Processes for updating guidelines: protocol for a systematic review

Karen Cardwell; Joan Quigley; Barbara Clyne; Barrie Tyner; Marie Carrigan; Susan Smith; Máirín Ryan; Michelle O'Neill

doi:10.12688/hrbopenres.13448.1

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Processes for updating guidelines: protocol for a systematic review

[version 1; peer review: 2 approved with reservations]

Karen Cardwell ¹, Joan Quigley¹, Barbara Clyne^1,2, [...] Barrie Tyner¹, Marie Carrigan¹, Susan Smith², Máirín Ryan^1,3, Michelle O'Neill¹

Karen Cardwell ¹, Joan Quigley¹, [...] Barbara Clyne^1,2, Barrie Tyner¹, Marie Carrigan¹, Susan Smith², Máirín Ryan^1,3, Michelle O'Neill¹

PUBLISHED 01 Nov 2021

Author details Author details

¹ Health Technology Assessment Directorate, Health Information and Quality Authority, Dublin, Ireland
² Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
³ Department of Pharmacology & Therapeutics, Trinity College Dublin, Dublin, Ireland

Karen Cardwell
Roles: Conceptualization, Methodology, Writing – Original Draft Preparation

Joan Quigley
Roles: Conceptualization, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Barbara Clyne
Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Barrie Tyner
Roles: Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Marie Carrigan
Roles: Methodology, Writing – Review & Editing

Susan Smith
Roles: Writing – Review & Editing

Máirín Ryan
Roles: Writing – Review & Editing

Michelle O'Neill
Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing

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Abstract

Background: National Clinical Guidelines are systematically developed statements, based on a thorough evaluation of the evidence, to assist practitioner and service users’ decisions. Clinical guidelines require updating to ensure validly of the recommendations contained within. The purpose of this systematic review is to describe the most recent guideline update processes, including prioritisation methods, used by international or national groups who provide methods guidance for developing and updating clinical guidelines.
Methods: A combination of searching a pre-defined list of international and national organisations that provide methods guidance for developing and updating clinical guidelines, together with grey literature searching, will be undertaken to identify relevant handbooks. This will be supplemented by a systematic literature search of Medline (EBSCO), Embase (OVID) and The Cochrane Methodology Register. As guideline development methodology has evolved considerably, the overall search span for this systematic review will be the last 10-years (2011-2021). Publications eligible for inclusion are methodological handbooks that provide updating guidance, including prioritisation methods, for clinical practice guidelines and peer-reviewed articles that describe or have implemented updating guidance, including prioritisation methods. Using Covidence, two reviewers will independently review titles/abstracts and full texts. Where disagreements occur, discussions will be held to reach consensus and where necessary, a third reviewer will be involved. Methodological handbooks will be quality assessed (using the GIN-McMaster Guideline Development Checklist) independently by two reviewers and any disagreements will be resolved by deliberation, or if necessary, a third reviewer. Data will be extracted by one reviewer and checked for inaccuracies/omissions by a second. A narrative synthesis will be undertaken.
Conclusions: Updating clinical guidelines is an iterative process that is both resource intensive and time-consuming. The findings of this systematic review will support clinical guideline developers to ensure appropriate investment of resources.

Keywords

Systematic review, guideline methodology, guideline update, prioritization methodology.

Corresponding author: Karen Cardwell

Competing interests: No competing interests were disclosed.

Grant information: This research was funded in part by the Health Research Board (HRB) under grant no. HRB-CICER-2016-1871. BC is funded by HRB Emerging investigator award [EIA-2019-09]
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2021 Cardwell K et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Cardwell K, Quigley J, Clyne B et al. Processes for updating guidelines: protocol for a systematic review [version 1; peer review: 2 approved with reservations]. HRB Open Res 2021, 4:116 (https://doi.org/10.12688/hrbopenres.13448.1) First published: 01 Nov 2021, 4:116 (https://doi.org/10.12688/hrbopenres.13448.1) Latest published: 01 Nov 2021, 4:116 (https://doi.org/10.12688/hrbopenres.13448.1)

Abbreviations

CG, Clinical guideline; CIMO, Context, intervention, mechanism, outcome; GIN, Guidelines International Network; NCG, National Clinical Guideline; PRISMA-P, Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols.

Introduction

In Ireland, the National Clinical Effectiveness Committee (NCEC), established in September 2010, works to prioritise and quality assure National Clinical Guidelines (NCGs) so as to recommend them to the Minister for Health to become part of a suite of NCGs¹. Clinical guidelines (CGs) are systematically developed statements, based on a thorough evaluation of the evidence, to assist practitioner and service users’ decisions about appropriate healthcare for specific clinical circumstances across the entire clinical system¹. The recommendations contained within CGs are underpinned by evidence syntheses, that is, systematic reviews or adaptation of existing CGs and or recommendations². Ongoing evolution of the scientific literature brings the emergence of new evidence which can change the findings of a systematic review and, as a consequence, change the recommendations made within a CG. As such, CGs need to be updated regularly to ensure validity of the recommendations contained within³.

Updating CGs is an iterative process that is both resource intensive and time-consuming. Typically, CGs are updated in accordance with a pre-defined time-period. For example, the National Institute for Health and Care Excellence⁴, American College of Physicians⁵ and US Preventive Services Task Force⁶ indicate that CGs should be updated every five years; in Ireland, the National Clinical Effectiveness Committee advises updating CGs every three years¹. However, it is also acknowledged that deciding to update a CG depends on factors other than pre-defined time periods, such as the volume and potential impact of new research published on the topic, clinical burden of the topic, economic impact and resources available to update a guideline¹. For that reason, policy makers and other stakeholders are advocating for a move away from updating guidelines based on a pre-defined time-period and moving towards updating guidelines based on prioritisation criteria, to ensure appropriate investment of resources⁷.

Just as evolution of the scientific literature brings new clinical evidence that can impact the recommendations within a CG, it also brings advancement in methodologies used in development and updating of CGs³. One such advancement has been the emergence of rapid and living guidelines which aim to provide timely advice for decision-makers by optimising the guideline development process whereby individual recommendations can be updated as soon as new relevant evidence becomes available⁸. The use of rapid and living guidelines has been especially evident throughout the COVID-19 pandemic where the emphasis was on development and implementation of strategies to manage the rapidly evolving evidence base in response to a public health emergency⁹.

