• How Should CPG’s be Updated?

    by Marc Colbeck. Last modified: 18/12/14


    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 main points:

    • Review of 35 guideline development handbooks and introduction of a very detailed (flowcharted) process for how and when CPGs should be reviewed, including a pragmatic discussion of how much resources it takes to run an effective monitoring system of new evidence.
    • They found that most publications focused on assessing whether or not a CPG needs updating and not on how to update them.
    • If you are responsible for authoring CPGs this will be a good article to help you refine your review process and rationalise your use of resources.  You should probably be using this flowchart.


    Keeping CPGs up to date takes a lot of work.  Paramedics are familiar with the constantly changing nature of CPGs and some may wonder why CPG authors don’t just “get it right and leave it alone”.

    For the authors of CPGs, a plethora of information (see the wonderfully titled article Seventy-five trials and eleven systematic reviews a day: how will we ever keep up?) and a lack of clear, validated methods for systematically determining when new evidence is published in an ongoing manner means it’s hard to know what all the “evidence” actually is, and when we’ve reached the ‘tipping point’ of when a change is required.

    To complicate matters further, if the authors determine that an update is necessary for some reason, they have to decide if the update can be published in the regular schedule (i.e. at the next, normal review date) or if it should be an exceptional (i.e. immediate and unscheduled) update.  For resource-rich organisations (find me one!) the idea of a continuous updating process (full reviews done – at least – annually) is ideal.

    This isn’t part of the article, but for our industry it’s important to keep the following in mind; the resources that authors in ambulance services have for reviewing the deluge of new information is limited.  Few ambulance services have a dedicated, full time researcher, (let alone a research team), so they rely on paramedics to either volunteer their time to review evidence, or to do so as paid employees outside their normal working hours.  If you’re a manager and you need to get several hundred to several thousand hours of review work done with paramedics (usually on overtime) making $30-$60 an hour, you can see that this will rapidly become a HUGE budget item; an item that most services simply don’t have the money for.  So reviewing the evidence in as organised and efficient a manner as possible becomes critical.

    The authors reviewed the existing best-methods for updating CPGs, refined them, and presented a new model.  This model directly addresses a deficiency that they found in most of the previous models – a lack of clear instructions on HOW (as opposed to WHEN) to conduct reviews of the existing literature.  Included in this work algorithm is a decision tree for when an update can be performed according to schedule, or if an ‘exceptional’ update is needed (for example, if there is a recall of a drug).


    Having a ‘guideline’ for updating guidelines makes perfect sense.  This guideline is based on, and still very much in alignment with a seminal article on the topic by Shekelle et al in 2001 and it seems pragmatic and well considered. If you author guidelines, you should probably be basing your review methodology on this process.


    Other references:

    Bastian H1, Glasziou P, Chalmers I. Seventy-five trials and eleven systematic reviews a day: how will we ever keep up? PLoS Med. 2010 Sep 21;7(9):e1000326. PMID: 20877712.
    Shekelle P1, Eccles MP, Grimshaw JM, Woolf SH. When should clinical guidelines be updated? BMJ. 2001 Jul 21;323(7305):155-7. PMID: 11463690.
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    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.

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