advisory Council, primarily comprised of parents) and the Toronto Catholic District School Board. Committed teachers met with a group of students called the "Fr. Stan Crew" every week over several months to do logistical planning. "Fr. Stan gives of himself so much, and we too encourage the kids (Crew) to give without counting the cost of what they get back in return, really give!" said Quaglia.
While Fr. Stan will be invited to return to the school, it is also anticipated that his third year of involvement with Dante will involve deeper exposure to worship and service with the Community of Franciscan Friars of the Renewal. Fr. Stan is one of the original eight members of the C.F.R., which has been serving the materially poor and evangelizing the Church for 20 years. His own apostolates include a recording studio and a youth cultural centre, both in the South Bronx.
"We hope to plan a trip to New York (in 2008) and visit the Francisan Community. The trip will be open to all past Fr. Stan crew members who have helped over the years. The trip will be a faith and culture event in New York City, maybe over the March Break," said Quaglia.
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Title Annotation: | Canada |
Publication: | Catholic Insight |
Date: | Sep 1, 2007 |
Words: | 622 |
Previous Article: | Archbishop Collins on the value of religion. |
Next Article: | Editor fired. |
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What a man believes upon grossly insufficient evidence is an index into his desires -- desires of which he himself is often unconscious. If a man is offered a fact which goes against his instincts, he will scrutinize it closely, and unless the evidence is overwhelming, he will refuse to believe it. If, on the other hand, he is offered something which affords a reason for acting in accordance to his instincts, he will accept it even on the slightest evidence. The origin of myths is explained in this way.
Bertrand Russell
The two worst strategic mistakes to make are acting prematurely and letting an opportunity slip; to avoid this, the warrior treats each situation as if it were unique and never resorts to formulae, recipes or other people's opinions.
Paulo Coelho
The majority, oppressing an individual, is guilty of a crime, abuses its strength, and by acting on the law of the strongest breaks up the foundations of society
Thomas Jefferson
Nation state as a fundamental unit of man's organized life has ceased to be the principal creative force: International banks and multinational corporations are acting and planning in terms that are far in advance of the political concepts of the nation-state
Zbigniew Kazimierz Brzezinski
Accept fate, and move on. Don't yield to the seductive pull of self-pity. Acting like a victim threatens your future.
It is a simple fact that all of us use the techniques of acting to achieve whatever ends we seek.
Marlon Brando
Acting serves as the quintessential social lubricant and a device for protecting our interests and gaining advantage in every aspect of life.
Marlon Brando
The principal benefit acting has afforded me is the money to pay for my psychoanalysis.
Marlon Brando
Getting ahead in a difficult profession - singing, acting, writing, whatever requires avid faith in yourself. You must be able to sustain yourself against staggering blows and unfair reversals. When I think back to those first couple of years in Rome, those endless rejections, without a glimmer of encouragement from anyone, all those failed screen tests, and yet I never let my desire slide away from me, my belief in myself and what I felt I could achieve
Sophia Loren
The creation of something new is not accomplished by the intellect but by the play instinct acting from inner necessity. The creative mind plays with the objects it loves
Carl Gustav Jung
Are we acting like a couple? Im just trying to get it straight. Cause Im over here convinced that its too early for mistakes.
More people have probably died from eating dodgy Chinese food than contracting some form of avian flu. The last thing we want is for the Daleks from Defra to start suggesting that they want to exterminate wildlifeas is their normal response when confronted with such a problem. We do not want any proposal that migrating birds are going to be destroyed because of alarmist figures and notions that appear in the Tory press.
Tony Banks


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Africa's shifting landscape inspires Food Security Group Published: Saturday, 18 May 2013
Having worked for years in Mali, Mozambique, Kenya and Zambia, MSU's Food Security group puts experience to work supporting food security around the world.
Spartan Engineers: Solving Real World Challenges Published: Thursday, 09 May 2013
At MSU, the College of Engineering is giving students the chance to provide solutions to real world challenges in developing nations.
When it has to get there, Spartan Teamwork Delivers Published: Friday, 03 May 2013
MSU's School of Packaging has been a trusted collaborator with the United States Agency for International Development (USAID) and the United States Department of Agriculture USDA, helping to ensure shipments of food during crisis arrive safely.
