Guidelines for Guidelines

For many developers the opportunity to adapt an existing guideline is tempting as superficially it has the potential to reduce development costs and avoid duplication of evidence reviews and advice. However, there is limited evidence to suggest that adapting a guideline saves time or money compared to developing one from scratch (Burgers, Anzueto et al. 2012; Darzi, Abou-Jaoude et al. 2017). This is consistent with the experiences of Australian guideline developers, many of whom report that adapting a guideline is not a straightforward exercise and may not offer the expected time saving.

The reality is that while there are many guidelines in circulation few of them are of sufficient quality to base derivative guidelines on—because a local or international guideline is available does not mean it should be used, let alone adapted for use elsewhere. For example, between 2005 to 2013 there were 102 guidelines on cardiovascular health in circulation in Australia, but only 15 of them included documentation showing them to be evidence based (NHMRC 2014).

It is rare to find one source guideline that contains recommendations covering the full scope of a proposed guideline; however, recommendations from multiple source guidelines can be considered, even when their scope is quite different. For example, the NHMRC Australian guidelines for the prevention and control of infection in healthcare adopted recommendations from the US Centers for Disease Control and Prevention Guidelines for Preventing Health-Care-Associated Pneumonia, 2003  (for droplet precautions) and the UK’s epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England (Pratt, Pellowe et al. 2007) (for safe handling of sharps), even though the focus of these two guidelines was quite different.

Adoption or adaptation of a whole guideline, its recommendations or other components (summarised in Table 1) can be considered if either:

• a suitable international source guideline is found and there is no Australian equivalent
• an Australian source guideline needs to be made more applicable to a new setting.

If a suitable but out of date source guideline is found it may be viable to update it by performing a repeat literature search and including any new evidence that is found. When existing guidelines are found to be unsuitable for adoption or adaptation, it is inevitably more timely and cost effective to start a new clinical guideline from scratch.

Table 1. Guideline components to consider adopting or adapting

Component	Description
Guideline questions	The questions on which the guideline and reviews of evidence are based.
Evidence tables	Tables that summarise the characteristics of the studies included.
Summary of findings table	A table containing the main findings of an evidence review based on a specific question and selection of outcomes.
GRADE evidence-to-decision tables (EtD table)	Frameworks that structure the formulation of recommendations, including detailed information on decisions made with regard to questions, criteria, evidence, judgements and conclusions.
Evidence statements	Statements that summarise the body of evidence with regard to specific questions.
Recommendations	The guideline’s recommendations for policy or practice.
Supporting content	Content in the guideline that supports the recommendations, such as tables, figures, practice points or other text.

 

If you find a suitable source guideline, the first step is to make sure that the decisions made during its development have been well-documented. This ensures that the motivations and judgements which underpin the original recommendations are clearly understood. If you find the guideline to be trustworthy you can either choose to adopt the recommendations without modifications or contextualise them for a different setting. Guidelines with a broad scope often include a mixture of recommendations that have been adopted (with or without contextualisation), adapted or developed from scratch.

You should consider when starting from scratch that the end users of your guideline may include other developers, therefore if your guideline is to be useful as a source for future guideline developers you should carefully document the way it was developed. You should include evidence sources and details of the context in which the guideline is intended to be used.

Adopting or adapting a guideline appears attractive because it can be seen as a way of reducing duplication of effort and funding, but this may not always be the case. In some circumstances the development process will become more complex than if starting from scratch, so it is important that you seek expert methodological advice early in the scoping phase to help you decide on the best approach.

This module focuses on methods that can be used to help you decide whether to adopt or adapt existing guidelines. Advice on the development of guidelines from scratch is provided in other modules.

What to do

1. Find out what guidance is available

As you determine the scope of your new guideline (see Scoping the guideline) you should try to locate all existing guidelines that are relevant to your topic. Online guideline libraries or portals are useful for identifying guidelines that are in development or currently in use, for example:

• Australian Clinical Practice Guidelines portal and register (Australia)
• Agency for Health and Research Quality (AHRQ) (US)
• Guidelines International Network (G-I-N) library (International)
• National Institute for Health and Care Excellence (NICE) (UK)
• World Health Organisation (WHO) (International)
• Centers for Disease Control and Prevention (CDC) (US)
• Scottish Intercollegiate Guidelines Network (SIGN) (UK)

Guidelines can also be found by searching databases such as MEDLINE (e.g. using the medical subject heading (MeSH) term ‘practice guideline.pt’), government websites and the websites of relevant professional organisations and condition groups.

