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The updating of clinical practice guidelines: insights from an international survey

Pablo Alonso-Coello12, Laura Martínez García1*, José Miguel Carrasco3, Ivan Solà1, Safia Qureshi4, Jako S Burgers5 and the Updating Guidelines Working Group

Author Affiliations

1 Iberoamerican Cochrane Centre, Institute of Biomedical Research (IIB Sant Pau), (C/Sant Antoni Maria Claret 171), Barcelona (08041), Spain

2 CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain

3 GuíaSalud-Biblioteca, Aragon Health Sciences Institute, (Avda. Gómez Laguna 25), Zaragoza, (50009), Spain

4 Scottish National Blood Transfusion Service, (21 Ellen's Glen Road), Edinburgh, (EH17 7Q7T), UK

5 Dutch College of General Practitioners, (Mercatorlaan 1200), Utrecht, (3528 GL), The Netherlands

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Implementation Science 2011, 6:107  doi:10.1186/1748-5908-6-107

Published: 13 September 2011



Clinical practice guidelines (CPGs) have become increasingly popular, and the methodology to develop guidelines has evolved enormously. However, little attention has been given to the updating process, in contrast to the appraisal of the available literature. We conducted an international survey to identify current practices in CPG updating and explored the need to standardize and improve the methods.


We developed a questionnaire (28 items) based on a review of the existing literature about guideline updating and expert comments. We carried out the survey between March and July 2009, and it was sent by email to 106 institutions: 69 members of the Guidelines International Network who declared that they developed CPGs; 30 institutions included in the U.S. National Guideline Clearinghouse database that published more than 20 CPGs; and 7 institutions selected by an expert committee.


Forty-four institutions answered the questionnaire (42% response rate). In the final analysis, 39 completed questionnaires were included. Thirty-six institutions (92%) reported that they update their guidelines. Thirty-one institutions (86%) have a formal procedure for updating their guidelines, and 19 (53%) have a formal procedure for deciding when a guideline becomes out of date. Institutions describe the process as moderately rigorous (36%) or acknowledge that it could certainly be more rigorous (36%). Twenty-two institutions (61%) alert guideline users on their website when a guideline is older than three to five years or when there is a risk of being outdated. Twenty-five institutions (64%) support the concept of "living guidelines," which are continuously monitored and updated. Eighteen institutions (46%) have plans to design a protocol to improve their guideline-updating process, and 21 (54%) are willing to share resources with other organizations.


Our study is the first to describe the process of updating CPGs among prominent guideline institutions across the world, providing a comprehensive picture of guideline updating. There is an urgent need to develop rigorous international standards for this process and to minimize duplication of effort internationally.