THYROID SPECIAL ARTICLE

Volume 28, Number 6, 2018

ª American Thyroid Association
ª Mary Ann Liebert, Inc.
DOI: 10.1089/thy.2018.0070

American Thyroid Association Guidelines and Statements:

Past, Present, and Future
American Thyroid Association Guidelines Policy and Procedures Task Force

Anna M. Sawka,1,* Sally E. Carty,2 Bryan R. Haugen,3 James V. Hennessey,4 Peter A. Kopp,5
Elizabeth N. Pearce,6 Julie A. Sosa,7 Ralph P. Tufano,8 and Jacqueline Jonklaas9,*

Background: The American Thyroid Association (ATA) is continually striving to improve the quality of its
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publications. The ATA Guidelines Policies and Procedures Task Force was active during 2017. It recently
recommended convening a formal standing committee to review and update policies and procedures for the
development of clinical practice guidelines (CPGs) and Statements on an ongoing basis.
Objective: This statement reviews the history of official ATA publications and discusses the challenges and
findings identified by the Task Force. We also wish to present our ‘‘work in progress’’ and propose future
directions for the new ATA Guidelines and Statements Committee (ATA GSC).
Methods: Our Task Force reviewed the publication record of the ATA with respect to CPGs. We also reviewed
existing ATA policies for CPGs and other official statements, examined policies of other organizations, solicited
input from external experts and organizations, and convened five conference calls and two in-person meetings.
Results: The ATA has a rich history of developing official publications that have been influential based on
download and citation records as well as changes in practice trends. Key future issues to be further addressed by
the ATA GSC include the following: (i) striving to improve the methodologic rigor of development of CPGs while
balancing considerations of feasibility and timeliness and the role of transparently communicated expert opinion;
(ii) formalizing a framework and process for development of new Statements; (iii) increasing stringency and
transparency of management of competing interests of individuals being considered for CPG/Statement panel
membership; (iv) encouraging consideration of equity and diversity in CPG/Statement development group
composition; (v) increasing relevant stakeholder representation (including patient representatives) in development
of CPGs/Statements; and (vi) expanding future guideline implementation strategies.
Conclusions: As shown by the completed literature search, the ATA has a long history of producing CPGs and
Statements with global impact on informing clinical management, education, and research in thyroid diseases. The
ATA remains committed to a process of continual improvement of its publications and to meeting stakeholder
information needs. Based on the work of our Task Force, we have identified many elements that are needed to
achieve this goal and areas of challenge for our new committee.

Keywords: clinical practice guidelines, statements, thyroid disease, clinical practice, clinical care, best prac-
tices, stakeholders

1
University Health Network, University of Toronto, Toronto, Ontario, Canada.
2
Division of Endocrine Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
3
Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado.
4
Division of Endocrinology, Harvard Medical School, Division of Endocrinology, Beth Israel Deaconess Medical Center, Boston,
Massachusetts.
5
Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University, Feinberg School of Medicine, Chicago,
Illinois.
6
Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, Massachusetts.
7
Departments of Surgery and Medicine, Duke Cancer Institute and Duke Clinical Research Institute, Duke University Medical Center,
Durham, North Carolina.
8
Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University
School of Medicine, Baltimore, Maryland.
9
Division of Endocrinology, Georgetown University Medical Center, Washington, DC.
This document has been approved by the ATA Executive Committee and Board of Directors.
*Co-chairpersons.