Previous systematic reviews on this topic have summarised guidance from methodological handbooks for updating clinical practice guidelines³, strategies for prioritisation of clinical guidelines that require updating⁷ and prioritisation processes for the de novo development, updating or adaptation of guidelines¹⁰. However, the evidence synthesised was largely published over a decade ago and related to update processes developed for a particular disease-specific guideline or specifically to updating systematic reviews, not updating clinical guidelines.

Therefore, the purpose of this systematic review is to describe the most recent guideline update processes, including up-to-date prioritisation methods, used by international or national groups who provide methods guidance for developing and updating clinical guidelines. The focus of this systematic review was not on adaptation, contextualization, or de novo development of guidelines, but instead updating processes for existing guidelines. This will support guideline development groups nationally and internationally in consideration of amendments to the current update processes.

Methods

Details of this protocol have been submitted to the PROSPERO database (registration number: CRD42021274400). Any amendments made to the protocol will be acknowledged on PROSPERO and in any subsequent publications. This protocol outlines the proposed approach to achieve the stated purpose and has been informed by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines¹¹.

Criteria for considering publications for this review

This systematic review protocol has been developed to answer the review question:

What are the most recent guideline update processes, including up-to-date prioritisation methods, used by international or national groups who provide methods guidance for developing and updating clinical guidelines?

The review question was formulated in line with the CIMO (Context, Intervention, Mechanism, Outcome) framework¹², as presented in Table 1. The CIMO framework describes “the problematic Context, for which the design proposition suggests a certain Intervention type, to produce, through specified generative Mechanisms, the intended Outcome(s)”¹². The context describes the environment within which change occurs, the intervention is what influences a change, the mechanism is triggered by the intervention and this produces the outcome¹².

Table 1. Context, Intervention, Mechanism, Outcome.

Context	▪ Clinical guidelines require updating to maintain relevancy.
Intervention	▪ International or national groups provide methods guidance (in published handbooks and/or peer-reviewed articles) for developing and updating clinical guidelines, as well as prioritising clinical guidelines for updating.
Mechanism	▪ Clinical guidelines considered for updating (includes full, modular, rapid updates). ▪ Tools or guidance available to support prioritisation.
Outcome	▪ Description of update (or retirement) process (including roles and responsibilities at each stage) ○ types of update that exist ○ criteria used to determine if update necessary ○ process for retiring a guideline ○ criteria to prioritise which guideline is updated first ○ criteria to prioritise which clinical questions within a guideline are updated ○ evidence synthesis methodologies used to update clinical questions ○ dissemination of updated guideline ○ resources required to undertake update ○ differences between review process for updated guideline verses original guideline ○ differences between approval and endorsement process for updated guideline versus original guideline ▪ Evaluation of the process ○ usability and or critique of the updating methodology ○ timeliness, that is, specific processes that enable a more efficient and timely update.

The types of publications eligible for inclusion will be:

▪ methodological handbooks that provide updating guidance, including prioritisation methods, for clinical practice guidelines
▪ peer-reviewed articles that describe or have implemented updating guidance, including prioritisation methods.

Only publications from 2011 onwards will be considered for inclusion; publications published before 2011 will have been included in the index documents^3,7 but will not be included in this review.

Exclusion criteria. The following exclusion criteria will be applied:

▪ Due to issues relating to transferability of guidelines developed for specific diseases, disease-specific publications (handbooks and or peer-reviewed publications which describe, or have implemented, guidance for updating disease-specific guidelines).
▪ Editorials/commentaries/opinion pieces.
▪ Abstracts only.
▪ Animal studies.
▪ Non-English language publications.

Search methods for identification of studies

Due to changes in process and methodologies in guideline development in the last 10 years, the overall search span for this review will be the last 10-years (2011–2021). The primary data source for this review will be methodological handbooks which detail update processes, including prioritisation methods, used by international or national groups who provide methods guidance for developing and updating clinical guidelines. Through scoping searches, we identified a published systematic review of methodological handbooks that provide guidance for updating clinical practice guidelines³. This systematic review by Vernooij et al.³ was published in 2014 and will be considered an index document, whereby for methodological handbooks, data from 2011–2012 will be taken from Vernooij et al.³ and data from 2013–2021 will be gathered through a new search of organisations’ websites and grey literature.

The secondary data source will be peer-reviewed articles which detail the development of, and or evaluation of guideline update processes. For peer-reviewed articles, data from 2011–2021 will be gathered through a database search. While peer-reviewed articles will not be the primary data source for this systematic review, they may serve as “sign-posts” to the handbooks and may also provide qualitative data relating to the usability of the handbooks and update processes.

In 2017, Martinez-Garcia et al.⁷ published a systematic review of prioritisation processes for updating guidelines which focused on peer-reviewed articles rather than methodological handbooks. Data specific to prioritisation methods from 2011–2015 will be taken from Martinez-Garcia et al.,⁷ and data from 2016–2021 will be gathered from the new database search.

Organisations. The websites of organisations listed in Table 2 will be searched for relevant methodological handbooks. The organisations were chosen based on advice from the Clinical Effectiveness Unit of the Department of Health (which supports the work of the National Clinical Effectiveness Committee), and or identification of the organisation from previous systematic reviews on this topic and guidance being available in English.

When guideline manuals are not found online, or where any data gaps are identified, these will be addressed by contacting organisations (via email) to gather information relating to guideline update processes (including prioritisation methods). Other relevant organisations identified during the searching process will also have their website searched.

Table 2. Organisations that will be searched for relevant methodological handbooks.