If you find an existing guideline it may be worth contacting the original developers for advice on its scope and topic selection, which will be helpful if you need to assess guidelines in greater detail (e.g. questions, recommendations or evidence tables) to confirm how relevant the content is to your chosen topic.

Guidelines can also be developed using a partial adaptation or hybrid approach. This is where some recommendations are adapted from source guidelines and some are developed from scratch, based on new evidence reviews. If more than one high quality source guideline is available it may be appropriate to adopt recommendations from multiple guidelines. The recommendations can be standardised using an appraisal method such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method, which involves directly comparing the individual GRADE scores of similar guidelines (see Assessing certainty of evidence). If necessary this may also involve reappraising the evidence of non-GRADE based guidelines using the GRADE method. Once this process is completed recommendations which have the highest GRADE score are selected for the new guideline (Alper, Tristan et al. 2016).

You can also directly engage with stakeholders in various ways to find out further information on:

• related advice or guidelines that people are currently using
• whether a guideline has ever been developed on this topic (and if so, if it was successfully implemented and well received)
• any policy or practice issues which need to be clarified or resolved (e.g. if there is variation in practice, if best practice is unknown, or there are other complexities related to the topic).

2. Check if a guideline is suitable to adopt or adapt

The fact that a guideline is available does not necessarily mean it is suitable to adopt or adapt. While the AGREE II instrument is a useful and commonly used tool for evaluating the overall quality of a guideline (Brouwers, Kho et al. 2010), it is primarily designed to focus on the process of guideline development rather than the quality of the evidence and evidence synthesis.

When you are evaluating whether a guideline is suitable to adopt or adapt it is important to understand:

• how the evidence was interpreted
• whether there were conflicts of interest
• what values and preferences were considered
• the context in which the recommendations meant to apply.

All these factors have been shown to affect the grading of recommendations (Agoritsas, Neumann et al. 2017) and should be transparently reported in a trustworthy guideline. Simply judging a guideline by the reputation of its developers or the applicability of its recommendations should not be used as the basis for adapting or adopting.

The evidence review process of the source guideline should be fully accessible, including well-documented evidence tables to support each recommendation. This will allow you to assess the original judgements of the evidence underpinning the recommendations.

You should consider:

• when the review was undertaken
• if new evidence has become available
• whether the evidence is likely to change.

Even if the evidence appears out of date (e.g. more than five years old), it may still be appropriate to adopt the recommendation if no additional evidence which contradicts the existing recommendations has been identified. In this case, the search strategy you use to look for new evidence should also be documented.

The transferability of guidelines can present problems as new guidelines are inevitably designed by the developers to maximise their applicability in a particular setting. When contemplating whether to adopt the recommendations from a source guideline you should consider:

• if it would be possible to implement them in the new context
• whether they would be feasible to administer
• whether they would be acceptable to new users
• whether resource constraints would prevent them being used.

If there are likely to be new or different barriers to implementation it may be more appropriate to adapt the recommendations rather than adopt them verbatim—a decision that might be best made after consulting stakeholders (see Engaging stakeholders).

Another important consideration is the method used by the original developers to formulate recommendations as it might be too difficult and time consuming to convert recommendations from one grading system to another.

Table 2 provides an overview of the factors you should consider when you assess a guideline’s suitability to adopt or adapt and suggestions for how to check this information. Training in frameworks such as CAN-IMPLEMENT might also be useful if you would like to know more about the practical steps required to adapt a guideline.

