Scientific knowledge is in constant change. The flow of new information requires a frequent re-evaluation of the available research results. Clinical practice guidelines (CPGs) are not exempted from this phenomenon and need to be kept updated to maintain the validity of their recommendations. The objective of our review is to systematically identify, describe and assess strategies for monitoring and updating CPGs.
Study design and setting
We conducted a systematic review of studies evaluating one or more methods of updating (with or without monitoring) CPGs or recommendations. We searched MEDLINE (PubMed) and The Cochrane Methodology Register (The Cochrane Library) from 1966 to June 2012. Additionally, we hand-searched reference lists of the included studies and the Guidelines International Network book of abstracts. If necessary, we contacted study authors to obtain additional information.
We included a total of eight studies. Four evaluated if CPGs were out of date, three updated CPGs, and one continuously monitored and updated CPGs. The most detailed reported phase of the process was the identification of new evidence. As opposed to studies updating guidelines, studies evaluating if CPGs were out of date applied restricted searches. Only one study compared a restricted versus an exhaustive search suggesting that a restricted search is sufficient to assess recommendations’ Validity. One study analyzed the survival time of CPGs and suggested that these should be reassessed every three years.
There is limited evidence about the optimal strategies for monitoring and updating clinical practice guidelines. A restricted search is likely to be sufficient to monitor new evidence and assess the need to update, however, more information is needed about the timing and type of search. Only the exhaustive search strategy has been assessed for the update of CPGs. The development and evaluation of more efficient strategies is needed to improve the timeliness and reduce the burden of maintaining the validity of CPGs.
Keywords:Clinical practice guidelines; Diffusion of innovation; Evidence-based medicine; Information storage and retrieval; Methodology; Updating; Implementation science; Dissemination and implementation; Knowledge translation
Scientific knowledge is in constant change, and new information requires frequent assessment to determine whether it changes the knowledge base . A clinical practice guideline (CPG) may be considered out of date if it does not include all recent, valid, and relevant evidence or does not reflect current clinicians’ experience and patients’ values and preferences . CPGs, hence, need to be updated regularly to remain valid.
Shekelle et al. evaluated the validity of a cohort of CPGs . Survival analysis indicated that 90% of CPGs were still valid in 3.6 years, but 50% were out of date in 5.8 years . Based on these results, most methodological handbooks for the development of CPGs propose three years as a reasonable time frame to update their guidelines [1,4].
In 2007, Moher et al. conducted a study about when and how to update systematic reviews . Although not included in the objectives, the authors identified and described several methods for updating CPGs. In their conclusions the authors argue that the methodology for updating CPGs, as opposed to systematic reviews, is well established. Nevertheless, a recent international survey showed high variability and a lack of standardization in the CPGs updating processes .
A few studies have evaluated different strategies for the CPGs updating process [3,7,8], however, no systematic reviews have been conducted about this topic. We therefore undertook a systematic review of the studies that assessed strategies for monitoring and updating CPGs.
Information sources and search
We performed a search in June 2012 in MEDLINE (accessed through PubMed, from 1966 onwards) and The Cochrane Methodology Register (accessed through The Cochrane Library, Issue 6 2012). We included studies regardless of their language or publication status. The search strategy is available as supplementary data (Additional file 1). Additionally, we hand searched reference lists of the included studies and in the Guidelines International Network book of abstracts (available online from 2009 until 2011 in http://www.g-i-n.net/ webcite). If necessary we contacted study authors to obtain additional information. Two authors were in charge of performing all searches (IS, LMG).
1. Type of study: We included studies evaluating one or more methods of updating (with or without monitoring) evidence-based CPGs or recommendations. We excluded studies that only reported updating methods (without actually testing them), methodological handbooks or CPGs updates. We made no restriction by health topic.
2. Type of design: We included studies assessing strategies for evaluating if CPGs are out of date; for updating CPGs; for continuous monitoring and updating of CPGs (Figure 1).
Figure 1. Updating Clinical Practice Guidelines Strategies.
Two authors independently reviewed the titles and abstracts, as well as the full text of the selected articles for a more detailed evaluation and approved their final inclusion (LMG, IAR). Any disagreement among the authors was initially resolved by consensus, and if necessary, we consulted a third author (IS).
Data extraction strategy
Two authors independently extracted information from the included studies using an ad hoc form (LMG, IAR) that can be requested from the authors. Disagreements among the authors were resolved by consensus and, if required, by a third author (IS). We contacted study authors by email when more information was needed.
We extracted the following information from each study: institution or guideline program and country; objective and design of the study; sample (selection and size) and health topic; time to update (number of years since the development of the original CPG); stages of the strategies; type of search (restricted or exhaustive, classified depending on databases consulted and types of studies searched); resource use (number of participants and time spent); search and update results; and advantages and limitations of strategies reported by the authors.
Data synthesis and presentation
We describe included studies both individually and narratively. We calculated the search performance of the strategies (as a proportion of included documents from all documents identified); and update performance of the strategies (as a proportion of updated recommendations or CPGs from all evaluated recommendations or CPGs).