Organisation name	Organisation URL
Agency for Healthcare Research and Quality, USA	https://www.ahrq.gov/
Australian National Health and Medical Research Council, Australia	https://www.nhmrc.gov.au/
Belgian Health Care Knowledge Centre, Belgium	https://kce.fgov.be/en
Canadian Agency for Drugs and Technologies in Health, Canada	https://www.cadth.ca/
European Network for Health Technology Assessment	https://www.eunethta.eu/
Finnish Institute for Health and Welfare, Finland	https://thl.fi/fi/
Guidelines International Network	https://g-i-n.net/
Institute of Medicine, USA	https://nam.edu/about-the-nam/
McMaster GRADE centre, Canada	https://cebgrade.mcmaster.ca/
National Institute for Health and Care Excellence, UK	https://www.nice.org.uk/
Ravijuhend, Estonia	https://www.ravijuhend.ee/
Scottish Intercollegiate Guidelines Network, Scotland	https://www.sign.ac.uk/
National Board of Health and Welfare, Sweden	https://www.socialstyrelsen.se/en/regulations- and-guidelines/national-guidelines/
Public Health Agency of Sweden, Sweden	https://www.folkhalsomyndigheten.se/the- public-health-agency-of-sweden/
The Best Practice Advocacy Centre New Zealand, New Zealand	https://bpac.org.nz/guidelines/
World Health Organization	https://www.who.int/

Grey literature. Other sources of grey literature will be searched for relevant methodological handbooks. These are listed in Table 3.

Table 3. Grey literature that will be searched for relevant methodological handbooks.

Grey literature source	URL
Google (first 10 pages of results)	www.google.com
Open Grey	http://www.opengrey.eu/
Reference chasing	NA

Databases. The following databases will be searched for peer-reviewed articles using the search strategy defined in Supplementary file 1:

▪ Medline (EBSCO)
▪ Embase (OVID)
▪ The Cochrane Methodology Register

Selection of eligible publications

Methodological handbooks will be identified through searching the websites of eligible organisations (see Table 2) and through screening the methodological handbooks included in the index document³. This will be done by one reviewer and relevant handbooks will be imported into Endnote (Version X8). Imported handbooks will be reviewed by a second reviewer to confirm their eligibility.

All citations identified from the collective search strategy (see Supplementary file 1), and through screening the peer-reviewed articles included in the index document⁷, will be exported to EndNote (Version X8) for reference management, where duplicates will be identified and removed. Using Covidence (www.covidence.org), two reviewers will independently review the titles and abstracts of the remaining citations to identify those for full-text review. The full texts will be obtained and independently evaluated by two reviewers applying the defined inclusion and exclusion criteria. Where disagreements occur, discussions will be held to reach consensus and where necessary, a third reviewer will be involved. Citations excluded during the full-text review stage will be documented alongside the reasoning for their exclusion and included in the PRISMA flow diagram.

Data extraction and management

Data will be extracted from methodological handbooks by one reviewer and checked for accuracy and omissions by a second. Where disagreements occur, discussions will be held to reach consensus and where necessary, a third reviewer will be involved. Data extraction will be conducted in Microsoft Word, using a data extraction form (Supplementary file 2). The data extraction form will be piloted first and refined as necessary.

Relevant data to be extracted will include:

▪ the types of update that exist, for example partial or full
▪ criteria used to determine if an update is necessary
▪ process for retiring a guideline
▪ criteria used to prioritise which guideline to update first
▪ criteria used to prioritise clinical questions to be updated within a guideline
▪ evidence synthesis methodologies used to update clinical guideline and clinical questions
▪ dissemination of updated clinical guideline
▪ resources required to undertake update
▪ process of reviewing the updated guideline
▪ process of approving and endorsing the updated guideline.

Peer-reviewed articles will not be the primary data source for this systematic review; the primary data source is most likely to be the methodological handbooks. However, in addition to signposting to methodological handbooks, and providing supplemental data relating to update and prioritisation processes, peer-reviewed articles may also provide usability and process evaluation data (relating to the associated handbook); these data will be extracted (see Supplementary file 2).

Quality assessment

Methodological handbooks will be quality assessed independently by two reviewers and any disagreements will be resolved by deliberation, or if necessary, a third reviewer. In the absence of an appropriate quality assessment tool that is specific for methodological handbooks or guidance, quality will be assessed using the GIN-McMaster Guideline Development Checklist, which is a checklist of items to consider during the development of guidelines. Specifically, we will use the six criteria relating to updating guidelines¹³. Reviewers will assess, that the methodological handbook covers the following areas:

1. Addresses policy, procedure and timeline for routinely monitoring and reviewing whether the guideline needs to be updated.
2. Addresses who will be responsible for routinely monitoring the literature and assessing whether new significant evidence is available.
3. Sets the conditions that will determine when a partial or a full update of the guideline is required.
4. Makes arrangements for guideline group membership and participation after completion of the guideline.
5. Addresses plans for the funding and logistics for updating the guideline in the future.
6. Addresses documentation of the plan and proposed methods for updating the guideline to ensure they are followed¹³.

Methodological quality of peer-reviewed articles will be independently assessed by two reviewers. Depending on study design an appropriate version of the Newcastle-Ottawa Scale¹⁴ or the Appraisal tool for Cross-Sectional studies (AXIS)¹⁵ will be used. The tools will be piloted first on a small number of included studies, and modifications made if needed, before standardising for the remaining studies. Any disagreements will be resolved by deliberation or, if necessary, a third reviewer.

Data synthesis

As the main data to be extracted for this review is descriptive in nature a narrative synthesis will be undertaken. Data will be summarised under the following headings:

▪ Description of update (or retirement) process (including roles and responsibilities at each stage)
▪ Evaluation of the process.

Dissemination

The PRISMA checklist will be used to report findings of the review. We will communicate the findings to the NCEC to inform updating processes in Ireland. Findings will also be communicated by publication in a peer-reviewed journal, and by participation in scientific meetings and national and international conferences.

Study status

Agreement on the study protocol, searching of organisations, grey literature and databases, data extraction and quality assessment is complete. Data synthesis is ongoing.

Discussion

Updating clinical guidelines is an iterative process that is both resource intensive and time-consuming. This systematic review will summarise the most recent updating and prioritisation processes for clinical guidelines. The findings will support guideline development organisations nationally and internationally to ensure appropriate investment of resources. It will support them in considering and or modifying their current methodologies for updating clinical guidelines. This will be of particular interest in light of new and updated methodologies that have been especially evident throughout the COVID-19 pandemic.

