Locally adapted guidelines: a scoping review

Clinical practice guidelines (CPGs) often fail to be fully implemented in practice. One barrier to CPG implementation is inconsistency between recommendations and existing practice patterns. This can include patients, personnel, structure, availability of resources, cultural and ethical values. To account for this, it is feasible to tailor national CPGs to a regional or local context (e.g. hospital). Local ownership can be beneficial and help to implement the guideline without affecting guideline validity. This process is also known as guideline adaptation. We aimed to identify randomized controlled trials (RCTs) investigating the effectiveness of locally adapted CPGs.

We performed a scoping review, following the JBI guidance. The scoping review was registered with the Open Science Framework ( https://osf.io/3ed2w ). The intervention had to be a locally adapted guideline (locally meaning adapted to any delineated area and/or entity at subnational and/or transnational level). Co-interventions were accepted. We did not restrict the control group. As we considered locally adapted guidelines as an intervention, and it seems feasible to test locally adapted guidelines in trials, we only considered RCTs, including cluster-RCTs. PubMed and Embase were searched in November 2024. Two reviewers independently screened titles and abstracts, full-text articles, and charted data. Conflicts were resolved by involving a third reviewer. Data were summarized descriptively. The findings were discussed with knowledge users.

Five cluster RCTs reported in 8 publications and published between 2000 and 2010, were included. The trials originated from the UK, Scotland, Australia, the US, and the Netherlands. The adapted CPGs focused on diabetes, asthma, smoking cessation, mental disorders, and menorrhagia and urinary incontinence. The number of sites (e.g. practices) ranged from 4 to 30. Reporting was mostly insufficient to understand how adaptation was performed. Interventions always included some form of dissemination, such as educational meetings or workshops.

There is a lack of RCTs investigating the effectiveness of locally adapted guidelines. A systematic review is unwarranted due to the clinical and methodological heterogeneity of these trials. The identified studies were largely conducted over 20 years ago, highlighting a significant knowledge gap. The reasons for the lack of similar studies today are unclear, which is surprising given advances in adaptation frameworks in guideline development. As the importance of contextualization is emphasized, future studies on locally adapted guidelines should be conducted with strong rationale supported by local data. Without a sound rationale, there is a risk that evidence-based, high-quality guidelines could be undermined. In future trials, authors should closely adhere to reporting guidelines.

https://osf.io/3ed2w .