Table 2. Assessing a guideline’s suitability to adopt or adapt  

Issue	Questions	Approach
Relevance	Is the clinical or public health context similar to Australia? Are the population, intended users and settings comparable? Are the recommended interventions available in Australia? Are the guideline questions relevant in the new context? Do the values and preferences considered in the guideline reflect the new context? Are relevant outcomes used?	Match the topic and scope using relevant keywords on the topic Check the subtopics or questions Break down questions into PICO or equivalent components for keywords Check how values and preferences were incorporated into the guideline (i.e. a literature search, consultation, representation on the development group) Check if relevant outcome sets exist (e.g. CORE)
Currency	When was the evidence review conducted? Is the evidence out of date? Is evidence likely to change? Has new evidence superseded the information contained in the recommendations? Does new evidence contradict the recommendations?	Check the details in the search strategy including the date cut-offs for inclusion of evidence Check whether the guideline made reference to emerging evidence at the time of publication
Trustworthiness	Is there a detailed description of the development process? Were conflicts of interest declared and managed? Was a grading system used for the recommendations? Are the evidence tables clearly laid out and accurate? Was the evidence review systematic and well-documented?	Assess overall quality using AGREE II Check what grading system was used Check that the evidence tables are available and complete
Access to evidence	Are the tables detailing the source evidence (e.g. GRADE Evidence to Decision tables) available? Can permission be sought to use these tables?	Check that the evidence tables are available and complete Contact the developers
Implementability	What information is provided in the guideline to assist implementation? What steps were taken to improve the guideline’s implementability?	Use an Implementability Planning checklist to assess implementability Check dissemination plan and materials
Acceptability	Are the recommendations acceptable? How do the recommendations relate to current practice? Are there barriers?	Consult with stakeholders Check if relevant audits have been conducted

3. Decide which parts of the guideline to adopt or adapt

When you scope a new guideline you may find that specific questions or guidance gaps that you identify are already addressed elsewhere. They may also be covered in guidelines that will soon be released (see the Australian Clinical Practice Guidelines Register for guidelines currently in development). If so, consider contacting the developers to discuss the scope of your respective guidelines and whether the evidence review can be shared. This can help avoid duplication of effort and ensure that resources are directed towards addressing gaps in the evidence base.

If the new guideline has a clearly defined scope it may sometimes be easier to adapt an existing source guideline in full. For guidelines with a broad scope it may be more practical to review the topics contained within existing guidelines and to draw on a variety of advice.

Using this approach new topics or questions will often need to be addressed. This might require new evidence reviews and new recommendations (if possible) to combine with the components adapted from existing source guidelines (see Identifying the evidence).

Even if only part of a guideline or recommendation is relevant for the intended setting, some guideline components may still be useful (see Table 1). For example, evidence tables or evidence statements might help in developing a more suitable recommendation. This will be particularly true if the reference guideline is well-documented and the decision making process is transparent.

In the example of the Australian Clinical practice guidelines for antenatal care given above, a recommendation on folate supplementation was sourced from a UK NICE guideline. The recommendation in its original form was not perfectly suited to Australian practice. Since the evidence underlying the recommendation was identical to that which was required to formulate a recommendation for an Australian setting, it was simply adapted and rephrased using the active voice:

NICE recommendation:

Pregnant women (and those intending to become pregnant) should be informed that dietary supplementation with folic acid, before conception and up to 12 weeks of gestation, reduces the risk of having a baby with neural tube defects (anencephaly, spina bifida). The recommended dose is 400 micrograms per day.

Australian Antenatal Care Guidelines recommendation:

Inform women that dietary supplementation with folic acid, from 12 weeks before conception and throughout the first 12 weeks of pregnancy, reduces the risk of having a baby with a neural tube defect (for example, anencephaly or spina bifida) and recommend a dose of 500 micrograms a day.

4. Adopt a guideline or its recommendations

If you decide to adopt an entire guideline (including all recommendations and supporting information) you should contextualise it so that it will be effectively implemented in practice. You should carefully document your rationale for deciding to adopt the source guideline and provide any additional information necessary for it to be implemented. For example, you may choose to adopt a source guideline but completely reformat it to encourage better uptake in a new setting.

If your guideline development group has reviewed the source guideline recommendations and decide that only some of them should be adopted, the rationale for this decision should again be recorded alongside each recommendation. This should include:

• when the decision was made
• when the recommendation should next be reviewed
• the most recent date that evidence was searched against each recommendation
• appropriate citations of your sources.

This is to keep track of whose judgement was responsible for each recommendation and when. For example, the NHMRC Clinical Practice Guidelines for the Management of Overweight and Obesity included recommendations adopted from a SIGN guideline which were clearly distinguished from the other recommendations (NHMRC 2013).

It is possible to make minor editorial changes to adopted recommendations to ensure they are consistent with the rest of the guideline (e.g. changing the wording from the passive to the active voice). However, care should be taken to avoid changing the meaning of a recommendation or the strength of the language used—the original wording is likely to have been carefully and deliberately chosen. You should consider asking the guideline developers to review any changes you make to the recommendations to check that their original meaning and intent has been retained.

