Fewer than half of organizations that have recently listed a large number of guidelines in the NGC have a COI policy directly related to CPGs. Of organizations with such policies, these vary widely with respect to types of COI addressed, from whom disclosures are collected, monetary thresholds for disclosure, approaches to management, and updating requirements. Not one organization's policy adhered to all seven of the IOM 2011 standards applicable to COI policies for CPGs, and approximately half of these organizations do not adhere to a single one of these standards.
There is a need for extensive improvements in COI policies for organizations producing CPGs. Every developer must have a COI policy specific to CPGs: a general COI policy for the organization or a policy that relates to research subjects, for example, is not adequate to address the issues of secondary interests relevant to guideline development. Guidelines involve multiple groups of individuals and processes, and the COI of all of these must be disclosed: authors of the systematic review, the guideline panel members, and other individuals involved in the formulation and approval processes. COI policies for CPGs must also address management of the disclosures, starting with the requirement that the guideline panel chair and co-chair have no relevant COI.
There are important implications of our findings for users of CPGs. Given the evidence that financial relationships of researchers are associated with study findings 
and that guideline panel composition correlates with panel recommendations 
, the reader needs to have ready access to accurate and up-to-date disclosures, and be assured that secondary interests have been appropriately managed.
Nonfinancial COI may be an important source of bias, and two-thirds of organizations make some mention of this type of COI in their policies. Definitions are variable, however, and often vague and difficult to interpret, potentially leading to inconsistent and incomplete reporting. The current knowledge base on the impact of nonfinancial COI on decision making is sparse, so that the development of evidence-based guidance on the disclosure and management of nonfinancial COI is difficult at the present time.
The IOM standards related to COI do not address all of the important issues for CPG developers and users. In particular, these standards do not address accessibility of COI policies, the relevance of secondary interests to the primary interest, and the optimal presentation of disclosures. We often encountered a great deal of difficulty locating COI policies: these policies should be readily accessible from the guideline organization's website. Policies on disclosures should address both relevance and an appropriate level of detail. Inadequate guidance within COI policies on these issues may reflect lack of evidence on both the relationship between specific types of conflicts and risk of bias, and what constitutes optimal disclosures for the reader. IOM standards also do not address accountability for accurate disclosures and adherence to the policy within the organization. In other words, adherence to these seven IOM standards does not ensure an optimal COI policy.
There are limitations to our approach. Most importantly, we did not assess if and how these policies were applied during CPG development and publication. Nor did we examine the impact of each organization's policy on their processes, disclosures, recommendations, and the use and interpretation of the guidelines by healthcare providers. Our descriptive work provides the basis for these important next steps in evaluating the nature and effect of COI policies in CPG development.
It is possible that our summary of these organizations' policies is not up to date. Given the current attention to COI policies by biomedical journals 
and organizations producing CPGs 
, the COI policies for the organizations that we examined may have changed between development of the CPGs listed on the NGC website, our examination of the policy, and the present. Our information on specific policies may be incomplete in spite of having two independent persons identifying COI policies due to difficulty locating policies in various locations in linked websites.
We did not contact organizations for additional, unpublished information, nor did we try to obtain information from organizations with protected websites. We felt that if the guideline was in the public domain the COI policy should be there also, given the presumed importance of transparency in COI processes and disclosures. We also encountered challenges in determining if an organization's COI policy was specific to CPGs. Two independent reviewers made this assessment and then came to consensus, but it is possible that some of the organizations that we assessed as not having a CPG-specific policy would consider themselves to have such a policy. We would counter that these policies need to be more transparent and to address the processes and individuals involved in CPGs specifically.
The applicability of our findings to other organizations producing CPGs may be limited. The COI policies of organizations producing a small number of CPGs (less than 5) may differ from the policies that we examined. In addition, we focused only on CPGs published in English and those listed in NGC: the policies of other organizations may differ from our findings. The IOM standards were developed by a US-based group of experts, and thus encompass the American perspective on guideline topics, methodology, available resources, and the standards target U.S. patient populations and health care providers. The evidence base examined in the IOM report encompasses studies from a variety of international settings, and thus the IOM standards are likely applicable to guideline development in the Western world.
The IOM standards 
were released after the publication of the CPGs examined herein. Thus our goal in comparing the IOM standards to existing organizational polices was to describe the current status of these policies and to identify areas where improvements are needed and not to criticize organizations for not having met these standards. Our reporting of the gaps in current approaches may aid organizations in planning updates of their COI policies and in comparing policies across organizations.
The IOM standards were not intended to be a quality assessment tool, thus implementing them as such was problematic. Standard 2.1 addresses both financial and nonfinancial COI, thus the two types of COI are not distinguished. Many of the standards are too vague to implement as quality assessment criteria: for example, standard 2.4a ().
COI policies among organizations producing a large number of CPGs currently do not measure up to IOM standards. Policy-makers, guideline funders, sponsors, and developers, as well as users need to address and demand improvements. Patients and populations need trustworthy CPGs, and the accurate disclosure and subsequent management of COI is essential to achieve that goal.