Diversity of Authorship in Clinical Practice Guidelines– Not There Yet

Precision medicine is a paradigm of medical care that takes variability in genes, environment, and lifestyle into account for each individual patient. It requires that health care providers assess not only genetic information but also social determinants of health. Important factors affecting social determinants of health are sex, a genetic variant that divides all human beings into two distinct populations with some variants; gender, social roles of females, males, and non-binary persons in our society; and race and ethnicity. The impact of sex, gender, race, and ethnicity on health care outcomes; however, are not routinely taken into consideration in clinical practice. ^1,2

Medical societies produce clinical practice guidelines (CPGs) to serve as evidence-based standards of clinical care. CPGs can affect access to care, diagnostic testing, treatment interventions, and resource distribution for patient populations worldwide. While CPGs can help standardize clinical practice, they can also result in a one-size-fits-all set of recommendations, rather than account for differences in patient factors. For example, although there are known differences between men and women in the epidemiology, presentation, rates of diagnosis, and management of heart disease, the American College of Cardiology (ACC) clinical practice guidelines do not make sex- and gender-specific recommendations for the prevention, diagnosis, and treatment of heart disease beyond pregnancy and lactation. ³ Several authors suggest methods to increase sex- and gender-specific recommendations in clinical practice guidelines. ^{4 –6} One option is to increase women’s authorship on clinical practice guideline writing committees as Nielson et al., having reviewed more than 1.5 million publications, found a positive correlation between the inclusion of sex and gender analyses and women’s authorship. ⁷ Furthermore, Sardar et al. emphasized that increasing the number of women authors on CPGs has the potential to diversify the perspective of the writing group, increase the attention to the need for recommendations specific to women, and identify knowledge gaps pertaining to sex- or gender-specific data. ⁸ Merman et al. examined the number of women authors on CPGs across multiple medical specialties and recommended increasing the representation of women authors on CPGs by standardizing the publication of methods used to select authors and the reporting of metrics of women’s representation. ⁹ To guarantee the inclusion of sex- and gender-specific recommendations in CPGs, Tannenbaum et al. suggest including a sex/gender champion on all guideline writing committees. ⁶

Similarly, clinical practice guideline writing committees also show a lack of racial and ethnic diversity among their authors. ^{10 –12} Silver et al. found that authors, particularly women authors, from racial and ethnic minority groups were underrepresented among authors of a CPG for low back pain. ¹¹ Verduzco-Gutierrez et al. evaluated 237 rehabilitation medicine guidelines with 3,696 panel members and also found that guideline writing committees had an underrepresentation of non-white women. ¹² Martin et al. also assessed pathology CPG authorship representation and found that women and Asian physicians were significantly underrepresented and white male physicians were significantly overrepresented. ¹³ Not only do inequalities of representation on CPG author committees contribute to inequalities in career opportunities and promotion for authors of underrepresented genders, ethnicities, and races, but these inequalities may also affect the content of the guidelines themselves. As CPG authors can exert influence over addressing certain topics in guidelines, increasing the diversity among CPG authorship can potentially increase the content in CPGs pertaining to sex, gender identity, race and ethnicity, and other social determinants of health. In a review of disparities among World Health Organization (WHO) guideline panel committees, Bohren et al. state that awareness is crucial to mitigate bias and 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, Martin et al. examined the diversity of the authors of clinical practice guidelines produced by the American Academy of Pediatrics (AAP) from January 2010 to May 2023. ¹⁵ The authors hypothesized that women and individuals from minority racial and ethnic groups would also be underrepresented as CPG authors. In their cross-sectional study, Martin et al. analyzed the gender, race, and ethnic composition of authors and subcommittee participants of AAP CPGs and compared the diversity of authorship with that of the 2010 and 2021 United States’ (US) population and the 2010 and 2022 US medical school pediatric faculty. They found that women and women physician authorship was significantly underrepresented while men and men physician authorship was significantly overrepresented compared with their respective composition in the US Census in 2010 and 2021 and in the medical school pediatric faculty in 2010 and 2022. Women comprised 42.5% of named author positions, an underrepresentation of 10.8% and 21.4% when compared with the 2021 US population and 2022 US medical school pediatric faculty, respectively, and women physicians comprised 36.4% of named author positions, an underrepresentation of 8.0% and 18.6% when compared to the 2021 US population and 2022 US medical school pediatric faculty, respectively. Women and women physicians from all racial and ethnic groups as well as men and men physicians from minority racial and ethnic groups were significantly underrepresented when compared to their respective composition in the US Census in 2010 and 2021 and in the pediatric faculty in 2010 and 2022. White individuals comprised 90.9% of all positions, an overrepresentation of 15.1% and 26.8% when compared with the 2021 US population and the 2022 US medical school pediatric faculty, respectively, and comprised 90.5% of named author positions, an overrepresentation of 14.6% and 26.4% when compared with the 2021 US population and the 2022 US medical school pediatric faculty, respectively. Of note, no Black men were identified as authors in any of the AAP clinical practice guidelines from January 2010 to May 2023.

Clinical practice guidelines are trusted, evidence-based sources of medical information and can significantly influence the care of patients worldwide. Medical societies that produce clinical practice guidelines should be aware of current authorship underrepresentation and overrepresentation in terms of gender, race, and ethnicity. All CPG guideline committees should be aware of the need for diversity among their authors, evaluate the composition of their authorship, and implement a process that promotes diversity. Including a diversity champion on all guideline writing committees is a potential method to promote authorship diversity such that authors are representative of the field and patient populations that they address.