Data availability

Underlying data

No data are associated with this article.

Extended data

Figshare: Supplementary files, https://doi.org/10.6084/m9.figshare.16723063.

This project contains the following extended data:

- Supplementary file 1: Search strategy
- Supplementary file 2: Data extraction tables

Reporting guidelines

Figshare: PRISMA-P Checklist for “Processes for updating guidelines: protocol for a systematic review”, https://doi.org/10.6084/m9.figshare.16723021.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Authors’ contribution

KC: Conceptualization, Methodology, Writing – Original Draft Preparation; JQ: Conceptualization, Methodology, Supervision, Writing – Original Draft Preparation; Writing – Review & Editing; BC: Conceptualization, Methodology, Writing – Original Draft Preparation; Writing – Review & Editing; BT: Methodology, Writing – Original Draft Preparation; Writing – Review & Editing; MC: Methodology, Writing – Review & Editing; SS: Writing – Review & Editing; MR: Writing – Review & Editing; MON: Conceptualization, Methodology, Supervision, Writing – Review & Editing.

Acknowledgements

The authors would like to thank the Clinical Effectiveness Unit of the Department of Health and acknowledge the support of the Health Technology Assessment directorate at HIQA.

Faculty Opinions recommended

References

1. Government of Ireland: How to develop a national clinical guideline: a manual for guideline developers. [updated 2019 Jan; cited 2021 Jul 29]. Reference Source
2. Sharp MK, Tyner B, Awang Baki DAB, et al.: Evidence synthesis summary formats for clinical guideline development group members: a mixed-methods systematic review protocol [version 1; peer review: 1 approved with reservations]. HRB Open Res. 2021; 4: 76. Publisher Full Text
3. Vernooij RW, Sanabria AJ, Solà I, et al.: Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implement Sci. 2014; 9: 3. PubMed Abstract | Publisher Full Text | Free Full Text
4. National Institute for Health and Care Excellence: Developing NICE guidelines: the manual (PMG20). [updated 2020 Oct 15; cited 2021 Sep 28]. Reference Source
5. Qaseem A, Kansagara D, Lin JS, et al.: The Development of Clinical Guidelines and Guidance Statements by the Clinical Guidelines Committee of the American College of Physicians: Update of Methods. Ann Intern Med. 2019; 170(12): 863–70. PubMed Abstract | Publisher Full Text
6. US Preventive Services Task Force: Procedure Manual. [updated 2021 May; cited 2021 Sep 28]. Reference Source
7. Martínez García L, Pardo-Hernández H, Sanabria AJ, et al.: Guideline on terminology and definitions of updating clinical guidelines: The Updating Glossary. J Clin Epidemiol. 2018; 95: 28–33. PubMed Abstract | Publisher Full Text
8. Akl EA, Meerpohl JJ, Elliott J, et al.: Living systematic reviews: 4. Living guideline recommendations. J Clin Epidemiol. 2017; 91: 47–53. PubMed Abstract | Publisher Full Text
9. Garritty C, Gartlehner G, Nussbaumer-Streit B, et al.: Rapid review methods guidance aids in Cochrane’s quick response to the COVID-19 crisis. In: Collaborating in response to COVID-19: editorial and methods initiatives across Cochrane. Cochrane Database of Systematic Reviews. 2021; 28–31. Reference Source
10. El-Harakeh A, Lotfi T, Ahmad A, et al.: The implementation of prioritization exercises in the development and update of health practice guidelines: A scoping review. PLoS One. 2020; 15(3): e0229249. PubMed Abstract | Publisher Full Text | Free Full Text
11. Moher D, Shamseer L, Clarke M, et al.: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4(1): 1. PubMed Abstract | Publisher Full Text | Free Full Text
12. Denyer D, Tranfield D, van Aken JE: Developing Design Propositions through Research Synthesis. Organization Studies. 2008; 29(3): 393–413. Publisher Full Text
13. GIN-McMaster: GIN-McMaster Guideline Development Checklist. [updated 2014 Jun 02; cited 2021 Jul 29]. Reference Source
14. Wells GA, Shea B, O'Connell D, et al.: The Newcastle-Ottawa Scale (NOS) for assessing the quality of non-randomised studies in meta-analyses. [updated 2001; cited 2021 Jul 29]. Reference Source
15. Downes MJ, Brennan ML, Williams HC, et al.: Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS). BMJ Open. 2016; 6(12): e011458. PubMed Abstract | Publisher Full Text | Free Full Text

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Version 1

VERSION 1 PUBLISHED 01 Nov 2021

Author details Author details

¹ Health Technology Assessment Directorate, Health Information and Quality Authority, Dublin, Ireland
² Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
³ Department of Pharmacology & Therapeutics, Trinity College Dublin, Dublin, Ireland

Karen Cardwell
Roles: Conceptualization, Methodology, Writing – Original Draft Preparation

Joan Quigley
Roles: Conceptualization, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Barbara Clyne
Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Barrie Tyner
Roles: Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Marie Carrigan
Roles: Methodology, Writing – Review & Editing

Susan Smith
Roles: Writing – Review & Editing

Máirín Ryan
Roles: Writing – Review & Editing

Michelle O'Neill
Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

This research was funded in part by the Health Research Board (HRB) under grant no. HRB-CICER-2016-1871. BC is funded by HRB Emerging investigator award [EIA-2019-09]
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (1)

version 1

Published: 01 Nov 2021, 4:116

https://doi.org/10.12688/hrbopenres.13448.1

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© 2021 Cardwell K et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Reviewer Report 21 May 2024

Brenda Wilson, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada

Approved with Reservations

https://doi.org/10.21956/hrbopenres.14656.r39498

Processes for updating guidelines: protocol for a systematic review.
Cardwell K, Quigley J, Clyne B, Tyner B, Carrigan M, Smith S, Ryan M, O’Neill M.

This manuscript describes the protocol for a systematic review of the ... Continue reading

Processes for updating guidelines: protocol for a systematic review.
Cardwell K, Quigley J, Clyne B, Tyner B, Carrigan M, Smith S, Ryan M, O’Neill M.