692
 GUIDELINES: PAST, PRESENT, AND FUTURE
INTRODUCTION
T he American Thyroid Association (ATA) was
founded in 1923 and currently includes over 1700
members from 43 countries (1). The ATA is a leading
worldwide organization dedicated to the advancement, un-
derstanding, prevention, diagnosis, and treatment of thyroid
biology, thyroid pathophysiology, thyroid disorders, and
thyroid cancer through excellence in research, clinical care,
education, and public health (1). The ATA has established a
role in educating patients, clinicians, and the public in this
field. It is active in the development of clinical practice
guidelines (CPGs) and other Statements, including position
statements.
The ATA has a long history of developing CPGs and
Statements, dating as far back as 1931, when the organization
was referred to as the American Association for the Study of
Goiter. The ATA continues to strive to improve the quality of
its CPGs and statements and recently established its first ATA
Guidelines Policy and Procedures Task Force to inform the
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planning of future clinical practice guidelines and statements.
This Task Force was charged with providing guidance on
standardization of methods for the development of CPGs and
Statements for the organization. After nine months of activ-
ity, this Task Force recommended the formation of a standing
committee to provide ongoing guidance regarding ATA
guidelines and statements. We summarize in this document
some of the past context, current findings and challenges, and
proposed future directions for the newly constituted and
commissioned ATA Guidelines and Statements Committee
(ATA GSC).
METHODS
We searched for documentation of prior ATA-sponsored
CPGs and Statements using the following sources: an
electronic database search, internal ATA records, and ATA
website listings. Electronic searches of PubMed and EM-
BASE were conducted from inception until December 2017,
by an information specialist librarian ( J.H.). The following
terms were used in the electronic search: American Goiter
Society, American Thyroid Association, guideline, state-
ment, consensus statement, position paper, policy state-
ment, research statement, and workshop or conference
statement. Hand searches also were conducted in an effort to
capture nonindexed articles (2). In the hand search, the
authors reviewed all pages of the ATA website, all elec-
tronic records of prior guidelines and statements retained by
the ATA (courtesy of Bobbi Smith), and queried historical
documents and society proceedings for information on any
additional relevant documents. Data on downloads and ci-
tations of documents have been provided by Mary Ann
Liebert, Inc., publishers, New Rochelle, NY, and Patricia
Smith and Kristi Homes, Galter Health Sciences Library,
Feinberg School of Medicine, Northwestern University,
Chicago, IL. Both Scopus and the Web of Science were
utilized for citation analysis. For simplicity in this docu-
ment, each individual CPG publication is referred to in the
singular, as a CPG.
Since January 2017, our Task Force has reviewed existing
ATA policies, policies of other organizations, sought input
from external experts and organizations, engaged in a di-
alogue with representatives of the National Guidelines
693
Clearinghouse, and convened five conference calls and two
in-person meetings. The Task Force co-chairpersons ( J.J. and
A.M.S.) formally presented the preliminary findings of the
group to the to the ATA Board of Directors at the Annual
Meeting of the ATA in Victoria, British Columbia, Canada
on October 18, 2017. The Board of Directors provided verbal
feedback, primarily relating to feasibility considerations. A
written Guidelines and Statements Policy and Procedures
document was developed by the Task Force, discussed
among the group members, and then revised, incorporating
additional input from all Task Force members and some
members of the Board of Directors. This internal policy
document was submitted to the ATA Executive Committee
on December 1, 2017, has been reviewed by the ATA Board
of Directors, and will be revised by the GSC in 2018. This
discussion summarizes some of our findings and provides an
update of our work in progress, as our policies and procedures
continue to be reevaluated and updated. Some of the relevant
topics being addressed by the group are presented here, to
update ATA members and relevant stakeholders on our
progress.
RESULTS
ATA Record of CPG and Statement Publication
Through 2017
Between 1931 and 2017, the ATA has published at least 34
CPGs (Tables 1–4) (3–46). The earliest identified CPG was
authored by Dr. Van Meter in 1931 as a work product of the
Committee on Goiter Classification and Nomenclature (3).
The most recent CPG, co-chaired by Drs. Alexander and
Pearce and published in 2017, was the second CPG addres-
sing thyroid dysfunction during pregnancy (45). The ATA
also has published at least 22 Statements (Table 5) (47–72).
The earliest identified Statement was published in 1977 by
Gorman et al., examining a potential relationship between
thyroid hormone and breast cancer development (47–49).
The most recent Statement, published by Leung et al. in
2017, addressed the role of potassium iodide in nuclear
emergencies (72). A review of the topics encompassed by
these CPGs and Statements illustrates a wide diversity and
the far-ranging expertise of ATA members. Each ATA CPG
resulted in at least four additional publications discussing,
debating, or applying the CPG recommendations or con-
trasting the CPG with those issued by another professional
society. The conclusions reached in ATA Statements have
been validated (73), for example in the case of refuting an
association between thyroid hormone replacement and breast
cancer (47–49). Thus, it is apparent that ATA CPGs have
played a pivotal role in inspiring a rich body of scholarly
literature. The number of downloads and citations received
by 9 of the 10 ATA CPGs published since 2012 are illustrated
in Figure 1. The data regarding downloads was collected on
December 11, 2017 and the dates of completion of the Scopus
and Web of Science citation analyses were December 21,
2017 and December 22, 2017 respectively. The citation data
for selected official ATA publications are shown in Table 6.
As has previously been reported (74), the citation numbers
were higher when Scopus was used as the database, com-
pared with use of the Web of Science. Currently the most
cited ATA CPG is the 2009 Thyroid Cancer Management
Guidelines (32) authored by Cooper et al., which has been
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Table 1. Chronology and Characteristics of ATA Guidelines 1931–1993

Committee/task force Number of discrete,
Lead author composition, numbered Journal where
No. Year (chair[s]) Topic male/female (% female) recommendations published Reference No.
1 1931 Van Meter Goiter nomenclature 3M (0% female) 4 West J Surgery 3
2 1969 Werner Classification of thyroid disease 6M (0% female) Not applicable JCEM 4
3 1969 Werner Classification of graves eye disease 5M (0% female) Not applicable JCEM 5,6
Am J Ophthalmology
4 1972 Solomon Nomenclature for tests of thyroid hormones 10M (0% female) 26(estimated) JCEM 7
5 1976 Solomon Revised nomenclature for tests of thyroid 10M (0% female) Not applicable JCEM 8
hormones
6 1976 Fisher Screening programs for congenital 4M/3F (43% female) 7 Am J Med 9,10
hypothyroidism Can J Med (1977)
7 1977 Werner Modification of classification of Graves eye 5M (0% female) 7 Am J Ophthalmology 11,12
disease JCEM
8 1987 Larsen Revised nomenclature for tests of thyroid 11M (0% female) Not applicable JCEM 13,15, 16