One issue you may face is the challenge of adopting recommendations from a guideline that has used a different grading system. There is no ‘one size fits all’ approach to manage this and you will need to consider and document your methods based on your specific circumstances (e.g. which components of the reference guideline are available to you). In some cases the conversion is straightforward. For example, recommendations previously graded ‘A’ under the NHMRC grading system (also known as FORM) (Hillier, Grimmer-Somers et al. 2011) can be generally trusted to guide policy and practice. These recommendations will translate well to ‘strong’ evidence-based recommendations in the GRADE system, as will any equivalent system for high quality evidence. For recommendations graded ‘B’ and below, it is best to evaluate the evidence base and work through the new grading process accordingly.

5. Adapt a guideline or its recommendations

Validated frameworks to adapt a guideline are available for you to use. Many of them describe how to assess and make decisions about recommendations by integrating the GRADE evidence-to-decision (EtD) model (Darzi, Abou-Jaoude et al. 2017). An adapted guideline development process may sometimes be more complex than starting from scratch so it is important that you seek expert methodological advice.

A pioneering model is the ADAPTE framework, which can be used to help guide the process of systematically selecting, appraising and customising a guideline for a specific setting (ADAPTE Collaboration 2009; Darzi, Abou-Jaoude et al. 2017). The Canadian Guideline Adaptation Study Group has expanded the ADAPTE framework and produced a modified three-phase approach called CAN-IMPLEMENT. This method integrates the full knowledge translation cycle into the ADAPTE framework (Harrison, Graham et al. 2013). It provides:

• greater methodological support
• tools to manage and document the process
• a component focussed on dissemination and implementation planning.

Another model is the GRADE- ADOLOPMENT framework, which combines advice on adoption, adaptation and the creation of recommendations from scratch (Schunemann, Wiercioch et al. 2017). The framework has been tested on 226 recommendations across 22 guidelines and has shown that its efficiency depends on the availability of a GRADE EtD table for each recommendation (Neumann, Brignardello-Petersen et al. 2016). This component would otherwise need to be created individually (GRADE 2013; Schunemann, Wiercioch et al. 2017). With an EtD table, you can decide if new judgements of the evidence differ from the original assessments (see Evidence to decision). You can then use this information to determine whether the direction and strength of a recommendation has changed and adapt it accordingly (Schunemann, Wiercioch et al. 2017).

Source guidelines and associated documents may remain the intellectual property of their developers. Before you choose to adapt an existing guideline it is recommended that you seek the permission of its developer to avoid potential copyright infringement. The source guideline should always be cited both to acknowledge the work of the original developers and to help users identify differences between the source guideline and your guideline. Details of any changes you make should be described in the adapted recommendation. For example, in the case described in Section 3 (adaptation of a recommendation on folate supplementation), the changes were marked in the evidence table as follows:

‘1 level I study supported the NICE recommendation on folic acid supplementation. Dosage changed in line with Australian advice.’ (DoHA 2012).

Deciding what to adapt and which framework to use requires methodological expertise to properly apply the framework and to identify and fix issues as they arise. Failed attempts at adaptation are typically the result of a lack of detail provided in the source guideline. Thorough prior assessment of a guideline’s suitability for adaptation can mitigate this risk.

In some cases it may be appropriate to modify an existing adaptation framework to suit your specific purposes. Remember that good guideline development is essentially a pragmatic exercise. Provided all decisions are transparent and well-documented, you should be able to create a trustworthy guideline with limited resources (Browman, Somerfield et al. 2015).

NHMRC requirements

An adapted clinical practice guideline is eligible for NHMRC approval if the source information, evidence and decision making process is transparent, well-documented and other criteria are met as per the procedures and requirements.

