Comparison of guideline development programmes

International comparison of guideline programmes

Jako Burgers, Richard Grol, Niek Klazinga, Akke van der Bij, Marjukka Mäkelä, Joost Zaat and The AGREE Collaborative Group

Background

Clinical practice guidelines are being used in many countries throughout the world to improve quality of patient care. An increasing concern is the number of guidelines of low quality (1,2) and guidelines that contain conflicting recommendations (3,4). There is a need for a common, valid and transparent approach to develop good clinical practice guidelines. However, different guideline development methods are still being used (5). In a previous study of the AGREE Collaboration the collaborative countries have been presented and illustrated the variations in policies and approaches to clinical guidelines across countries (6). Most countries developed guidelines within a national guideline programme, other countries have plans to set up a guideline programme.

The aim of this survey was to systematically describe the structures and working methods of current guideline programs in different countries throughout the world, covering the entire scope of guideline development, dissemination, implementation, and evaluation.

Methods

A guideline programme was defined as "a structured and coordinated programme designed with the specific aim of producing several clinical practice guidelines". We selected guideline programmes with a high impact on national level from countries involved in the AGREE Collaboration (Table 1). To widen the scope of our study, we also included the well-known technology-assessment program from Sweden and the national guideline programme used in Australia.

A conceptual framework covering all relevant aspects of guideline programmes was produced using criteria for (good) guideline programmes from different authors (7-11). Based on this framework we designed a questionnaire (Appendix 1), which was sent to key informants of the guideline programmes. The answers received were summarised in tables. For validation we sent the first draft of the results back to the informants, asking them to check our interpretations.

Results

Most guideline programmes were established to improve the quality and effectiveness of health care. Most use electronic databases to collect evidence and systematic reviews to analyse the evidence. Consensus procedures are used when evidence is lacking. All guidelines are reviewed before publication. Authorisation is commonly used to endorse guidelines. All guidelines are furnished with tools for application and the Internet is widely used for dissemination. Implementation strategies vary among different organisations, larger organisations leaving this to local organisations. Almost all have a quality assurance system for their programs. Half of the programs do not have formal update procedures.

Conclusions

Principles of evidence-based medicine dominate current guideline programmes. Recent programmes are benefiting from the methodology created by longstanding programmes. Differences are found in the emphasis on dissemination and implementation, probably due to differences in health care systems and political and cultural factors. International collaboration should be encouraged to improve guideline methodology and to globalise the collection and analysis of evidence needed for guideline development.

Note

The paper presenting the complete results of this study will be published as "Towards evidence-based clinical practice: an international survey of 18 clinical guideline programmes" in the first issue of the International Journal for Quality in Health Care in 2003.

References

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5) Mäkelä M. International experiences with guidelines. In: Selbmann H.K. Guidelines in health care. Report of a WHO-Conference January 1997. Baden-Baden: Nomos Verlagsgesellschaft, 1998: 85-91.

6) Cluzeau F., for the AGREE Collaborative Group.Guideline development in Europe: an international comparison. International Journal of Technology Assessment in Health Care 2000; 16 (4), 1036-46.

7) Institute of Medicine. Field S, Lohr K (eds). Guidelines for Clinical Practice: from Development to Use. Washington DC: National Academy Press, 1992.

8) Lohr K.N. The quality of practice guidelines and the quality of health care. In: Selbmann HK. Guidelines in health care. Report of a WHO-Conference January 1997. Baden-Baden: Nomos Verlagsgesellschaft, 1998: 42-52.

9) Cluzeau F, Littlejohns P, Grimshaw J, Feder G, Moran SE. Development and application of a generic methodology to assess the quality of clinical guidelines. International Journal of Quality in Health Care 1999; 11: 21-8.

10) Mäkelä M., Thorsen T. A framework for guidelines implementation studies. In: Changing Professional Practice. Theory and practice of clinical guidelines implementation. Copenhagen: Danish Institute for Health Services, 1999.

11) National Guideline Clearinghouse, United States: http//www.guideline.gov./index.asp.

Table 1. Selected guideline programmes, organisations responsible for guideline development

Appendix 1. Questionnaire for description of guideline development programmes