694
hormones Clin Chem
Arch Path Lab Med
9 1987 Holtzman Newborn screening for congenital 6M/5F (45% female) Not applicable Pediatrics 14
hypothyroidism
10 1990 Surks Guidelines for the use of laboratory tests in 5M (0% female) Not applicable JAMA 17
thyroid disorders
11 1991 Hay Assessment of current free thyroid hormone 4M/2F (33% female) Not applicable Clin Chem 21
and thyrotropin measurements
12 1991 McLaughlin* Nomenclature for thyroid autoantibodies 17M/2F (11% female)* 6 Thyroid, Clin Endo, 18, 19, 20, 22, 23
Acta Endocrinol,
JCEM 1992,
Autoimmunity
13 1993 LeFranchi Newborn screening for congenital 16M/6F (27% female) Not applicable Pediatrics 24
hypothyroidism
All guidelines above predated the routine documentation of conflict of interest (COI), utilization of systematic reviews, and grading of recommendations.
*Female chair(s)/lead author(s).
F, females; M, males.
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Table 2. Chronology and Characteristics of ATA Guidelines 1995–2009

Committee/
task force Critical Method
composition, Number of discrete, appraisal of formulating Journal
male/female COI numbered of evidence recommendations where Reference
No. Year Author Topic (% female) reported recommendations performed (grading system) published No.
14 1995 Singer Treatment guidelines for 9M (0% female) No Not applicable No Informal consensus JAMA 25
hyperthyroidism (expert opinion)
and hypothyroidism
15 1996 Singer Treatment guidelines for thyroid 11M (0% female) No Not applicable No Informal consensus Arch Int Med 26
nodules and well-differentiated (expert opinion)
Thyroid Cancer
16 2000 Ladenson Guidelines for detection of thyroid 8M (0% female) No Not applicable No Informal consensus Arch Int Med 27
dysfunction (expert opinion)
17 2004 Surks Subclinical thyroid dysfunction 9M/4F (31% female) Yes 18 Yes Modified USPSTF, JAMA 28

695
informal consensus
(expert opinion)
18 2006 Cooper Management guidelines for thyroid 8M/2F (20% female) Yes 85 Yes Modified USPSTF, Thyroid 30
nodules, differentiated thyroid informal consensus
cancer (expert opinion)
19 2006 Rose* Update on newborn screening 3M/4F writing group No Not applicable No Informal consensus Pediatrics 29
Brown* (57% female)* (expert opinion)
20 2009 Kloos Medullary thyroid cancer: 10M/1F (9% female) Yes 122 Yes Modified USPSTF, Thyroid 31
management guidelines informal consensus
(expert opinion)
21 2009 Cooper Revised management guidelines 11M/2F (15% female) Yes 80 Yes Modified USPSTF, Thyroid 32
thyroid nodules, differentiated Informal consensus
thyroid cancer (expert opinion)
*Female chair(s), lead author(s).
USPSTF, United States Preventive Services Task Force.
 696 SAWKA ET AL.

where Reference
downloaded 118,460 times and received 1440 citations.
Furthermore, the 2015 Thyroid Cancer Guidelines have al-

No.
34

35

33

37

38
ready been downloaded 473,758 times, exceeding downloads

ACP, American College of Physicians; AACE, American College of Clinical Endocrinologists; GRADE, Grading of Recommendations Assessment, Development, and Evaluation.
of the prior guideline iteration. Both the 2009 and 2015

Endo Pract,
Thyroid Cancer Management Guidelines have been down-
documented recommendations performed (grading system) published

Thyroid
Journal

Thyroid,
loaded throughout the world, with data for selected regions

Thyroid

Thyroid

Thyroid
Endo
Pract
shown in Table 7.

Agencies Relevant to Future ATA Guideline

(expert opinion)
of evidence recommendations
of formulating

Development
Method

applicable applicable

2010 AACE
consensus Development of CPGs is a key priority for the ATA. Three
Informal
GRADE

method
agencies are of particular relevance to these future activities.
USPSTF,
Modified

ACP
(i) Institute of Medicine. The Institute of Medicine, now
Not

known as the United States National Academy of Sciences,

Table 3. Chronology and Characteristics of ATA Guidelines 2011–2012

Engineering, and Medicine (abbreviated as IOM for sim-

appraisal
Critical

plicity), currently defines CPGs as ‘‘statements that include

recommendations intended to optimize patient care that are
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Yes