This manuscript describes the protocol for a systematic review of the methods used, by organisations developing clinical guidelines (CGs), for updating their recommendations. This review will be useful because CGs are dependent on an evidence base that may be changing in significant ways, with implications for health outcomes and resource use. Updates themselves require significant resources, so understanding how to prioritise them and carry them out efficiently and to good effect is important.

The proposed review will focus on the most recent timeframe, and include guidance by major CG organisations internationally as well as peer reviewed reports. The analysis will be descriptive and narrative and offer useful insights to users, funders and those who develop CGs.

Is the rationale for, and objectives of, the study clearly described?

The rationale for the review is clear and I agree with the thinking.

The review has the following objective:
“What are the most recent guideline update processes, including up-to-date prioritization methods, used by international or national groups who provide methods guidance for developing and updating clinical guidelines?”

The authors indicate that the intent is a descriptive review, with findings presented as a narrative synthesis (page 6). However, the abstract states that the review findings “… will support clinical guideline developers to ensure appropriate investment of resources”. This could imply some kind of evaluation or recommendation coming from this review.

I don’t think the latter is the intention of the authors, and I do think there is value in a purely descriptive review: if so, I would suggest slightly modifying for clarity the last sentence of the abstract to avoid misunderstanding. If, actually, there is a thought to going further with the results, for example to highlight evaluations that indicate update approaches that are somehow more ‘effective’ than others, then the review question needs to signal this too.

I’m not familiar with the CIMO framework used to develop the review question, and I could not access the full source reference content. The framework seems quite logical in itself but I was confused by how the review details were mapped across to the domains in Table 1. I think that’s a fairly minor point, but I did note that the ‘Outcome’ domain includes “Evaluation of the process” and items that do actually seem to suggest some kind of judgement emerging from the review.

I’m not sure that Table 1 adds anything to the protocol and it may provide confusion to readers unfamiliar with the framework.

Is the study design appropriate for the research question?

The general review design is appropriate. I note a few points below.

Time frame
(First, I diplomatically point out that the period 2011-2021 probably covers eleven years, not ten.)

I agree with the reasoning for focusing on more recent guidance. Given the attention that this topic has been attracting in the last couple of years, and the emergence of new technologies such as AI in the review field, could there be a case for shifting the ten years forward, so starting with 2013 or 2014 and moving the end date even to 2023?

Eligibility criteria
Reading the Methods as a whole, I am unclear about the scope of the review in terms of the kinds of organisations whose guidance would be eligible.
Working from the definition on p3 - “… CGs are systematically developed statements … to assist practitioner and service users’ decisions about appropriate healthcare for specific clinical circumstances across the entire clinical system" – I take ‘clinical practice’ to include rehabilitation and preventive care, etc. This sets a wider scope for eligibility of organisations developing CGs than is indicated in Table 2. I was surprised to see national entities such as the UK Screening Committee and the Canadian Task Force for Preventive Health Care excluded both from this review and from that by Vernooij et al 2014 (being used as an index document).

Also, the unit of analysis for the review is (I think) ‘update guidance developed by an organisation’. I did not fully understand how this translates over in practice to ‘disease-specific publications’ in a way that leads to exclusion. Does this mean that major organisations that focus on, e.g., cancer or cardiovascular disease would be excluded? If so, I think the review could miss relevant data.

Data extraction
I reviewed Supplementary file 2. Overall, the data extraction form makes sense. This will very much be a text-based exercise, consistent with a narrative review approach. CG recommendations are generally based on finely-balanced judgements of benefits versus harms and costs. Updates may be driven by factors other than changing clinical effectiveness evidence. The form may need to be adaptable to accommodate the full spectrum of thinking presented by guideline organisations.

Data synthesis
The details given are very brief and high level, but this may be appropriate at this stage. I comment above on the nature of the data that will be extracted. The analysis will be in keeping with a qualitative synthesis approach. I assume that the ‘evaluation of the process’ means a description of the evaluations that are identified, and their findings, rather than an evaluation by the authors of which processes appear to be most effective (see comments above).

Are sufficient details of the methods provided to allow replication by others?

Yes, for the main part. The data synthesis methods are rather high level.

Are the datasets clearly presented in a useable and accessible format?
Not applicable

Overall

This is a generally well-written protocol for a review that is not in any way ‘cookie cutter’. This is a tricky review as the ‘data’ will not be standardised or lend themselves to a simple analysis. The topic is important and is likely to be of interest to a wide range of audiences.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Public health, health services research, clinical guideline development

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 11 Jan 2022

Julian Little, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

Approved with Reservations

https://doi.org/10.21956/hrbopenres.14656.r31006

A systematic review of processes for updating guidelines will be a valuable piece of work. The protocol is well written and clear. Here are a number of comments for consideration:

Reference is made to “national clinical

A systematic review of processes for updating guidelines will be a valuable piece of work. The protocol is well written and clear. Here are a number of comments for consideration:

