April 2016 - Internet Resources Digest


Clinical Practice Guidelines

AIHA Internet Resources Digest 
April 2016

Supporting Access to High Quality Online Resources

Spotlight on: Clinical Practice Guidelines

“Practice Guidelines - directions or principles presenting current or future rules of policy for assisting health care practitioners in patient care decisions regarding diagnosis, therapy, or related clinical circumstances. The guidelines may be developed by government agencies at any level, institutions, professional societies, governing boards, or by the convening of expert panels. The guidelines form a basis for the evaluation of all aspects of health care and delivery.” (MeSH definition)

Data Bases and Search Tools

NICE Evidence Search

Evidence search provides access to selected and authoritative evidence in health, social care and public health.

  • It combines evidence on health, drugs and technologies, public health, social care, and healthcare management and commissioning in one place;
  • brings together high quality consolidated and synthesised evidence from hundreds of trusted sources;
  • includes guidance, systematic reviews, evidence summaries and patient information;
  • freely available, without needing to log in;
  • content is refreshed regularly and up to date;
  • full text of the search results can be freely obtained in most cases;
  • offers filters to manage search results, allowing access to relevant information more quickly.

Sources include: British National Formulary, Clinical Knowledge Summaries, SIGN, the Cochrane Library and Royal Colleges, Social Care Online and GOV.UK


National Guideline Clearinghouse

NGC is a public resource for evidence-based clinical practice guidelines. NGC is an initiative of the U.S. Department of Health and Human Services. NGC was originally created by AHRQ in partnership with the American Medical Association and the America's Health Insurance Plans (AHIP).

The NGC mission is to provide physicians and other health professionals, health care providers, an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.

There is a tool to generate side-by-side comparisons for any combination of two or more guidelines. The guidelines selected are retained throughout your session, so you may compare guidelines from multiple searches and browses. My NGC allows you to save your favorite guideline summaries and organizations, create custom e-mail alerts, and set up topic alerts.


Guidelines International Network (G-I-N)

Guidelines International Network is an international not-for-profit association of organizations and individuals involved in the development and use of clinical practice guidelines. G-I-N seeks to improve the quality of health care by promoting systematic development of clinical practice guidelines and their application into practice.

Founded in 2002, G-I-N has grown to 99 organizational members and partners representing 34 countries from Africa, America, Asia, Europe and Oceania.

The international guideline library contains more than 6,400 guidelines, evidence reports and related documents, which have been developed or endorsed by the organisational members. Not all documents are aviailable to non-memebrs in full-text, but it provides information about original web-sites.


TRIP database

The TRIP Database searches over 75 sites of high-quality medical information. The TRIP Database is a clinical search tool designed to allow health professionals to rapidly identify the highest quality clinical evidence for clinical practice.

All the best evidence-based publications are searched monthly by experts and indexed fully before being presented in an easy-touse format with access to full-text articles, medical images, patient leaflets and more. The TRIP Database gives you direct, hyperlinked access to the largest collection of 'evidence-based' material on the web as well as articles from premier on-line journals such as the BMJ, JAMA, NEJM etc. Types of sources searched by TRIP: Evidence Based Synopses, Clinical Questions, Guidelines, ETextbooks, Medical Images, Patient Information Leaflets, Systematic Reviews, Clinical Calculators, Core general medical journals. Registered users (registration is free) benefit from extra features such as search history, and collaborative tools.


Manuals and Guides

Vernooij RW, Sanabria AJ, Solà I, et al. Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implement Sci. 2014 Jan 2;9:3. doi: 10.1186/1748-5908-9-3

Updating clinical practice guidelines (CPGs) is a crucial process for maintaining the validity of recommendations. Methodological handbooks should provide guidance on both developing and updating CPGs. However, little is known about the updating guidance provided by these handbooks.

The authors conducted a systematic review to identify and describe the updating guidance provided by CPG methodological handbooks and included 35 handbooks that provide updating guidance for CPGs. Most handbooks (97.1%) focus mainly on developing CPGs, including variable degrees of information about updating. Guidance on identifying new evidence and the methodology of assessing the need for an update is described in 11 (31.4%) and eight handbooks (22.8%), respectively. The period of time between two updates is described in 25 handbooks (71.4%), two to three years being the most frequent (40.0%). The majority of handbooks do not provide guidance for the literature search, evidence selection, assessment, synthesis, and external review of the updating process.

CONCLUSIONS: Guidance for updating CPGs is poorly described in methodological handbooks. This guidance should be more rigorous and explicit. This could lead to a more optimal updating process, and, ultimately to valid trustworthy guidelines.


Developing NICE Guidelines: The Manual 2014

UK National Institute for Health and Clinical Excellence (NICE) is the independent organization responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

NICE clinical guidelines are recommendations, based on the best available evidence, for the care of people by healthcare and other professionals. They are relevant to clinicians, health service managers and commissioners, as well as to patients and their families and carers. The guidelines manual explains how NICE develops clinical guidelines and provides advice on the technical aspects of guideline development.


SIGN 50: A guideline developers' handbook, 2015

The Scottish Intercollegiate Guidelines Network (SIGN) develops evidence based clinical practice guidelines for the National Health Service (NHS) in Scotland. SIGN guidelines are derived from a systematic review of the scientific literature and are designed as a vehicle for accelerating the translation of new knowledge into action to meet our aim of reducing variations in practice, and improving patient-important outcomes.