Yes

Yes

Yes
Not

informed by a systematic review of evidence and an assess-

ment of the benefits and harms of alternative care options’’
(75). In 2011 the IOM published eight standards for the de-
Number of

applicable
numbered

velopment of CPGs (75). These standards are focused on the

discrete,

following concepts: (a) establishing transparency of the

100

76

65

34
Not

development process (i.e. methods), (b) management of

competing interests, (c) composition of the guidelines de-
velopment group (GDG), (d) the intersection between CPGs
and systematic reviews, (e) establishing evidence founda-
tions and rating the strength of recommendations, (f)
COI

Yes

Yes

Yes

Yes

Yes

standardized wording of recommendations, (g) external

review of CPGs, and (h) documentation and process of
updating CPGs (75).
Hyperthyroidism and other causes 10M/3F (23% female)*
task force composition,

Radiation safety in the treatment 10M/4F (29% female)

8M/3F (27% female)

25 2012 Smallridge Guidelines for management of patents 9M/4F (31% female)

Guidelines for hypothyroidism in 7M/2F (22% female)

(ii) Guidelines International Network. Soon after publi-

male/female

cation of the IOM standards, the Guidelines International

Committee/

(% female)

Network (GIN), representing guideline developers, sug-

gested that the list of standards developed by the IOM could
be considered aspirational, but was not feasible to follow in
its entirety (76). GIN developed its own standards for pro-
moting improvement of CPGs, while recognizing that some
variations in approaches would be ‘‘inevitable and appro-
thyroid disease during pregnancy

priate’’ (76). Key components of the GIN standards include

of patients with thyroid disease
of thyrotoxicosis: management

concepts similar to the IOM standards, including transpar-

with anaplastic thyroid cancer
Diagnosis and management of

ency of reporting of methods, managing competing interests,

GDG composition, use of systematic review methods, clear
articulation of recommendations (considering benefits,
harms, and, if possible, cost), rating of evidence and rec-
Topic

ommendations, and established, clearly reported updating

and postpartum

by radioiodine

procedures (76). Additional GIN standards, include: a clear

description of the scope of the CPG, an established, clearly
guidelines

reported method of consensus development, and disclosure of

*Female chair(s), lead author(s).
adults

any financial support for the evidence review and CPG rec-
ommendations (76).

(iii) National Guidelines Clearinghouse. Another agency

Author

23 2011 Stagnaro
Green

with major influence in informing standards for CPG

26 2012 Garber
22 2011 Bahn*

24 2011 Sisson

development is the National Guidelines Clearinghouse

(NGC), which is sponsored by the Agency for Healthcare
Research and Quality through the U.S. Department of Health
No. Year

and Human Services (77). The NGC mission is ‘‘to provide

physicians and other health care professionals, health care
providers, health plans, integrated delivery systems,
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Table 4. Chronology and Characteristics of ATA Guidelines 2013 (Continued)–2017

Committee/ task Number Critical Method of
force composition, of discrete, appraisal formulating Journal
male/female COI numbered of evidence recommendations where
No. Year Author Topic (% female) documented recommendations performed (grading system) published Ref. No.
27 2013 Rosenthal* Professional ethics guidelines for 4M/4F (50% female)* Yes Not Not Not Thyroid 39
the practice of thyroidology applicable applicable applicable
28 2014 Jonklaas* Guidelines for treatment of hypo- 7M/4F (36% female)* Yes 24 (some multipart) Yes ACP Thyroid 40
Bianco thyroidism
29 2015 Wells Management of medullary thyroid 12M/6F (33% female) Yes 67 Yes Modified USPSTF, Thyroid 42
cancer informal consensus
(expert opinion)
30 2015 Francis Guidelines for children with thyroid 9M/5F (36% female) Yes 34 Yes Modified USPSTF, Thyroid 41

697
nodules and differentiated thyroid informal
cancer consensus
(expert opinion)
31 2016 Haugen Guidelines for adults with thyroid 12M/4F (25% female) Yes 101 Yes ACP Thyroid 43
nodules and differentiated thyroid
cancer
32 2016 Ross Diagnosis and management of hy- 7M/4F (36% female) Yes 124 Yes GRADE Thyroid 44
perthyroidism
33 2017 Haugen Renaming encapsulated follicular 10M/8F (44% female) Yes 1 Not Not Thyroid 46
variant papillary thyroid cancer applicable applicable
34 2017 Alexander Diagnosis and management of thy- 8M/4F (33% female)* Yes 97 Yes ACP Thyroid 45
Pearce* roid disease during pregnancy
and postpartum
*Female chair(s), lead author(s).
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Table 5. Chronology and Characteristics of American Thyroid Association Statements

Lead Committee/task force Journal
author composition, M/F COI where Reference
No. Year (chair[s]) Topic (% female) reported published No.
1 1977 Gorman Breast cancer and thyroid hormone therapy 8M (0% female) No JAMA, Ann Intern Med, 47,48,49
Am J Surg
2 1984 Becker Iodine thyroidal blocking agent 9M (0% female) No JAMA 50
3 2004 Not reported Levothyroxine bioequivalence Not reported N/A Thyroid 51
4 2005 Gharib Subclinical thyroid disease 5M/1F (17% female) No Thyroid, JCEM, 52,53,54
Endo Pract (2004)
5 2005 Not reported Maternal thyroid insufficiency Not reported N/A Thyroid 55
6 2006 Becker Iodine supplementation for pregnancy 8M/3F (27% female) No Thyroid 56
7 2009 Bahn* Role of propylthiouracil 9M/3F (25% female) No Thyroid 57
8 2009 Carty* Terminology central neck dissection 12M/2F (14% female) Yes Thyroid 58
9 2012 Carling Prophylactic central neck dissection trial 12M/5F (29% female) Yes Thyroid 59