Reference is made to “national clinical guidelines” in the abstract and the first paragraph of the introduction. However, the remit of the proposed work seems broader. Guidelines may be in place for jurisdictions that are sub-national, and for professional organizations. In addition, I was left uncertain whether preventive health care and public health were within scope.
In the second paragraph of the introduction, signal detection methods have been proposed for triggering updates of evidence syntheses that underpin guidelines. See for example Newberry SJ et al. ¹, Shekelle PG et al. ². Briefly showing the readers that these have been considered in developing the searches in the systematic review will increase confidence in the evidence as to whether or not these methods have been used; if they have been used, how much and what has been the experience; if there is no evidence that they have been used, is there any on why not.
I was surprised that there was no mention of the concept of living guidelines – see Akl EA et al. ³ (the same comment as for the signal detection methods; the COVID-19 pandemic has catalyzed interest) or the AGREE statement⁴ (https://www.agreetrust.org/agree-ii/), which includes a point about updating procedures (domain 3, point 14). The AGREE II instrument is a tool to assess the quality and reporting of practice guidelines and is internationally used. Having guidelines based on up-to-date evidence is obviously an important domain of guideline quality, and I think it's important to make the link to this in the review.
Table 1 – what belongs under “Mechanism” and under “Outcome” is unclear.
Table 2 – consideration might be given to Canadian and US Task Forces on Preventive Health Care, the UK National Screening Committee, and the IARC Cancer Prevention Handbooks (e.g. cervical cancer screening is covered in Vol. 10 and the upcoming Vol. 18; breast cancer in Vols. 7 and 15). This links back to the comments I made on the scope of the review. If preventive health is within scope, these strike me as well recognized international sources to consider.
There has been a large investment in clinical research in China, and there are many clinical guidelines⁵. I think this work needs at least to be recognized. There are Chinese databases, e.g. CKNI and WanFang (see Cohen JF et al.⁶). China accounts for more than 18% of the world’s population. There are also large proportions in India and in African countries, but there is less investment in clinical research. There has been a lot of activity in clinical guideline development in China⁵. I do not have comprehensive knowledge of guidelines in China, but having seen a few, my sense is that they consider Chinese evidence, evidence from other jurisdictions, and also consider Chinese traditional medicine, so they have a mixture of unique attributes and those common to other jurisdictions. I’m not sure how much the Chinese guidelines will be picked up in the search strategy proposed in the protocol, which is why I suggested the Chinese databases. It may be that the investigators decide that investigating Chinese guidelines other than what would be picked up in the search strategy presented in the protocol is out of scope, but I think it's important to be clear in reporting this decision and the rationale for it. The guideline development in India⁷ and Africa⁸ (this reference on hypertension guidelines may be helpful) may in large part be based on adapting guidelines from other jurisdictions, and thus be more likely to be picked up in the strategy in the protocol.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

References

1. Newberry SJ, Ahmadzai N, Motala A, Tsertsvadze A, et al.: Surveillance and Identification of Signals for Updating Systematic Reviews: Implementation and Early Experience. PubMed Abstract
2. Shekelle PG, Motala A, Johnsen B, Newberry SJ: Assessment of a method to detect signals for updating systematic reviews.Syst Rev. 2014; 3: 13 PubMed Abstract | Publisher Full Text
3. Akl EA, Meerpohl JJ, Elliott J, Kahale LA, et al.: Living systematic reviews: 4. Living guideline recommendations.J Clin Epidemiol. 2017; 91: 47-53 PubMed Abstract | Publisher Full Text
4. Brouwers MC, Kerkvliet K, Spithoff K, AGREE Next Steps Consortium: The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines.BMJ. 2016; 352: i1152 PubMed Abstract | Publisher Full Text
5. Chen Y, Wang C, Shang H, Yang K, et al.: Clinical practice guidelines in China. BMJ. 2018. Publisher Full Text
6. Cohen JF, Korevaar DA, Wang J, Spijker R, et al.: Should we search Chinese biomedical databases when performing systematic reviews?. Syst Rev. 2015; 4: 23 PubMed Abstract | Publisher Full Text
7. Mehndiratta A, Sharma S, Gupta N, Sankar M, et al.: Adapting clinical guidelines in India—a pragmatic approach. BMJ. 2017. Publisher Full Text
8. Okwen PM, Maweu I, Grimmer K, Margarita Dizon J: Evaluation of all African clinical practice guidelines for hypertension: Quality and opportunities for improvement.J Eval Clin Pract. 2019; 25 (4): 565-574 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Epidemiology and Prevention of Congenital Anomalies; Psychosis and affective psychosis; Cancer Epidemiology and Prevention; Molecular and Human Genome Epidemiology; Evidence synthesis related to public health; Health services research

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Julian Little, University of Ottawa, Ottawa, Canada
Brenda Wilson, Memorial University of Newfoundland, St. John's, Canada

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21 May 2024 | for Version 1

Brenda Wilson, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada

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Approved With Reservations

Processes for updating guidelines: protocol for a systematic review.
Cardwell K, Quigley J, Clyne B, Tyner B, Carrigan M, Smith S, Ryan M, O’Neill M.

This manuscript describes the protocol for a systematic review of the methods used, by organisations developing clinical guidelines (CGs), for updating their recommendations. This review will be useful because CGs are dependent on an evidence base that may be changing in significant ways, with implications for health outcomes and resource use. Updates themselves require significant resources, so understanding how to prioritise them and carry them out efficiently and to good effect is important.

The proposed review will focus on the most recent timeframe, and include guidance by major CG organisations internationally as well as peer reviewed reports. The analysis will be descriptive and narrative and offer useful insights to users, funders and those who develop CGs.

Is the rationale for, and objectives of, the study clearly described?

The rationale for the review is clear and I agree with the thinking.

The review has the following objective:
“What are the most recent guideline update processes, including up-to-date prioritization methods, used by international or national groups who provide methods guidance for developing and updating clinical guidelines?”

The authors indicate that the intent is a descriptive review, with findings presented as a narrative synthesis (page 6). However, the abstract states that the review findings “… will support clinical guideline developers to ensure appropriate investment of resources”. This could imply some kind of evaluation or recommendation coming from this review.

I don’t think the latter is the intention of the authors, and I do think there is value in a purely descriptive review: if so, I would suggest slightly modifying for clarity the last sentence of the abstract to avoid misunderstanding. If, actually, there is a thought to going further with the results, for example to highlight evaluations that indicate update approaches that are somehow more ‘effective’ than others, then the review question needs to signal this too.

I’m not familiar with the CIMO framework used to develop the review question, and I could not access the full source reference content. The framework seems quite logical in itself but I was confused by how the review details were mapped across to the domains in Table 1. I think that’s a fairly minor point, but I did note that the ‘Outcome’ domain includes “Evaluation of the process” and items that do actually seem to suggest some kind of judgement emerging from the review.

I’m not sure that Table 1 adds anything to the protocol and it may provide confusion to readers unfamiliar with the framework.

Is the study design appropriate for the research question?

The general review design is appropriate. I note a few points below.

Time frame
(First, I diplomatically point out that the period 2011-2021 probably covers eleven years, not ten.)

