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of interest among experts who craft guidelines: Institute of Medicine. Conflict of Interest in Medical Research, Education, and Practice (Washington, DC: National Academies Press, 2009); Pamela Hartzband, Jerome Groopman, “Keeping the patient in the equation: Humanism and health care reform, NEJM 361 (2009), pp. 554–555; Courtney Humphries, “Deeply conflicted: How can we insulate ourselves from conflicts of interest? The most popular solution—disclosing them—turns out not to help,” Boston Globe, May 15, 2011.

64 Ongoing controversy around such guidelines and the risks-versus-benefits effects of statins are found in Jennifer Couzin, “Cholesterol veers off script,” Science 322 (2008), pp. 220–223; J. Abramson, J. M. Wright, “Are lipid-lowering guidelines evidence-based?” Lancet 369 (2007), pp. 168–169; Nortin M. Hadler, Worried Sick: A Prescription for Health in an Overtreated America (Chapel Hill: University of North Carolina Press, 2008). The issue of treating to maximally lower the LDL levels: Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) Collaborative Group, “Intensive lowering of LDL cholesterol with 80 mg versus 20 mg simvastatin daily in 12064 survivors of myocardial infarction: A double-blind randomised trial,” Lancet 376 (2010), pp. 1658–1669; Bernard M. Y. Cheung, Karen S. L. Lam, “Is intensive LDL-cholesterol lowering beneficial and safe?” Lancet 376 (2010), pp. 1622–1623; Rodney A. Hayward, Timothy P. Hofer, Sandeep Vijan, “Narrative review: Lack of evidence for recommended low-density lipoprotein treatment targets: A solvable problem,” Ann Intern Med 145 (2006), pp. 520–530.

64 The durability of one hundred recommendations from expert committees: Kaveh G. Shojania et al., “How quickly do systematic reviews go out of date? A survival analysis,” Ann Intern Med 147 (2007), pp. 224–233. Also see Paul G. Shekelle et al., “Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: How quickly do guidelines become outdated?” JAMA 286 (2001), pp. 1461–1467. Suspending practice guidelines at five years: Amir Qaseem et al., “The development of clinical practice guidelines and guidance statements of the American College of Physicians: Summary of methods,” Ann Intern Med 153 (2010), pp. 194–199.

65 The controversy about hormonal replacement therapy for postmenopausal women continues; see Rowan T. Chlebowski et al., “Estrogen plus progestin and breast cancer incidence and mortality in postmenopausal women,” JAMA 304 (2010), pp. 1684–1692; Peter B. Bach, “Postmenopausal hormone therapy and breast cancer: An uncertain trade-off,” JAMA 304 (2010), pp. 1719–1720. Also see recent debate over estrogen replacement for women who had a hysterectomy: Andrea Z. LaCroix et al., “Health outcomes after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy: A randomized controlled trial,” JAMA 305 (2011), pp. 1305–1314; Emily S. Jungheim, Graham A. Colditz, “Short-term use of unopposed estrogen: A balance of inferred risks and benefits,” JAMA 305 (2011), pp. 1354–1355. Regarding women’s health, there also is debate among experts about the indications for bisphosphonate medications: Murray J. Favus, “Bisphosphonates for osteoporosis,” NEJM 363 (2010), pp. 2027–2035; Natasha Singer, “Questions for doctors, and juries: Cases cast doubt on frequent use of bone-loss drugs,” New York Times, November 11, 2010.

65 Another example of the complexity of applying guidelines involves asthma treatment and real world practice: David Price et al., “Leukotriene antagonists as first-line or add-on asthma-controller therapy,” NEJM 364 (2011), pp. 1695–1707; Sven-Erik Dahlen, Barbro Dahlen, Jeffrey M. Drazen, “Asthma treatment guidelines meet the real world,” NEJM (editorial) 364 (2011), pp. 1769–1770; James H. Ware, Mary Beth Harmel, “Pragmatic trials—Guides to better patient care?” NEJM 364 (2011), pp. 1685–1687.

65 Informed patient preferences at the “pinnacle” of quality care: Institute of Medicine (National Academy of Sciences), Crossing