American College of Chest Physicians' cough guidelines

Abstract

We appreciate the opportunity to respond to the Editorial “Cough guidelines choke on evidence” (Jan 28, p 276).1The LancetCough guidelines choke on evidence.Lancet. 2006; 367: 276Scopus (14) Google Scholar We are delighted that The Lancet acknowledges that we “obviously worked hard” on “this massive task” to update what is known about diagnosing and managing cough, the most common complaint for which patients seek medical care.2Woodwell D National ambulatory medical care survey: 1998 summary. National Center for Health Statistics, Hyattsville, MD2000Google Scholar However, we wish to clarify and correct the misconceptions and inaccuracies in the Editorial regarding American College of Chest Physicians' (ACCP) evidence-based guideline development in general and the Cough Guidelines in particular,3American College of Chest PhysiciansDiagnosis and management of cough: ACCP evidence-based clinical practice guidelines.Chest. 2006; 129: 1S-292SPubMed Google Scholar and the ambiguous statement about funding of the cough guidelines. ACCP uses the most rigorous and current methods to develop its evidence-based clinical practice guidelines, including those for cough. As this field has evolved, so has ACCP's process.4Guyatt G Gutterman D Baumann M et al.Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians Task Force.Chest. 2006; 129: 174-181Crossref PubMed Scopus (1006) Google Scholar, 5Guyatt G Baumann M Pauker S et al.Addressing resource allocation issues in recommendations from clinical practice guideline panels: suggestions from an American College of Chest Physicians Task Force.Chest. 2006; 129: 182-187Crossref PubMed Scopus (46) Google Scholar Recommendations are based on the best available evidence and consideration of the benefits to patients. The Duke University Center for Clinical Health Policy served as the Evidence-based Practice Center that independently searched and synthesised the scientific literature. When the evidence was not robust, the panel had to decide whether to do nothing or to offer some guidance to clinicians faced with patients in need of medical management. The highly respected members of this international panel provided guidance even when there were no published clinical trial results. To be totally transparent, all such recommendations were graded with an E to identify that the level of evidence was expert-based. Therefore, the grade for the recommendation advocating for smoke-free workplaces was not graded A as noted in The Lancet Editorial, but rather as E/A, denoting expert-based (E) quality of evidence with a substantial net benefit for patients (A). The benefit to the patient or the population is essential to the understanding of how to use evidence-based recommendations because it represents the balance of benefits and harms. These explanations appear in the section on methodology and grading of the full guidelines3American College of Chest PhysiciansDiagnosis and management of cough: ACCP evidence-based clinical practice guidelines.Chest. 2006; 129: 1S-292SPubMed Google Scholar that does not seem to have been read when the Editorial was written. For example, there were 880 references cited in the guidelines, not 275 as stated in the Editorial. Although the publication cost of the guidelines was funded with an unrestricted grant by two pharmaceutical companies, numerous firewalls have existed to prevent influence or the perception of influence by the sponsors. The ACCP's guideline process is transparent and designed to be free from influence from industry. Each cough guideline panelist also disclosed personal and financial conflicts. ACCP policies cover both these issues. In such a climate of full disclosure, and when The Lancet requires that all clinical trials are registered before the first patient is enrolled, we would have preferred to have known who personally wrote this Editorial suggesting that we participated in a “hollow exercise”. We declare that we have no conflict of interest.