I agree with the reasoning for focusing on more recent guidance. Given the attention that this topic has been attracting in the last couple of years, and the emergence of new technologies such as AI in the review field, could there be a case for shifting the ten years forward, so starting with 2013 or 2014 and moving the end date even to 2023?

Eligibility criteria
Reading the Methods as a whole, I am unclear about the scope of the review in terms of the kinds of organisations whose guidance would be eligible.
Working from the definition on p3 - “… CGs are systematically developed statements … to assist practitioner and service users’ decisions about appropriate healthcare for specific clinical circumstances across the entire clinical system" – I take ‘clinical practice’ to include rehabilitation and preventive care, etc. This sets a wider scope for eligibility of organisations developing CGs than is indicated in Table 2. I was surprised to see national entities such as the UK Screening Committee and the Canadian Task Force for Preventive Health Care excluded both from this review and from that by Vernooij et al 2014 (being used as an index document).

Also, the unit of analysis for the review is (I think) ‘update guidance developed by an organisation’. I did not fully understand how this translates over in practice to ‘disease-specific publications’ in a way that leads to exclusion. Does this mean that major organisations that focus on, e.g., cancer or cardiovascular disease would be excluded? If so, I think the review could miss relevant data.

Data extraction
I reviewed Supplementary file 2. Overall, the data extraction form makes sense. This will very much be a text-based exercise, consistent with a narrative review approach. CG recommendations are generally based on finely-balanced judgements of benefits versus harms and costs. Updates may be driven by factors other than changing clinical effectiveness evidence. The form may need to be adaptable to accommodate the full spectrum of thinking presented by guideline organisations.

Data synthesis
The details given are very brief and high level, but this may be appropriate at this stage. I comment above on the nature of the data that will be extracted. The analysis will be in keeping with a qualitative synthesis approach. I assume that the ‘evaluation of the process’ means a description of the evaluations that are identified, and their findings, rather than an evaluation by the authors of which processes appear to be most effective (see comments above).

Are sufficient details of the methods provided to allow replication by others?

Yes, for the main part. The data synthesis methods are rather high level.

Are the datasets clearly presented in a useable and accessible format?
Not applicable

Overall

This is a generally well-written protocol for a review that is not in any way ‘cookie cutter’. This is a tricky review as the ‘data’ will not be standardised or lend themselves to a simple analysis. The topic is important and is likely to be of interest to a wide range of audiences.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Public health, health services research, clinical guideline development

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Respond to this report

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Reviewer Report

92 Views

11 Jan 2022 | for Version 1

Julian Little, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

92 Views Cite this report Responses(0)

Approved With Reservations

A systematic review of processes for updating guidelines will be a valuable piece of work. The protocol is well written and clear. Here are a number of comments for consideration:

Reference is made to “national clinical guidelines” in the abstract and the first paragraph of the introduction. However, the remit of the proposed work seems broader. Guidelines may be in place for jurisdictions that are sub-national, and for professional organizations. In addition, I was left uncertain whether preventive health care and public health were within scope.
In the second paragraph of the introduction, signal detection methods have been proposed for triggering updates of evidence syntheses that underpin guidelines. See for example Newberry SJ et al. ¹, Shekelle PG et al. ². Briefly showing the readers that these have been considered in developing the searches in the systematic review will increase confidence in the evidence as to whether or not these methods have been used; if they have been used, how much and what has been the experience; if there is no evidence that they have been used, is there any on why not.
I was surprised that there was no mention of the concept of living guidelines – see Akl EA et al. ³ (the same comment as for the signal detection methods; the COVID-19 pandemic has catalyzed interest) or the AGREE statement⁴ (https://www.agreetrust.org/agree-ii/), which includes a point about updating procedures (domain 3, point 14). The AGREE II instrument is a tool to assess the quality and reporting of practice guidelines and is internationally used. Having guidelines based on up-to-date evidence is obviously an important domain of guideline quality, and I think it's important to make the link to this in the review.
Table 1 – what belongs under “Mechanism” and under “Outcome” is unclear.
Table 2 – consideration might be given to Canadian and US Task Forces on Preventive Health Care, the UK National Screening Committee, and the IARC Cancer Prevention Handbooks (e.g. cervical cancer screening is covered in Vol. 10 and the upcoming Vol. 18; breast cancer in Vols. 7 and 15). This links back to the comments I made on the scope of the review. If preventive health is within scope, these strike me as well recognized international sources to consider.
There has been a large investment in clinical research in China, and there are many clinical guidelines⁵. I think this work needs at least to be recognized. There are Chinese databases, e.g. CKNI and WanFang (see Cohen JF et al.⁶). China accounts for more than 18% of the world’s population. There are also large proportions in India and in African countries, but there is less investment in clinical research. There has been a lot of activity in clinical guideline development in China⁵. I do not have comprehensive knowledge of guidelines in China, but having seen a few, my sense is that they consider Chinese evidence, evidence from other jurisdictions, and also consider Chinese traditional medicine, so they have a mixture of unique attributes and those common to other jurisdictions. I’m not sure how much the Chinese guidelines will be picked up in the search strategy proposed in the protocol, which is why I suggested the Chinese databases. It may be that the investigators decide that investigating Chinese guidelines other than what would be picked up in the search strategy presented in the protocol is out of scope, but I think it's important to be clear in reporting this decision and the rationale for it. The guideline development in India⁷ and Africa⁸ (this reference on hypertension guidelines may be helpful) may in large part be based on adapting guidelines from other jurisdictions, and thus be more likely to be picked up in the strategy in the protocol.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

