Key quality considerations for advancing quality appraisal for living practice guidelines: a scoping review

The AGREE II, released in 2010, is an international gold standard for assessing the quality of guidelines. Since then, conceptual and methodological advancements in the field of livingness have emerged. The AGREE instrument requires updating to account for this progress. As a first step, a systematic search for concepts uniquely focused on livingness is required to identify potential new items, criteria, domains, and examples. This scoping review was designed to identify key concepts that define the quality of the living aspect of living guidelines. Results of this review will inform new criteria, items, and domains that can be incorporated into the AGREE III.

We searched electronic databases (Medline, Embase, Web of Science, and Scopus) from their inception until August 2024 for living guidelines and concept papers related to living guidelines. Eligible studies included concept papers which discussed living guidelines or evaluated livingness on any clinical health topic. English language articles from any setting were considered eligible for inclusion. Retrieved articles were screened in duplicate, and data were charted and synthesized using a deductive open coding approach. The resulting concepts were considered in the context of the existing AGREE II structure and as new items or domains.

Thirty-five studies were eligible for inclusion. In total, 27 new concepts were created. Most of the new concepts aligned with the rigor of development domain and could be mapped as new items or new criteria to existing items. Key themes included justification of adopting a living approach, management of guideline questions and incorporation of new evidence throughout the living guideline cycle, continuous engagement and feedback from all relevant stakeholders, and ensuring appropriate and timely dissemination of guideline updates.

Our findings highlight defining features of livingness that should be incorporated into the assessment of guideline quality. These will be tested as candidate AGREE III items and new criteria in subsequent stages of this program of research.

Clinical practice guidelines (also known simply as guidelines) provide evidence-based recommendations to help health-care professionals and patients make informed decisions for the treatment of specific health conditions. The AGREE II tool was created to ensure that these guidelines are well developed and meet the needs of those who use them. Since the AGREE II was developed in 2010, the health care and guideline landscapes have changed. In particular, the increased use of living guidelines (defined as guidelines that are updated as soon as new evidence emerges) during the COVID-19 pandemic has demonstrated their usefulness while also highlighting that they are not currently properly evaluated by the AGREE II. Considering this, the objective of this scoping review is to identify key aspects of living guidelines that are missing from the AGREE II to ensure that they are properly evaluated. These identified criteria, items, and domains will be used to create the AGREE III. To do this, we pulled together all relevant resources that discussed key components of living guidelines. Through a systematic search, we found and included 35 relevant articles. We found that key aspects of living guidelines include ensuring that the reasoning for using a living approach is justified, engaging users of the living guidelines (including health-care workers and patients) to provide feedback on recommendations, shifting guideline development to an ongoing, regularly updated process, and quickly delivering guideline updates to those who need them. The results of this work will be evaluated by a team of experts in the field for addition to the AGREE III.