NICE process and methods

14 Updating guideline recommendations

14 Updating guideline recommendations

14.1 Scheduling updates

When scheduling updates of guideline recommendations, NICE prioritises topic areas according to need for both new and updated guidelines.

14.2 Full updates of guidelines

If a full update of a guideline is needed either:

  • a new scope is prepared, following the process described in the chapter on the scope or

  • the scope of the published guideline is used and registered stakeholders are informed.

Sometimes an existing topic-specific committee is asked to update a guideline in their topic area. Sometimes a new topic-specific committee is set up for the update. Recruitment of committee members follows the usual process (see the chapter on decision-making committees). Where possible, the developer informs all members of the topic-specific committee, or topic-expert members of the standing committee, for the published guideline if 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 the chapter on the validation process for draft guidelines, and dealing with stakeholder comments). The developer should maintain records appropriate for audit (see the section on committee meetings in the chapter on decision-making committees). The usual process for finalising and publishing the guideline is followed (see the chapter on finalising and publishing the guideline).

14.3 Updates of topic areas in guidelines

If only some topic areas of a guideline need 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about exactly which sections of the guideline are being updated and which are not, including any sections that may be withdrawn (for example, if they are now covered in another guideline). Recommendations that are outside the scope of an update may be refreshed (see the section on refreshing the guideline).

The update is developed using the same methods and process as for a new guideline. Updates of some topic areas 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.

Update of topic areas in a guideline 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 consultation period of up to 6 weeks, depending on length and complexity (see the chapter on the validation process for draft guidelines, and dealing with stakeholder comments). The developer should maintain records appropriate for audit (see the section on committee meetings in the chapter on decision-making committees). The usual process for finalising and publishing the guideline is followed (see the chapter on finalising and publishing the guideline).

14.4 Refreshing the guideline recommendations

Refreshing guideline recommendations allow us to improve the usability of recommendations without changing the intent and therefore without the need for an evidence review or committee input. All refreshing changes are signed off by NICE's guidance executive.

Refreshing changes can be made to guideline recommendations even when the surveillance decision is not to update the guideline. All changes to recommendations made as part of the surveillance process should be agreed by the NICE surveillance team (see the chapter on ensuring that published guidelines are current and accurate).

When it has been agreed which topic areas need updating, the publishing team also identifies recommendations that may need refreshing to feed into the scoping process. Occasionally during development of the update, additional recommendations that are not part of the update may be identified for refreshing by the committee or the publishing team.

Refreshing might involve:

  • amending or adding cross references to other NICE guidance or hyperlinks to other NICE-endorsed tools or resources

  • adding or amending a footnote to reflect changes to a medicine's marketing authorisation, to reflect changes in service configuration (for example, a change from primary care trusts to clinical commissioning groups) or a change to an organisation's name

  • ensuring recommendations take into account the latest government policy or guidelines, for example, on alcohol consumption

  • amending recommendations to reflect the current practice context, for example, removing references to tools or resources that no longer exist

  • bringing recommendations in line with NICE's current policy on wording without affecting the intent, for example:

    • reflecting the involvement of people in decisions about their care

    • using person-centred language.

Refreshing changes that are made during scoping and guideline development should be agreed with NICE staff with responsibility for quality assurance.

14.5 Presenting updates

A full update replaces an existing guideline and has a new set of recommendations, a new set of rationale and impact sections, 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.

When presenting updates of topic areas within 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.

Preparing an update of topic areas for consultation

Before consultation on an update of topic areas within a guideline, the developer should check the following:

  • All sections have been updated as agreed.

  • It is clear which sections have been updated and are open for comment during consultation.

  • Recommendations from sections which have not been updated have been checked to determine whether any changes are essential (for example, if a medicine is no longer available).

  • Refreshing changes (see the section on refreshing the guideline) to 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 in 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.

Preparing the final version of an update of topic areas for publication

The developer should check the following:

  • It is clear which sections have been updated, and whether the recommendations have been updated or amended.

  • The summary of changes to recommendations has been revised in line with the final recommendations.

Resources to support implementation are also checked for current relevance.

14.6 Post-publication changes

Measures are in place throughout the development of a guideline to avoid errors in the collection, synthesis, interpretation or presentation of the evidence as far as possible. On rare occasions errors are found after publication of the guideline, or users may ask for clarification.

Corrections or changes to published guideline recommendations are made if an error or lack of clarity:

  • 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.

Errors or clarifications that do not warrant immediate changes to the recommendations are logged for consideration when the guideline undergoes surveillance (see the chapter on ensuring that published guidelines are current and accurate).

If an error or clarification meets the criteria for changing a published guideline recommendation, 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 is amended. Resources to support implementation are also amended if necessary. The changes are explained in the guideline. Depending on the nature and significance of the change and the time since publication of the guideline, registered stakeholders may also be notified.

Routine maintenance

Routine maintenance changes may also be made after publication or update of a guideline. These include minor changes such as updating or fixing broken links or updating standard text in line with agreed template changes.

14.7 References and further reading

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

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