698
10 2012 Stack Lateral neck dissection 5M/3F (38% female) Yes Thyroid 60
11 2012 Carty* Communication of perioperative information 7M/2F (22% female) Yes Thyroid 61
12 2013 Hodak Molecular diagnosis testing 6F/6F (50% female) Yes Thyroid 62
13 2013 Terris Outpatient thyroidectomy 8M/3F (27% female) Yes Thyroid 63
14 2014 Bianco Guide to investigating thyroid hormone 13M/2F (13% female) Yes Thyroid 64
economy and action in rodent
and cell models
15 2014 Chen* Surgical management of goiter 5M/2F (29% female) No Thyroid 65
16 2015 Yeh Preoperative imaging 6M/3F (33% female) Yes Thyroid 66
17 2015 Leung* Risks of excess iodine 8M/6F (43% female) No Thyroid 67
18 2015 Tufano Nodal disease surveillance 8M (0% female) Yes Thyroid 68
19 2015 Ferris Molecular profiling thyroid nodules 12M/2F (14% female) Yes Thyroid 66
20 2016 Berber Remote access thyroid surgery 9M (0% female) Yes Thyroid 70
21 2017 Pearce* Salt iodization 1F (100% female) Yes Thyroid 71
22 2017 Leung* Potassium iodide nuclear emergency 7M/3F (30% female) Yes Thyroid 72
*Female chair(s), lead author(s).
 GUIDELINES: PAST, PRESENT, AND FUTURE 699
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FIG. 1. Timeline, downloads, and citations of most recent American Thyroid Association guidelines (published 2012–2017).

purchasers and others an accessible mechanism for obtaining
objective, detailed information on clinical practice guidelines
and to further their dissemination, implementation, and use’’
(78). The NGC currently manages a repository of CPGs,
meeting the organization’s specific standards. As of the time
of writing this document, there is uncertainty regarding the
future of the NGC and its repository, due to some proposed
changes in federal infrastructure and funding. Our Task Force
is grateful to the NGC representatives for their helpful advice
regarding ATA CPG policy development.
APPLICATION OF AGENCY STANDARDS TO THE ATA
The ATA is committed to continually improving the
quality of its CPGs and striving to achieve the standards
established by the IOM (75) and GIN (76). Key elements
of the IOM and GIN standards that are of relevance to the
ATA, along with the challenges that these standards pose, are
summarized below.
1. Establishing transparency of CPG development: The
IOM has indicated that processes by which a CPG is

Table 6. Citations of Official ATA Publications

Web of Science
Year Topic Chairperson(s) Scopus citations citations Ref No.
2017 Thyroid disease during pregnancy Alexander, Pearce 51 38 45
2016 Hyperthyroidism Ross 68 63 44
2016 Differentiated thyroid cancer Haugen 1132 1,045 43
2015 Pediatric thyroid cancer Francis 126 114 41
2015 Medullary thyroid cancer Wells 246 221 42
2014 Hypothyroidism Jonklaas, Bianco 163 155 40
2014 Thyroid hormone economy Bianco 53 51 64
2013 Professional ethics Rosenthal 9 7 39
2012 Anaplastic thyroid cancer Smallridge 204 186 37
2012 Hypothyroidism Garber Endo Pract = 259 Thyroid = 237 200 38
2011 Thyroid disease during pregnancy Stagnaro-Green 767 645 35
2011 Radiation safety Sisson 85 68 33
2011 Hyperthyroidism Bahn Endo Pract = 271 Thyroid = 408 219 34
2009 Differentiated thyroid cancer Cooper 3987 3113 32
2009 Medullary thyroid cancer Kloos 822 647 31
2006 Differentiated thyroid cancer Cooper 1440 1206 30
Gray shading indicates over 1000 citations.
 700 SAWKA ET AL.

