• How Often Should Clinical Practice Guidelines be Updated – A review of CPG development handbook recommendations.

    by Marc Colbeck. Last modified: 10/12/14

     

     
    Vernooij RW, Sanabria AJ, Solà I, Alonso-Coello P1, Martínez García L. Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implement Sci. 2014 Jan 2;9:3. PMID: 24383701.

    openaccess

    Paramedics use clinical practice guidelines (CPGs) to … well … guide their clinical practice.  How often are the CPGs in your service reviewed?  How often should they be reviewed?  Vernooij et al have wondered the same thing about CPGs in general (not just for paramedics) and they decided to look into it in this study.  A lot of organisations publish handbooks on how to develop (write, update, disseminate, etc) CPGs and that’s where the authors decided to get their answer from.

    In order to do this they identified as many existing handbooks on CPG development as they could find, pared it down to 35 relevant books (from 1992!), and two authors independently reviewed the handbooks to extract recommendations (with a third author adjudicating disagreements).  They state that as far as they know theirs is “the first study to examine the guidance about the updating process provided by CPG methodological handbooks”.

    They may be the first to review methodological handbooks, but they’re not the first to think about this topic.  Shekelle et al reviewed 17 clinical practice guidelines in 2001 …

     
    Shekelle PG1, Ortiz E, Rhodes S, Morton SC, Eccles MP, Grimshaw JM, Woolf SH. Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated? JAMA. 2001 Sep 26;286(12):1461-7. PMID: 11572738.

    And Becker et al published a systematic review on methods and development of an updating procedure for CPGs in 2014:

     
    Becker M1, Neugebauer EA, Eikermann M. Partial updating of clinical practice guidelines often makes more sense than full updating: a systematic review on methods and the development of an updating procedure. J Clin Epidemiol. 2014 Jan;67(1):33-45. PMID: 24125894.

    I’ll be looking at those studies in later posts. To introduce the topic in this particular paper Vernooij et al state:

    Most handbooks (97.1%) focus mainly on developing CPGs, including variable degrees of information about updating. Guidance on identifying new evidence and the methodology of assessing the need for an update is described in 11 (31.4%) and eight handbooks (22.8%), respectively. The period of time between two updates is described in 25 handbooks (71.4%), two to three years being the most frequent (40.0%). The majority of handbooks do not provide guidance for the literature search, evidence selection, assessment, synthesis, and external review of the updating process.

    The authors note that the state of CPG development generally lags behind the best practices that have been identified in the literature. They used a check sheet to formally extract the following information from the handbooks they identified:

    1.      characteristics of the handbook and institution, 2.      group responsible for updating CPGs, 3.      strategy for identifying new evidence, 4.      methodology for assessing the need for an update, 5.      methods for the literature search, 6.      evidence selection, 7.      evidence assessment, 8.      evidence synthesis, 9.      external review, 10.  and for the edition and dissemination of the updated CPG.

    They found:

    Twenty-five (71.4%) of the included handbooks recommend a time frame between publishing a CPG and commencing an updating process with two to three years being the most frequently recommended (40.0%) … three handbooks (8.6%) suggest a time frame of less than one year and eight handbooks (22.9%) include a four to five year time frame

    I found this to be the most concise (and startling) summary of their findings:

    This study including a sample of 17 guidelines, estimated that approximately one-half of the CPGs will be outdated after 5.8 years (95% CI: 5.0 – 6.6), and 10% are obsolete after 3.6 years (95% CI: 2.6 – 4.6). However, these average estimates can be misleading as CPG deteriorating speed is highly topic-specific, with some fields with rapid developments requiring more frequent surveillance for new evidence than others.

    To me, that says that any CPG that hasn’t been updated in the last five years is suspect as it has a 50% chance of being out of date – or an even higher chance in rapidly evolving fields.  It’s interesting to note (although the authors don’t mention it) that the ILCOR advanced cardiac life support guidelines, which cover a rapidly evolving field, come out … every five years.  That doesn’t sound so good, does it? If you’re interested or involved in updating CPGs the authors included a recommendation that they developed for a process of how to update existing CPGs (Figure 3 in their paper).

    1748-5908-9-3-3

     

    (Vernooij RW, Sanabria AJ, Solà I, Alonso-Coello P, Martínez García L. Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implement Sci. 2014 Jan 2;9:3)

    Finally, they conclude:

    Our results show that overall the updating guidance is poorly described. Crucial elements in identifying new evidence, the assessment for the need for an update and the updating strategy itself, are generally lacking or include solely a reference to the development process. Our findings resonate with previous findings that suggest that there is a need for rigorous international guidance for updating CPGs

    References

     
    1.

    Vernooij RW, Sanabria AJ, Solà I, Alonso-Coello P1, Martínez García L. Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implement Sci. 2014 Jan 2;9:3. PMID: 24383701.

     
    2.

    Shekelle PG1, Ortiz E, Rhodes S, Morton SC, Eccles MP, Grimshaw JM, Woolf SH. Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated? JAMA. 2001 Sep 26;286(12):1461-7. PMID: 11572738.

     
    3.

    Becker M1, Neugebauer EA, Eikermann M. Partial updating of clinical practice guidelines often makes more sense than full updating: a systematic review on methods and the development of an updating procedure. J Clin Epidemiol. 2014 Jan;67(1):33-45. PMID: 24125894.

    The following two tabs change content below.
    Marc Colbeck

    Marc Colbeck

    Senior Lecturer at Australian Catholic University
    Marc is a Canadian Critical Care Paramedic with 14 years of clinical experience who has been working as a professional educator since the early 2000's. He has taught at the College and University level in the Middle East and Australia, and worked as the General Manager of Clinical Governance for an Australian State Ambulance Service. He is currently a Senior Lecturer at Australian Catholic University in Queensland, Australia. His undergraduate degree is in PreHospital Care and his MA is in Counseling Psychology. He is currently working on a PhD in Translational Health Sciences with the Joanna Briggs Institute at the University of Adelaide, with a special interest in the development and maintenance of paramedic CPGs. His website is www.marccolbeck.info.

    Tags: , , ,

    One thought on “How Often Should Clinical Practice Guidelines be Updated – A review of CPG development handbook recommendations.

    Leave a Reply