14 Updating guidelines
When scheduling updates of guidelines, NICE prioritises topics according to users' need for both new and updated guidelines.
If a full update of a guideline is needed either:
Recruitment of Committee members follows the usual process (see chapter 3). The Developer informs all members of the topic-specific Committee, or topic‑expert members of the standing Committee, for the published guideline that a new Committee is being recruited. The composition of the Committee should be tailored to new requirements if a new scope has been developed. The guideline is developed using the same methods and process as for a new guideline and the draft is subject to the normal 4‑ to 6‑week consultation period (see chapter 10). The Developer should maintain records appropriate for audit (see section 3.8). The usual process for finalising and publishing the guideline is followed (see chapter 11).
If only part of a guideline needs to be updated, either:
In both cases, the scope is clear about exactly which sections of the guideline are being updated and which are not, including any sections that may be withdrawn (for example, if they are now covered in another guideline). The scope also makes it clear that all the recommendations in the published guideline, including those that are not being updated, will be checked to ensure that they comply with NICE's equality duties. These recommendations can also be considered for refreshing (see section 14.4).
The guideline is developed using the same methods and process as for a new guideline. Partial updates using the scope of the published guideline use the review questions and review protocols already defined by the existing guideline. However, if the review questions and/or protocols are unavailable, need refinement, or if there is ambiguity in the published guideline, the Developer may approach the Committee members with topic expertise for advice before starting the evidence review.
Partial updates of guidelines are subject to the same level of scrutiny as full updates and new guidelines. The underlying principles of transparency of process and methodological rigour continue to hold. The draft is subject to a 4‑week consultation period (see chapter 10). The Developer should maintain records appropriate for audit (see section 3.8). The usual process for finalising and publishing the guideline is followed (see chapter 11).
Sometimes a decision is made not to update the guideline or parts of it but the recommendations may need refreshing to ensure that they remain in line with current editorial standards and current practice context (for example, changing from primary care trusts to clinical commissioning groups). Refreshing recommendations ensures that they are checked for any essential changes.
These might involve:
changing recommendations in older guidelines from the passive voice to direct instructions
changes to reflect NICE's current policy on recommendation wording (for example, to reflect the involvement of people using services and the public in decisions)
changes so that recommendations do not conflict with NICE's duties under legislation and NICE's equality policy
changes to reflect the current wording of any recommendations incorporated from other NICE guidance
changes to reflect a change in the availability of medicines or a change in service configuration (for example, a change from primary care trusts to clinical commissioning groups)
changes to address any feedback received on clarity and interpretation.
Changes should be kept to a minimum and should not change the intent of the recommendation unless the change relates to the availability of a medicine, a change in service configuration, legislation or equality duty.
Refreshing a guideline ensures that recommendations do not promote practice that has a negative impact on equality, do not conflict with other NICE guidance, and reflect current treatment options.
A full update replaces an existing guideline and has a new set of recommendations, new evidence reviews and new sections detailing the Committee's discussion of the evidence. When a full update is published the old guideline is withdrawn. The NICE Pathway is revised in line with the new recommendations.
When presenting partial updates of guidelines, the aim is to ensure that there is a single set of publications that bring together the updated information and relevant information from all previous versions of the guideline. In this way, readers of the updated guideline will be able to easily identify what has changed. The rest of this section covers general principles to be used when part of a guideline has been updated.
Before consultation, the Developer should check the following:
All sections of the guideline have been updated as agreed.
It is clear in the guideline which sections have been updated, which text has been replaced, and which sections are open for comment during consultation.
Recommendations from sections in which the evidence has not been re‑considered have been checked to determine whether any changes are essential (for example, if a medicine is no longer available).
Changes to refreshed recommendations in sections that have not been updated are kept to a minimum (for example, changing from the passive voice to direct instructions).
A summary of changes to recommendations is included.
The status of any guidance incorporated into the previous version of the guideline has been confirmed with NICE. For example, has the other guidance been updated by the guideline update?
All recommendations (new, updated and unchanged) have been assessed with respect to NICE's equality duties.
The Developer should check the following:
It is clear in the guideline which sections have been updated, and whether the recommendations have been updated or amended, or are unchanged from the previous published version of the guideline.
The summary of changes to recommendations has been revised in line with the final recommendations.
The NICE Pathway is also updated, and resources to support implementation are checked for current relevance.
Measures are in place throughout the development of a guideline to ensure that errors in the collection, synthesis, interpretation or presentation of the evidence are avoided as far as possible. However, on rare occasions errors may be found after publication of the guideline. There may also be occasions when clarification is requested and, if warranted, changes may be made in response to enquiries. Errors may not always warrant changes to the guideline, in which case they will be logged for consideration when the guideline is considered for updating. If an error is found, the following criteria and process is used to determine whether changes are necessary.
Corrections or changes to a published guideline are made if an error:
puts users of health or care services at risk, or affects their care or provision of services, or
damages NICE's reputation, or
significantly affects the meaning of a recommendation.
If it is necessary to correct an error or include a clarification in a published guideline, NICE's process for dealing with post‑publication changes is followed. An explanation of the decisions and actions taken is sent to the person or organisation that reported the error or requested clarification.
Sometimes recommendations need to be removed because a medicine has been removed from the market or a few recommendations have been updated or replaced by recommendations in another guideline.
The guideline and the NICE Pathway are amended. Resources to support implementation are also amended if necessary. The changes are explained in the guideline and pathway. Depending on the nature and significance of the change and the time since publication of the guideline, registered stakeholders may also be notified.
Clark E, Donovan EF, Schoettker P (2006) From outdated to updated, keeping clinical guidelines valid. International Journal for Quality in Health Care 18: 165–6
Eccles M, Rousseau N, Freemantle N (2002) Updating evidence‑based clinical guidelines. Journal of Health Services Research and Policy 7: 98–103
Shekelle P, Eccles MP, Grimshaw JM et al. (2001) When should clinical guidelines be updated? British Medical Journal 323: 155–7
Shekelle PG, Ortiz E, Rhodes S et al. (2001) Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated? JAMA 286: 1461–7
Shojania KG, Sampson M, Ansari MT et al. (2007) Updating systematic reviews. AHRQ Technical Reviews and Summaries, technical review 16. Rockville, MD: Agency for Healthcare Research and Quality
Turner T, Misso M, Harris C et al. (2008) Development of evidence-based clinical practice guidelines (CPGs): comparing approaches. Implementation Science 3: 45–52