Table 7. Downloads of the 2009 and 2015 American of process and declaration of all relevant COIs for GDGs and
Thyroid Association Thyroid Nodule SDGs. The evolution and increased awareness of the need for
and Cancer Guidelines documentation of COI can be illustrated by review of the
characteristics of CPGs and Statements seen in Tables 1–4
2009 2015
Region of the world guidelines guidelines and Table 5, respectively. We have developed a three-part
form for vetting of COI. Part 1 of the form involves the self-
United States and Canada 51,177 186,617 declaration by the prospective GDG or SDG member and part
Asia, Far East, and Oceania 21,791 94,707 2 of the form documents the review by the GDG or SDG
Europe 17,476 62,107 chairperson. If there is a COI, then part 3 of the form docu-
Latin America and Caribbean 9255 45,448 ments further review with vetted members of the GDG or
Africa 268 1220 SDG, with documentation of whether the COI can be man-
Data as of December 26, 2017, for selected regions of the world. aged or not. The method of management of the COI is also
documented.
3. Guideline development group composition: Consistent
developed and funded should be detailed explicitly and ac- with IOM (75) and GIN standards (76), the ATA recom-
cessible to the public (75), and GIN has indicated that CPGs mends that the GDG or SDG be multidisciplinary, including
should clearly describe their methodology and include the relevant healthcare professional stakeholders, one or more
process of consensus development (76). The ATA is methodologists, and at least one patient representative. The
committed to detailing the methods of CPG or Statement methodologist is required to have experience in conducting
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development, within the methods section of each CPG or systematic reviews, and preference will be given to individ-
Statement document and/or freely available supplementary uals with experience in developing CPGs. This presents
materials. The objective and scope of each CPG or Statement challenges given the dearth of methodologists within the
will be reported in either the Introduction or Methods, and the society and highlights the need for the ATA to explore means
process of consensus development will be reported in the of ensuring consistent involvement of methodologists in CPG
methods section. development. The benefit of a multidisciplinary GDG is ac-
2. Management of conflict of interest (COI): Consistent knowledged; still, inclusion of some speciality areas may be
with the IOM (75) and GIN standards (76), the ATA has challenging given the overall membership composition of
established that all interests and activities of members of the ATA (Table 8). For example, only 3% of ATA members
GDGs, statement development groups (SDGs), and any other work in nuclear medicine. We will strive for balanced rep-
authors or writing group members must be declared. Activ- resentation on future GDGs, using means such as reaching
ities that may potentially result in conflicts of interest (COIs) out to sister societies for complementary skills, or member-
with the CPG development group activity must be declared in ship drives intended to enrich diversification. The ATA is
writing to those convening the GDG (beginning during the open to partnering with other organizations on CPGs or
selection process of GDG members) and scrutinized by the Statements, as the organization has done in the past. The
ATA GSC and Board of Directors. Divestment of financial ATA is also committed to increase patient involvement in
investments of potential GDG group members or their family development of CPGs and Statements. The ATA recognizes
may be required for relevant COIs. Noncompliance with the important unique perspective of patients, such as advising
ATA COI standards by a GDG or SDG member may result in
exclusion from, or removal from, that GDG or SDG. Com-
peting interests of all GDG and SDG members are reported in Table 8. Composition of the American Thyroid
the final CPG or Statement document. In 2018 the ATA GSC Association
will discuss establishing a new policy whereby those con- Characteristic Subcategories Number Percentage
vening any new group (the already vetted co-chair persons of
the GDG and the subset of the GSC assisting with identifying Gender Male 1,091 61
the remainder of the GDG) must have no COIs. This would be Female 707 39
in addition to the current ATA policy formulated in 2017 that Age (years) <40 509 28
‡50% of those actually developing the document (GDG or 40–69 1033 58
SDG members) must not have any relevant COIs. >69 256 14
Funders and industry have not had any role in ATA CPG or Practice setting Academic 920 52
Private practice 304 17
Statement development since 2005, and this will remain the Other 574 31
case going forward. Consistent with the GIN standard (76), Specialty areas Adult endocrinology 1074 60
any financial support for evidence reviews and guideline Nuclear medicine 43 3
recommendations must be reported in the document. The Surgery 325 18
ATA acknowledges that COIs among CPG panelists is Pediatric 45 2.5
common (79,80), and also may occur among organizations endocrinology
sponsoring CPGs. For example, Neuman et al. have reported Other 311 17
that 52% of GDG members on American and Canadian CPGs Geographic area North America 1347 74
had COIs (79), which is likely a reflection of the content South America 47 3
expertise of many such individuals. Balancing content ex- Asia 217 12
Europe 159 9
pertise and COIs of GDG/SDG members is likely to pose Oceania 25 1
some challenges for the ATA, as it has for many other or-
ganizations. However, the ATA is committed to transparency Data as of November 3, 2017.
 GUIDELINES: PAST, PRESENT, AND FUTURE
that a side effect of treatment considered minor by clinicians
may be considered very important by patients. We will solicit
patient involvement under the guidance of the Patient Affairs
and Education Committee. Involvement of patient panels
