A framework to develop living practice guidelines in healthcare
Clinical practice guidelines are the most important resource to assist-decision making in healthcare. Nevertheless, their applicability can decrease over time, as new evidence emerges, the sanitary context mutates or the preferences of patients change.
An international multidisciplinary collaboration in which Epistemonikos took part produced a framework for the planification, production, report and dissemination of living practice guidelines, a display that aims to avoid going out of date by updating the evidence-based recommendations as a unit.
Scientific information can take an average of 17 years to apply to patient care [1]. Clinical practice guidelines (CPGs) are the most important documents for the incorporation of scientific evidence in health decision making through the formulation of recommendations [2]. If adequately implemented, CPGs have the potential of reducing variability and translating scientific research into clinical practice and consequently improve the quality and safety of healthcare [3].
A reliable CPG is one that was developed using the best available evidence at the moment of its elaboration through the most rigurous and transparent methodology. Also, a CPG that is ready to implement is one where the evidence is adapted to the local context. Taking this into consideration, the obsolescence of a CPG might occur because of new scientific research, including the development of new technologies in treatment and diagnosis alternatives, economic differences, or changes in values and preferences [3].
Some authors suggest that an update is generally required after three to five years [3], through a process that requires a major investment in both time and money.
The ‘living mode’
Living systematics reviews [4] and living clinical practice guidelines have been proposed as the solution to the need to timely inform decision-making in health when scientific evidence evolves rapidly. Living guidelines are defined as an optimization of the guideline development process to allow updating individual recommendations as soon as new relevant evidence becomes available [5]. A major implication of that definition is that the unit of update is the individual recommendation and not the whole guideline.
The World Health Organization (WHO) was one of the first organizations to adopt this methodology, with the 2002 establishment of the Continuous Identification of Research Evidence (CIRE) to monitor and incorporate the most recent evidence to their guideline on contraceptive use [6].
However, the development of living guidelines faces several challenges that are not shared with traditional guideline development [1]. These challenges include the need to establish a living evidence synthesis process, maintain quality standards despite rapid cycles of updates, determine an appropriate update schedule, and define criteria for inclusion of new evidence and for changing recommendations. From an output perspective, there is a need to avoid updates being too frequent, leading to flipping recommendations back and forth. Also, end users are challenged with keeping up with the living guideline recommendations.
A framework for the development of living guidelines
The protocol for the development of the framework started with 3 background formative reviews and expert input on a draft version. Later, a multidisciplinary group of 51 persons from 6 world regions was assembled, including guideline-developing organization representatives, guideline methodologists, systematic reviewers, trialists, journal editors, clinical and public health practitioners, public and patient representatives, and information technologists. Among them was our Executive Director, Gabriel Rada MD.
The result was a framework that will help guideline developers in planning, producing, reporting, and disseminating living guideline projects. It is also expected to help research methodologists on the study of the processes of living guidelines.
References
[1] Centers for Disease Control and Prevention. The Adapting Clinical Guidelines for the Digital Age (ACG) initiative. https://www.cdc.gov/csels/phio/clinical-guidelines/index.html
[2] Ariel Franco JV, Arancibia M, Meza N, Madrid E, Kopitowski K. Clinical practice guidelines: Concepts, limitations and challenges. Medwave 2020;20(3):e7887 doi: 10.5867/medwave.2020.03.7887
[3] Vernooij, R.W., Sanabria, A.J., Solà, I. et al. Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implementation 2014 Sci 9, 3. DOI: https://doi.org/10.1186/1748-5908-9-3
[4] Elliott JH, Turner T, Clavisi O, Thomas J, Higgins JPT, et al. Living Systematic Reviews: An Emerging Opportunity to Narrow the Evidence-Practice Gap. PLoS Med 2014, 11(2): e1001603. doi:10.1371/journal.pmed.1001603
[5] Akl EA, Meerpohl JJ, Elliott J, Kahale LA, Schünemann HJ; Living Systematic Review Network. Living systematic reviews: 4. Living guideline recommendations. J Clin Epidemiol. 2017, 91:47-53. doi: 10.1016/j.jclinepi.2017.08.009.
[6] World Health Organization. Selected practice recommendations for
contraceptive use. 3rd ed. World Health Organization; 2016. www.ncbi.nlm.nih.gov/books/NBK409187/