All SIGN guidelines are considered for review three years after publication. As medical practice continues to develop and new options for treatment become available, guidelines inevitably fall behind current best practice. They must therefore be kept under constant review and updated when necessary. The Quick Reference Guide provides a summary of SIGN 50: A guideline developer’s handbook.


The ADAPTE Guideline Adaption: The Resource Toolkit

Guideline adaptation reduces duplication by taking advantage of existing guidelines. The ADAPTE Collaboration has developed a systematic approach for the adaptation of guidelines produced for use in one cultural and organizational context to be used in a different cultural and organizational context. The ADAPTE collaboration has developed a Manual for guideline adaptation as well as a Resource Toolkit. 2010


AGREE Instrument

AGREE is an international collaboration of researchers and policy makers who seek to improve the quality and effectiveness of clinical practice guidelines by establishing a shared framework for their development, reporting and assessment.

The Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument evaluates the process of practice guideline development and the quality of reporting. The original AGREE Instrument has been updated and methodologically refined. The AGREE II is now the new international tool for the assessment of practice guidelines.

The AGREE II is both valid and reliable and comprises 23 items organized into the original 6 quality domains. The AGREE Instrument has been translated into many languages, endorsed by several organizations (e.g., National Institute for Health and Clinical Excellence), and used by many development groups (e.g., WHO Advisory Committee on Health Research).


Articles and Links


The site was created, in order to provide in a single place access to most of the good quality free medical education resources available on the web, which are continuously organized and regularly updated. eBook - Guidelines and reviews organized by diseases and conditions.


Alper BS, Tristan M, Ramirez-Morera A., et al. RAPADAPTE for rapid guideline development: high-quality clinical guidelines can be rapidly developed with limited resources. Int J Qual Health Care. 2016 Apr 19. pii: mzw044.

Guideline development is challenging, expensive and labor-intensive. A high-quality guideline with 90 recommendations for breast cancer treatment was developed within 6 months with limited resources in Costa Rica. Twelve steps are presented to facilitate rapid guideline development and enable further adaptation by others.

This is a case report and the RAPADAPTE method was retrospectively derived. Prospective replication and validation will support advances for the guideline development community. If guideline development can be accelerated without compromising validity and relevance of the resulting recommendations this would greatly improve our ability to impact clinical care.


Gopalakrishna G, Langendam MW, Scholten RJ, et al. Guidelines for guideline developers: a systematic review of grading systems for medical tests. Implement Sci. 2013 Jul 10;8:78. doi: 10.1186/1748-5908-8-78. Review.

A variety of systems have been developed to grade evidence and develop recommendations based on the available evidence. However, development of guidelines for medical tests is especially challenging given the typical indirectness of the evidence; direct evidence of the effects of testing on patient important outcomes is usually absent.

Five systems for grading evidence about medical tests in guideline development addressed to differing degrees of explicitness the need for and appraisal of different bodies of evidence, the linking of such evidence, and its translation into recommendations. At present, no one system addressed the full complexity of gathering, assessing and linking different bodies of evidence.


Bero LA, Hill S, Habicht J, Mathiesen M, Starkopf J. The updated clinical guideline development process in Estonia is an efficient method for developing evidencebased guidelines. J Clin Epidemiol. 2013 Feb;66(2):132-9. doi: 10.1016/ j.jclinepi.2012.07.007. Review.

„Clinical practice guidelines are one of the tools available to improve the quality of health care. However, it may be difficult for countries to develop their own national guidelines "from scratch" because of limitations in time, expertise, and financial resources. The Estonian Health Insurance Fund (EHIF), in collaboration with other stakeholders, has launched a national effort to develop and implement evidence-based clinical practice guidelines aimed at improving the quality of care...

This study summarizes the evaluation of and revisions to the process. Estonia has made substantial changes in its processes of clinical practice guideline development and implementation as part of an overall program aiming for systematic quality improvement in health care. This experience may be relevant to other small or resource-limited countries.“


Developing and implementing guidelines for health policy and clinical practice in Estonia: interim appraisal of progress. September 2015. 66 pp.

The Estonian Health Insurance Fund (EHIF), with support from partners including WHO, has invested in the development of a clinical guideline development process since 2011 that has resulted in:

  • five completed high-quality clinical guidelines, of international standard, and 10 in progress, which were developed with reference to the Estonian handbook for guideline development , and with local ownership by health professionals participating in guideline panels and guideline development;
  • completion of patient guidelines on six topics;
  • over 200 health professionals in Estonia trained in evidence-based guideline development;
  • developments linking the new guidelines with effective and appropriate quality standards;
  • progress in transforming health professional workforce capabilities to practice evidence-based medicine using best practice internationally.


AIHA Internet Resources Digest Forthcoming Topics [Provisional]

  • Adolescent Health
  • Hospital Information Systems

About the AIHA Internet Resources Digest

The Internet Resources Digest — previously called the Health Resources Digest — is distributed free of charge as a service of the American International Health Alliance’s Knowledge Management Program thanks to the generous support of the American people through the US President’s Emergency Plan for AIDS Relief (PEPFAR). The Knowledge Management Program is implemented through AIHA’s HIV/AIDS Twinning Center Program, which is funded through a cooperative agreement with the US Department of Health and Human Services, Health Resources and Services Administration (HRSA).

The Internet Resources Digest is compiled by Irina Ibraghimova, PhD, Library and Information Management Specialist, HealthConnect International (healthconnect-intl.org). The contents are the responsibility of AIHA and do not necessarily reflect the views of PEPFAR, HRSA, or the United States Government.

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