already has been incorporated into recent ATA Satellite
Symposia and a CPG in the process of development (Ana-
plastic Thyroid Cancer update).
The ATA is also committed to encouraging gender equity
and diversity of GDG/SDG membership. In reflection of its
membership profile, the ATA’s goal is for approximately half
of the GDG/SDG membership to be female. Gender equity is
important for planning the composition of GDGs (81), and is
particularly poignant for the ATA, given that thyroid disease
is more prevalent in women than men. The gender compo-
sition of prior ATA CPG and Statements is shown in
Tables 1–4 and Table 5. It is apparent that there is a trend over
time towards a composition that better reflects the composi-
tion of the ATA (Table 8) by increasing inclusion of women.
4. Clinical practice guidelines—systematic review inter-
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section: We believe that systematic reviews meeting IOM
standards (82) or the pragmatic interpretation of the IOM
standards by the NGC (77), should be incorporated, as much
as is feasible, in the development of ATA CPGs. The ATA
acknowledges the immense value of systematic reviews in
determining the recommendations in high quality CPGs, but
also recognizes the significant challenges that are posed by
this process. These challenges, which have already been
recognized by the IOM (75), include resource and time lim-
itations, limited availability of methodologic expertise, and
potential need to limit guideline scope. The ATA CPGs have
traditionally been supported by the volunteer efforts of all
authors. Going forward, some budgetary allocation of fi-
nancial resources will likely be necessary to support inclusion
of de novo systematic reviews in CPGs.
The ATA also encourages the development of Statements,
which are supplementary documents intended to complement
ATA CPGs. Although use of systematic reviews is not man-
dated for development of Statements, the methods used, in-
cluding details of achievement of consensus, must be reported
within the document. Some examples of Statements include
policy statements/declarations, research reports, consensus
statements, workshop or conference reports, technological or
procedural declarations, and rapid response statements. The
ATA recognizes the important contribution of other organi-
zations such as the American Thoracic Society in establishing
a taxonomy and methodology for developing Statements (83),
and similar approaches for some Statement types has been
adapted by the ATA.
5. Establishing evidence foundations for and rating
strength of recommendations: For each recommendation,
the strength of the recommendation and quality of the evi-
dence underpinning the evidence must be reported and ex-
plained, as per IOM (75) and GIN (76) standards. A
discussion of potential harms and benefits of the recom-
mendation, including alternative options is also required
(76,77,82). Quality of evidence and reporting of strength of
the recommendation is required to be reported in a stan-
dardized manner (75,76). The ATA is currently piloting use
of the Grading of Recommendations Assessment, Develop-
ment, and Evaluation (GRADE) system for rating the
strength of recommendations and the quality of the body of
evidence used to inform the recommendations (84–86). The
701
GRADE approach is well-established. Yet, it is a complex
process that requires significant methodologic input and
trained reviewers, with the disadvantage of limited ability to
predict changes in treatment effects with advancing evidence
(87). We appreciate that the GRADE Working Group is
continually working on improving this system. Furthermore,
the ATA recognizes the value of Best Practice Statements, to
be incorporated within CPGs, where ungraded statements are
made to guide practice, particularly in situations where there
is little or no direct evidence to answer a clinical question, but
the net clinical benefit of the action or intervention is deemed
substantial (88).
6. Recommendations should be articulated in a stan-
dardized, detailed manner, which clearly details the re-
commended action and appropriate circumstances for its
application: The IOM has outlined standardized recom-
mendation reporting. The ATA is committed to reporting
recommendations in a standardized or consistent, clearly
articulated manner, so that the necessary actions can be
clearly understood. Formulation of standardized reporting of
recommendations will be a priority ‘‘action item’’ for the new
ATA GSC. The ATA also will strive to incorporate elements
of the GRADE approach in reporting of recommendations
(84,85). However, challenges are expected not only for rec-
ommendations limited by low quality, conflicting, or sparse
evidence, but also for recommendations where preferences
are likely to vary substantially among stakeholders.
7. Order of authorship: In the generation of CPGs and
Statements, the ATA has evolved an approach to order of
authorship that is designed to be equitable. The ATA often
has two co-chairpersons involved in their CPGs and State-
ments and these individuals are listed as either first and last
authors, or first and second authors. The co-chairpersons
generally have responsibility for tasks including data col-
lection, idea formation, generation of the first manuscript
draft, and correspondence with the journal. Other authors that
have made additional contributions may be recognized by
being listed next after the co-chairpersons, and the remaining
authors who have contributed equally are listed in alphabet-
ical order. An issue for future discussion by the ATA GSC is
the incorporation of the methodologist into the authorship of
the CPG. A GDG member with both content and methods
expertise might, for example, serve a lead role as a co-
chairperson, or might play a major role that merits being
listed after the co-chairpersons. Alternatively, a contracted
methodologist without content expertise might be listed al-
phabetically or in the acknowledgements. The interaction
between methods experts and content experts may require