Producing clean energy, reducing waste Published: Friday, 12 Apr 2013
MSU scientists collaborate with leading researchers in Costa Rica and Nicaragua to bring clean energy to rural areas.
Economic growth in Malawi Published: Thursday, 04 Apr 2013
Michigan State University's collaboration with Lincoln University and the University of Malawi to help find new ways to contribute more effectively to African development and transformation through agriculture-led economic growth.
Conservation: One Bird Song at a Time Published: Tuesday, 26 Mar 2013
A passionate ornithologist builds a scientifically valuable bird sound database.
We Have Bad News for TB Published: Tuesday, 19 Mar 2013
Researchers at Michigan State University are developing strategies to combat drug-resistant TB.
MSU: A champion for resilient communities Published: Thursday, 28 Feb 2013
MSU and its partners in Tanzania are committed to unraveling the multi-faceted issues of poverty and are placing a priority on facilitating resilient communities.
Mexican Collaboration Shines Ligh on Osteopathic Medicine Published: Tuesday, 26 Feb 2013
Michigan State University has a new partnership in hyperbaric medicine with the Yucatan Department of Health, which now has a 23-patient capacity hyperbaric chamber.
Nourishing People - and an economy Published: Friday, 22 Feb 2013
In an effort to double the capacity of Malawi's dairy value chain, MSU researchers led by Puliyur MohanKumar, professor in the College of Veterinary Medicine, are applying successful outcomes from a similar MSU partnership project that helped transform India's dairy industry. India, now the world's top milk producer, shares similar environmental and cultural traits with Malawi.
Follow MSU 's crew as it chronicles Spartan impact around the world Published: Thursday, 31 Jan 2013
The SPARTANS WILL. 360 crew is taking you on an adventure—around the world and on the scene—to see the indispensable work of MSU's scientists, scholars, and students.
Learn more about the project or start exploring for a firsthand look at Spartan impact in locations from East Lansing to East Africa.
MSU to lead global food system innovation center on behalf of USAID Published: Friday, 09 Nov 2012
Michigan State University will use a $25 million grant from the United States Agency for International Development to improve agricultural production and reduce poverty in areas of the world suffering from rapid urbanization, population growth and skills gaps.
Professor Takes on Debilitating Diseases Afflicting Millions Published: Thursday, 26 Apr 2012
They don't kill, so they don't make many headlines. But river blindness and elephantiasis cause untold suffering for tens of millions of people worldwide, leaving many unable to provide for themselves and their families, and locking them into a cycle of poverty.
The diseases may soon be history, though, thanks in large part to Charles Mackenzie, a professor of veterinary pathology at Michigan State University.
New Links Create Opportunities for Medical Students and Research Published: Thursday, 26 Apr 2012
In an effort to boost medical research and enhance global health care training, Michigan State University is creating new strategic partnerships with colleges and teaching hospitals in South Africa and the Dominican Republic.
The initiative, led by Reza Nassiri, professor and acting director of MSU's Institute of International Health, will include faculty and student exchanges and may eventually expand collaborations in clinical research projects.
Tri - University Partnership to Advance Understanding of Veterinary Medicine Published: Thursday, 26 Apr 2012
Along with faculty from Makerere University in Uganda and Tamil Nadu Animal and Veterinary Sciences University in India, MSU faculty are bringing together leading researchers, educators and outreach specialists in veterinary medicine to address shared concerns with human, livestock and wildlife interfacing.
Providing Surgery to those in Need, Improving Quality of Life in Mexico Published: Thursday, 26 Apr 2012
A long-term collaboration between a non-profit organization in Playa del Carmen, Mexico and the colleges of communication arts and sciences and osteopathic medicine has been expanded to include the city government of Solidaridad. Together the partners will address ways to improve access to surgical care for low-income families in the region.
Strengthening Agriculture and Trade in West Africa Published: Thursday, 26 Apr 2012
John Staatz leads a set of agricultural research projects in West Africa, with funding totaling $7.5 million, aimed at improving the performance of West Africa's food system. Researchers, farmers, traders, government officials and non-governmental organizations are all part of a collaborative effort to improve agricultural productivity and access to food in Mali and other countries in West Africa.