NHMRC Standards

The following Standards apply to the Adopt, adapt or start from scratch module:

2. To be transparent guidelines will make publicly available:

2.1. The details of all processes and procedures used to develop the guideline

2.2. The source evidence

2.3. The declarations of interest of members of the guideline development group and information on how any conflicts of interest were managed

2.4. All sources of funding for the guideline.

 

6. To be evidence informed guidelines will:

6.1. Be informed by well conducted systematic reviews

6.2. Consider the body of evidence for each outcome (including the quality of that evidence) and other factors that influence the process of making recommendations including benefits and harms, values and preferences, resource use and acceptability

6.3. Be subjected to appropriate peer review.

 

7. To make actionable recommendations guidelines will:

7.1 Discuss the options for action

7.2 Clearly articulate what the recommended course of action is, and when it should be taken

7.3 Clearly articulate what the intervention is so that it can be implemented

7.4 Clearly link each recommendation to the evidence that supports it

7.5 Grade the strength of each recommendation

Useful resources

The ADAPTE framework

AGREE II assessment tool

CAN-IMPLEMENT

GRADE working group

GRADE Evidence to decision framework from the GRADE Handbook

GRADE- ADOLOPMENT framework

GRADE’s Database of Evidence profiles and Evidence to Decision frameworks

Australian Clinical Practice Guidelines portal (Australia)

Agency for Health and Research Quality (US)

Guidelines International Network (G-I-N) library (International)

National Institute for Health and Care Excellence (NICE) (UK)

World Health Organisation (WHO) (International)

PubMed

References

ADAPTE Collaboration (2010). The ADAPTE Process: Resource Toolkit for Guideline Adaptation.

Agoritsas, T., I. Neumann, et al. (2017). Guideline conflict of interest management and methodology heavily impacts on the strength of recommendations: comparison between two iterations of the American College of Chest Physicians Antithrombotic Guidelines. Journal of Clinical Epidemiology 81: 141-143.

Alper, B. S., M. Tristan, et al. (2016). RAPADAPTE for rapid guideline development: high-quality clinical guidelines can be rapidly developed with limited resources. International Journal for Quality in Health Care 28(3): 268-274.

Brouwers, M. C., M. E. Kho, et al. (2010). AGREE II: advancing guideline development, reporting and evaluation in health care. Canadian Medical Association Journal 182(18): E839-842.

Browman, G. P., M. R. Somerfield, et al. (2015). When is good, good enough? Methodological pragmatism for sustainable guideline development. Implementation Science 10: 28.

Burgers, J. S., A. Anzueto, et al. (2012). Adaptation, evaluation, and updating of guidelines: article 14 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Proceedings of the American Thoracic Society 9(5): 304-310.

Darzi, A., E. A. Abou-Jaoude, et al. (2017). A methodological survey identified eight proposed frameworks for the adaptation of health related guidelines. Journal of Clinical Epidemiology 86: 3-10.

Department of Health and Ageing (DoHA) (2012). Clinical practice guidelines: Antenatal care - Module 1, Australian Government.

Gardener, G., L. Daly, et al. (2016). Clinical practice guideline for the care of women with decreased fetal movements, The Centre of Research Excellence in Stillbirth.

GRADE Working Group (2013). GRADE Handbook: Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach.

Harrison, M. B., I. D. Graham, et al. (2013). Guideline adaptation and implementation planning: a prospective observational study. Implementation Science 8: 49.

Hillier, S., K. Grimmer-Somers, et al. (2011). FORM: an Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BioMedCentral Medical Research Methodology 11: 23.

National Health and Medical Research Council (NHMRC) (2013). Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia, Australian Government.

National Health and Medical Research Council (NHMRC) (2014). Australian Clinical Practice Guidelines 2014 Annual Report.

Neumann, I., R. Brignardello-Petersen, et al. (2016). The GRADE evidence-to-decision framework: a report of its testing and application in 15 international guideline panels. Implementation Science 11(1): 1-8.

Pratt, R. J., C. M. Pellowe, et al. (2007). epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. The Journal of Hospital Infection 65: S1-64.

Royal College of Obstetricians and Gynaecologists (RCOG) (2013). Small-for-Gestational-Age Fetus, Investigation and Management (Green-top Guideline No. 31).

Schunemann, H. J., W. Wiercioch, et al. (2017). GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. Journal of Clinical Epidemiology 81: 101-110.

Acknowledgements

NHMRC would like to acknowledge and thank Associate Professor Philippa Middleton from the South Australian Health & Medical Research Institute for her contribution to the development of this module as editor.

Version 5.2. Last updated 22/11/2018.

Suggested citation: NHMRC. Guidelines for Guidelines: Adopt, adapt or start from scratch. https://www.nhmrc.gov.au/guidelinesforguidelines/plan/adopt-adapt-or-start-scratch. Last updated 22/11/2018.