skillful and constructive management (89).
8. External reviews: The IOM (75) and GIN (76) have in-
dicated that CPGs must be subject to external review by
relevant stakeholders, such as scientific and clinical experts,
organizations (e.g., health care, specialty societies), agencies
(e.g., federal government), patients, and/or the public prior to
publication; such reviews should generally remain confi-
dential (75). ATA CPGs are subject to rigorous reviews, as
they are shared with the ATA membership, other societies
with an interest in the topic, leadership of patient support
groups, and expert peer reviewers from Thyroid, the official
journal of the ATA. ATA Statements are also subject to
scrutiny by peers, conducted by reviewers for Thyroid. The
ATA is aware of patient feedback about prior guidelines,
 702
such as in the form of Facebook posts, and will seek patient
involvement in CPGs under the guidance of the Patient Af-
fairs and Education Committee. Going forward, the ATA will
also solicit patient review through the ATA Patient Affairs
and Education Committee.
9. Updating the CPG: The IOM (75) and GIN (76) have
highlighted the importance of reporting on the updating of
CPGs. The IOM (75) indicated that the CPG publication date,
date of systematic evidence review, and proposed date for
future review/update should be reported in the CPG (75).
Furthermore, the IOM has recommended that the literature
relevant to the CPG should be regularly monitored, and any
CPG recommendations updated as warranted (75). The ATA
strives to update its CPGs at least every five years, although it
will not specifically post an expiration date, as the rate of
accumulation of relevant new literature may vary from topic to
topic. The ATA is establishing a new policy in which a GDG,
with associated chairpersons, will regularly monitor the liter-
ature for critical updates, such that a Rapid Response State-
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ment may be developed, if needed prior to the next planned
iteration of a CPG. An example of this being put into practice is
the clarification of evolving classification of thyroid neoplasias
by the Thyroid Cancer Guidelines Task Force (46).
CONCLUSION
The Task Force members recognize the creative wealth of
CPGs and Statements that have been developed over the
years by dedicated ATA members, committees, and task
forces. These publications have contributed to advancements
in the field and stimulation of new research. Here, the Task
Force has summarized some of the work in progress, as the
ATA, in part through future activities of the ATA GSC,
strives continually to improve the quality of its official pub-
lications, including CPGs and Statements. Some of the pro-
cesses described in this document may be implemented
sooner than others due to feasibility considerations and the
existing limitations in resources and expertise. Additional
policies and procedures will be developed for several im-
portant issues, including strategies for dissemination and
implementation of CPGs. The ATA welcomes feedback from
its members, patients, stakeholder users of their guidelines,
and the larger public.
ACKNOWLEDGMENTS
The Task Force members would like to acknowledge the
inspiration and wisdom provided by ATA board liaison Dr.
Victor Bernet. The expert guidance and assistance provided by
ATA staff liaisons Bobbi Smith and Sharleene Cano is also
greatly appreciated. Special thanks to Vicki Cohn, Mary Ann
Liebert, Inc., publishers, New Rochelle, NY, and to Patricia
Smith and Kristi Holmes, Galter Health Sciences Library,
Feinberg School of Medicine, Northwestern University, Chi-
cago, IL, for providing download and citation data for Thyroid.
Thank you also to Jonathan Hartmann, MLS, Senior Clinical
Informationist, Head of Data Management, Dahlgren Memorial
Library, Georgetown University, Washington, DC, for con-
ducting literature searches for this manuscript.
The authors also would like to acknowledge the im-
mensely valuable advice provided to us by multiple experts in
clinical practice guideline development and methods of im-
plementation.
SAWKA ET AL.
AUTHOR DISCLOSURE STATEMENT
For A.M.S., no competing financial interests exist. S.E.C.
serves on the ATA Board of Directors. B.R.H. has received
honoraria from Eisai Co., Ltd. and Sanofi Genzyme and
serves as a consultant for Eisai. J.V.H. serves on the Editorial
Board of Thyroid. He is a consultant for Best Doctors and
advises regarding clinical research protocol development for
Abbvie Pharma and Allergan Pharma. E.N.P. serves as the
president-elect of the ATA. She is also a management council
member of the Iodine Global Network. She serves as an as-
sociate editor of Thyroid and Clinical Thyroidology. She
serves as an editorial board member of Endocrine Practice,
Thyroid Research, the European Journal of Clinical Nutri-
tion, Lancet, Diabetes and Endocrinology, the Journal of
Clinical and Translational Endocrinology, and Clinical En-
docrinology. J.A.S. serves as the ATA treasurer. She is a
member of the Data Monitoring Committee of the Medullary
Thyroid Cancer Consortium Registry supported by Novo
Nordisk, GlaxoSmithKline, Astra Zeneca, and Eli Lilly.
P.A.K. is the editor-in-chief of Thyroid; he has been blinded
to the review process of this manuscript. R.P.T. serves on the
editorial board of Thyroid and on the ATA Board of Direc-
tors. He has served as a consultant for Medtronic and He-
mostatix. J.J. serves on the editorial boards of Thyroid, the
Journal of Clinical Endocrinology and Metabolism, and
Frontiers in Thyroid Endocrinology. She served on the ATA
Board of Directors in 2017.
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Address correspondence to:
Jacqueline Jonklaas, MD, PhD
Division of Endocrinology
Georgetown University Medical Center
4000 Reservoir Road, Northwest
Washington, DC 20007
E-mail: jonklaaj@georgetown.edu
Anna M. Sawka, MD, PhD
University Health Network
University of Toronto
Toronto, Ontario
Canada
E-mail: sawkaam@yahoo.com