References

1. Newberry SJ, Ahmadzai N, Motala A, Tsertsvadze A, et al.: Surveillance and Identification of Signals for Updating Systematic Reviews: Implementation and Early Experience. PubMed Abstract
2. Shekelle PG, Motala A, Johnsen B, Newberry SJ: Assessment of a method to detect signals for updating systematic reviews.Syst Rev. 2014; 3: 13 PubMed Abstract | Publisher Full Text
3. Akl EA, Meerpohl JJ, Elliott J, Kahale LA, et al.: Living systematic reviews: 4. Living guideline recommendations.J Clin Epidemiol. 2017; 91: 47-53 PubMed Abstract | Publisher Full Text
4. Brouwers MC, Kerkvliet K, Spithoff K, AGREE Next Steps Consortium: The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines.BMJ. 2016; 352: i1152 PubMed Abstract | Publisher Full Text
5. Chen Y, Wang C, Shang H, Yang K, et al.: Clinical practice guidelines in China. BMJ. 2018. Publisher Full Text
6. Cohen JF, Korevaar DA, Wang J, Spijker R, et al.: Should we search Chinese biomedical databases when performing systematic reviews?. Syst Rev. 2015; 4: 23 PubMed Abstract | Publisher Full Text
7. Mehndiratta A, Sharma S, Gupta N, Sankar M, et al.: Adapting clinical guidelines in India—a pragmatic approach. BMJ. 2017. Publisher Full Text
8. Okwen PM, Maweu I, Grimmer K, Margarita Dizon J: Evaluation of all African clinical practice guidelines for hypertension: Quality and opportunities for improvement.J Eval Clin Pract. 2019; 25 (4): 565-574 PubMed Abstract | Publisher Full Text

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Epidemiology and Prevention of Congenital Anomalies; Psychosis and affective psychosis; Cancer Epidemiology and Prevention; Molecular and Human Genome Epidemiology; Evidence synthesis related to public health; Health services research

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Respond to this report

Responses (0)

[1] 1. Government of Ireland: How to develop a national clinical guideline: a manual for guideline developers. [updated 2019 Jan; cited 2021 Jul 29]. Reference Source

[2] 2. Sharp MK, Tyner B, Awang Baki DAB, et al.: Evidence synthesis summary formats for clinical guideline development group members: a mixed-methods systematic review protocol [version 1; peer review: 1 approved with reservations]. HRB Open Res. 2021; 4: 76. Publisher Full Text

[3] 3. Vernooij RW, Sanabria AJ, Solà I, et al.: Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implement Sci. 2014; 9: 3. PubMed Abstract | Publisher Full Text | Free Full Text

[4] 4. National Institute for Health and Care Excellence: Developing NICE guidelines: the manual (PMG20). [updated 2020 Oct 15; cited 2021 Sep 28]. Reference Source

[5] 5. Qaseem A, Kansagara D, Lin JS, et al.: The Development of Clinical Guidelines and Guidance Statements by the Clinical Guidelines Committee of the American College of Physicians: Update of Methods. Ann Intern Med. 2019; 170(12): 863–70. PubMed Abstract | Publisher Full Text

[6] 6. US Preventive Services Task Force: Procedure Manual. [updated 2021 May; cited 2021 Sep 28]. Reference Source

[7] 7. Martínez García L, Pardo-Hernández H, Sanabria AJ, et al.: Guideline on terminology and definitions of updating clinical guidelines: The Updating Glossary. J Clin Epidemiol. 2018; 95: 28–33. PubMed Abstract | Publisher Full Text

[8] 8. Akl EA, Meerpohl JJ, Elliott J, et al.: Living systematic reviews: 4. Living guideline recommendations. J Clin Epidemiol. 2017; 91: 47–53. PubMed Abstract | Publisher Full Text

[9] 9. Garritty C, Gartlehner G, Nussbaumer-Streit B, et al.: Rapid review methods guidance aids in Cochrane’s quick response to the COVID-19 crisis. In: Collaborating in response to COVID-19: editorial and methods initiatives across Cochrane. Cochrane Database of Systematic Reviews. 2021; 28–31. Reference Source

[10] 10. El-Harakeh A, Lotfi T, Ahmad A, et al.: The implementation of prioritization exercises in the development and update of health practice guidelines: A scoping review. PLoS One. 2020; 15(3): e0229249. PubMed Abstract | Publisher Full Text | Free Full Text

[11] 11. Moher D, Shamseer L, Clarke M, et al.: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4(1): 1. PubMed Abstract | Publisher Full Text | Free Full Text

[12] 12. Denyer D, Tranfield D, van Aken JE: Developing Design Propositions through Research Synthesis. Organization Studies. 2008; 29(3): 393–413. Publisher Full Text

[13] 13. GIN-McMaster: GIN-McMaster Guideline Development Checklist. [updated 2014 Jun 02; cited 2021 Jul 29]. Reference Source

[14] 14. Wells GA, Shea B, O'Connell D, et al.: The Newcastle-Ottawa Scale (NOS) for assessing the quality of non-randomised studies in meta-analyses. [updated 2001; cited 2021 Jul 29]. Reference Source

[15] 15. Downes MJ, Brennan ML, Williams HC, et al.: Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS). BMJ Open. 2016; 6(12): e011458. PubMed Abstract | Publisher Full Text | Free Full Text

Processes for updating guidelines: protocol for a systematic review

Abstract

Keywords

Abbreviations

Introduction

Methods

Criteria for considering publications for this review

Table 1. Context, Intervention, Mechanism, Outcome.

Search methods for identification of studies

Table 2. Organisations that will be searched for relevant methodological handbooks.

Table 3. Grey literature that will be searched for relevant methodological handbooks.

Selection of eligible publications

Data extraction and management

Quality assessment

Data synthesis

Dissemination

Study status

Discussion

Data availability

Underlying data

Extended data

Reporting guidelines

Authors’ contribution

Acknowledgements

References

Comments on this article Comments (0)

Open Peer Review

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Reviewer Reports

Comments on this article

Are you a HRB-funded researcher?

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Processes for updating guidelines: protocol for a systematic review

Abstract

Keywords

Abbreviations

Introduction

Methods

Criteria for considering publications for this review

Table 1. Context, Intervention, Mechanism, Outcome.

Search methods for identification of studies

Table 2. Organisations that will be searched for relevant methodological handbooks.

Table 3. Grey literature that will be searched for relevant methodological handbooks.

Selection of eligible publications

Data extraction and management

Quality assessment

Data synthesis

Dissemination

Study status

Discussion

Data availability

Underlying data

Extended data

Reporting guidelines

Authors’ contribution

Acknowledgements

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Competing Interests Policy

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Are you a HRB-funded researcher?

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