Market - Driven Development in Burundi Published: Thursday, 26 Apr 2012
For the first time in Burundi's 80-year history of coffee production, the once war-torn, African country is producing specialty coffee to be sold direct to the markets, thanks to training and research provided by Michigan State University.
Community Development in Peru Published: Thursday, 26 Apr 2012Providing opportunities for interdisciplinary teams of students to engage in community-based research and development projects in agricultural and engineering, Irving Widders, professor of horticulture, and Brian Thompson, professor of mechanical engineering, have started a study abroad program to examine and meet the needs of underserved communities in the Andean highlands.
New Supporters Develop Mango Industry in India Published: Thursday, 26 Apr 2012
With support from the Agricultural Product Export Development Authority, the Federation of Indian Chambers of Commerce and the National Institute of Marketing Boards, the Indian Horticulture Development Alliance is promoting growth in the Indian mango market.


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Naming Evil, Judging Evil
Is it more dangerous to call something evil or not to? This fundamental question deeply divides those who fear that the term oversimplifies grave problems and those who worry that, to effectively address such issues as terrorism and genocide, we must first acknowledge them as evil. Recognizing that the way we approach this dilemma can significantly affect both the harm we suffer and the suffering we inflict, a distinguished group of contributors engages in the debate with this series of timely and original essays.
Drawing on Western conceptions of evil from the Middle Ages to the present, these pieces demonstrate that, while it may not be possible to definitively settle moral questions, we are still able—and in fact are obligated—to make moral arguments and judgments. Using a wide variety of approaches, the authors raise tough questions: Why is so much evil perpetrated in the name of good? Could evil ever be eradicated? How can liberal democratic politics help us strike a balance between the need to pass judgment and the need to remain tolerant? Their insightful answers exemplify how the sometimes rarefied worlds of political theory, philosophy, theology, and history can illuminate pressing contemporary concerns.
Alasdair MacIntyre
Part 1: Speaking About Evil
Chapter 1 Where Did All the Evils Go?
Michael Allen Gillespie
Chapter 2 Seeing Darkness, Hearing Silence: Augustine's Account of Evil
Stanley Hauerwas
Chapter 3 The Rousseauan Revolution and the Problem of Evil
Ruth W. Grant
Chapter 4 Inequality and the Problem of Evil
Nannerl O. Keohane
Part 2: Making Judgments, Passing Judgment, Taking a Stand, Biting Your Tongue
Chapter 5 The Butler Did It
J. Peter Euben
Chapter 6 Evil and the Morality of Conviction
David Wong
Chapter 7 Combining Clarity and Complexity: A Layered Approach to Cross-Cultural Ethics
Elizabeth Kiss
Chapter 8 Liberal Dilemmas and Moral Judgment
Malachi Hacohen
Chapter 9 Between Bigotry and Nihilism: Moral Judgment in Pluralist Democracies
Thomas A. Spragens, Jr.
Philosophy: General Philosophy
Political Science: Political and Social Theory
Religion: Religion and Society
You may purchase this title at these fine bookstores. Outside the USA, see our international sales information.


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Lot 4020 |
2010 January Orlando, FL FUN US Coin Auction #1136
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Auction Ended On: | Jan 8, 2010 |
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Location: | Orlando, FL |
Elusive 1850-O Eagle, AU53
1850-O $10 AU53 NGC. The current offering is another
condition rarity in the Liberty No Motto eagle series. The combined
NGC and PCGS population data documents seven examples at the Mint
State level, although Doug Winter opines that the Eliasberg coin
(MS65 PCGS) is the only Uncirculated 1850-O ten in existence--the
other six coins are listed in the NGC Census Report as MS60
specimens. The reality is that most collectors, regardless of
finances, must gladly accept a lightly circulated example for
inclusion in their sets. It is not a matter of waiting, but rather
a factor of availability; only a few Mint State pieces have
weathered the relentless perils of time. We proudly offer this
example, which retains a significant amount of reflectivity in the
fields on each side. The surfaces are lightly abraded and there are
a number of small abrasions peppered over both the obverse and
reverse. Census: 25 in 53, 35 finer (12/09).(Registry
values: N2998) (NGC ID# 2639, PCGS# 8605)
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