The Composition of Clinical Practice Guidelines Authorship and Why It Should Change

Clinical practice guidelines (CPGs) are developed by medical societies to serve as evidence-based recommendations for the prevention, diagnosis, and management of medical disorders. These guidelines can potentially influence various aspects of patient care, including diagnostic algorithms, treatment options, health insurance coverage of diagnostic testing and treatment, which may affect patients’ access to services, and the allocation of resources across global populations. While the goal of CPGs is to promote consistency across clinical practices, adopting a uniform approach may, however, overlook individual patient differences. To provide individualized and personalized care, health care professionals must consider not only patients’ genetic factors but also their lifestyle choices, environmental influences, and social determinants of health. Key elements shaping these social determinants include sex, gender, race, and ethnicity; yet, the impact of these factors on health outcomes is frequently not taken into consideration when making routine clinical decisions.^1,2 Integrating these considerations into CPGs could enhance the quality and equity of health care delivery.

Current CPGs offer limited consideration of sex, gender, race, and ethnicity. For instance, despite well-documented differences between men and women in the epidemiology, presentation, diagnosis rates, and management of heart disease, the American College of Cardiology (ACC) guidelines provide few sex- and gender-specific recommendations beyond the settings of pregnancy and lactation. ³ To address this gap, several researchers have proposed strategies to enhance the inclusion of sex- and gender-specific guidance in CPGs.^4–6 One approach is to increase the representation of women on guideline writing committees, as Nielson et al., after analyzing over 1.5 million publications, identified a positive correlation between female authorship and the presence of sex and gender analyses. ⁷ Sardar et al. further argued that greater involvement of women in guideline development can broaden the perspectives of writing groups, highlight the need for female-specific recommendations, and uncover knowledge gaps in sex- and gender-related data. ⁸ Having reviewed CPG authorship trends across various medical specialties, Merman et al. advocated for increasing the representation of women authors on CPGs by standardized reporting of author selection processes and metrics on women’s representation. ⁹ Tannenbaum et al. recommend appointing a dedicated sex/gender champion to every guideline writing committee to ensure meaningful inclusion of sex- and gender-specific recommendations. ⁶

With respect to race and ethnicity, there is a similar lack of diversity in CPG authorship. Several studies have highlighted this disparity, demonstrating the underrepresentation of racial and ethnic minority authors, especially of non-white women, and the disproportionate overrepresentation of white male physicians in the authorship of CPGs.^10–13 This disparity may not only limit career advancement and recognition for authors from underrepresented groups but may also influence the scope and content of the CPGs themselves. Since guideline authors exert influence over the content that is prioritized, increasing diversity within CPG writing teams could lead to more inclusive recommendations that address sex, gender identity, race, ethnicity, and other social determinants of health. In their review of disparities among guideline panel committees in the World Health Organization, Bohren et al. emphasized the importance of awareness in reducing bias, stating that “when people from diverse backgrounds—including different genders, cultures, ethnicities, and religions—join forces, they bring with them their own experiential knowledge that enriches discussions and promotes equality.” ¹⁴

In this issue, Taneja et al. evaluated the representation of women and individuals from minoritized racial and ethnic groups among authors and contributors of CPGs. ¹⁵ The authors performed a comprehensive literature search in databases including OVID MEDLINE, Embase.com, Web of Science, Cochrane CENTRAL, and ClinicalTrials.gov from inception to September 2023. They found 2,436 studies focusing on CPG authorship disparities by gender, race, and ethnicity. Of these studies, only 20 reported data on gender, racial, and ethnic composition among CPG authors and were included in their review and meta-analysis. These 20 studies included representation from ten specialties (cardiology, gastroenterology, oncology, urology, critical care, radiation oncology, pathology, otolaryngology, neurology, and physical medicine and rehabilitation) and a total of 36,783 author positions. While all 20 studies reported sex/gender representation among authors, only three studies reported race composition. The authors found that the proportion of women authors ranged from 10.6% to 45.0% across the studies, with an overall proportion of 25.7% (95% CI: 21.8–30.1%). Of the three studies reporting race composition, most authors were identified as White, with minimal representation from Black, Hispanic, and Asian authors.

In 2024, Martin et al. examined the diversity of the authorship of the American Academy of Pediatrics (AAP) CPGs and found similar results. ¹⁶ They found that female and female physician authors among AAP clinical practice guideline writing committees were significantly underrepresented, whereas male and male physician authors were significantly overrepresented compared to their respective composition in the U.S. Census and in the medical school pediatric faculty. ¹⁶ Martin et al. also found that women and women physicians from all racial and ethnic groups, in addition to men and men physicians from minority racial and ethnic groups, were markedly underrepresented when compared to their respective composition in the U.S. Census and in the medical school pediatric faculty. ¹⁶ Of note, during the study period from January 2010 to May 2023, there were no Black men identified as authors in any of the AAP CPGs. ¹⁶

CPG are evidence-based sources of medical information that can significantly influence and establish the standard of care for patients worldwide. Medical organizations that are responsible for developing CPG should recognize the current underrepresentation and overrepresentation among CPG authors in terms of sex, gender, race, and ethnicity and understand the impact that authorship representation can have on the content, relevance, and acceptance of CPGs as well as on the professional development of their contributing authors. CPG committees should routinely assess the diversity of their authorship and proactively establish procedures to foster inclusive representation in their writing committees. One effective strategy would be to include a diversity champion on every guideline writing committee, ⁶ with the goal of promoting authorship diversity such that authors reflect both the medical community and the patient populations they serve.