Background: Despite the widespread claim that clinical practice guidelines (CPGs) follow the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, its implementation remains unclear.
Objective: To identify existing standards, criteria, or assessment tools for evaluating adherence to GRADE in CPGs, and summarize findings from studies applying these criteria.
Methods: We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library from January 2004 to November 2024, supplemented by manual reviews of the GRADE handbook, GRADE Working Group website, and GRADE centers and networks. We included studies that proposed criteria to evaluate GRADE adherence or applied such criteria, summarizing findings descriptively.
Results: We identified 11 eligible publications, including eight studies that proposed evaluation criteria, the most frequently reported domains addressed the certainty of evidence (CoE) (87.5%) and recommendation formulation (87.5%). Less frequently addressed domains included framing research question (37.5%), following evidence-to-decision frameworks (37.5%), and selecting outcomes (37.5%). Three studies applied evaluation criteria, reporting inconsistent adherence to the GRADE approach among the CPGs that claimed to use it.
Discussion: These findings highlight the inconsistent application of GRADE in CPGs and a lack of structured evaluation tools for assessing adherence. Improving guideline developer’s adherence to GRADE presents a challenge. A user-friendly standardized instrument to assess the application of GRADE in CPGs may help improve transparency and guideline quality. Future work should focus on developing and validating such an instrument to support both guideline developers and users.

Background: Standards for developing trustworthy guidelines requires recommendations be based on systematic reviews. Performing de novo reviews, however, can be time- and resource-intensive.

Objective: We describe our approach using published systematic reviews to inform forthcoming pan-Canadian clinical practice guidelines on the management of 30 infectious syndromes, using pharyngitis as an example.

Methods: We performed a search of medical research databases to identify systematic reviews and meta-analyses comparing various antibiotics and antibiotic regimens for managing pharyngitis. For each clinical question and outcome, we prioritized reviews according to an algorithm considering recency and methodological quality. When reviews did not assess certainty of evidence, we applied the GRADE approach.

Results: For pharyngitis, we identified six eligible reviews. These reviews presented low certainty evidence that, in cases of bacterial pharyngitis, antibiotics, compared to no antibiotics, may reduce the risk of sore throat and rheumatic fever at follow-up. Thus, the panel favored the prescription antibiotics.
The overview, however, found no compelling evidence that any antibiotic is superior to any other for achieving clinical cure. Thus, the panel considered other factors to make recommendations on choice of antibiotics. Consistent with principles of antibiotic stewardship, the panel prioritized the narrowest spectrum antibiotic and recommended penicillin. The panel considered, however, that children may prefer amoxicillin over penicillin for its taste and availability as an oral suspension.

Discussion: Overviews of systematic reviews that consider review quality and recency can inform guideline recommendations while reducing time and resources needed to perform de novo systematic reviews.

Background:

Living guidelines rely on high throughput methods of evidence identification and incorporation to ensure that recommendations remain up to date. Although the focus has historically been on evidence from new clinical studies, other non-clinical based information is equally important in ensuring that the applicability and implementability of living recommendations is maximised.

Objective:

The objective is to identify areas where non-clinical evidence-based information was used to update the Australian Living COVID-19 Clinical Guidelines, and determine what impact the addition of this information had.

Methods:

A comprehensive analysis of all 135 updates to the Living Australian National COVID-19 Clinical Guidelines identified instances in which non-clinical evidence-based information was used to update living recommendations. Changes were categorised based on impact, impetus, source of the information and location of change within the recommendation.

Results:

Impactful updates occurred frequently across recommendations, supporting information and evidence to decision elements. Changes were based on numerous types and sources of non-clinical information, including government approvals and subsidies, consumer and other stakeholder input, and the use of in vitro evidence and vaccine nomenclature.

Discussion:

Although clinical evidence is critical in identifying treatments and strategies that are safe and effective, the use of other non-clinical information is equally important in contextualising care and maximising the implementability of a guideline. Due to the endurance of living guidelines and the frequency of updating, developers need to ensure that the guideline remains up-to-date not only from a clinical perspective, but also with regards to applicability and implementability.

Background: In GRADE guideline development, experts evaluate the balance between desirable and undesirable effects, judging their magnitude as large, moderate, small, or trivial. However, expert judgments in this process may lack transparency.

Objective: To define decision thresholds (DTs) for magnitude of effects within the European Commission initiative on Cervical Cancer (EC-CvC) screening guidelines.

Methods: The EC-CvC expert panel (18 members) prioritized key outcomes, including cervical cancer incidence, mortality, CIN2+/CIN3+ detection, quality of life, overdiagnosis, recall for assessment, pre-cancer treatments, major adverse events, preterm birth, and HPV infection. Recognizing these outcomes are not independent, first two core DTs were determined: incidence reduction and referral to colposcopy, from which DTs for related outcomes could be derived. An online survey among the panel was conducted to vote on core DTs and to comment on methods for defining related outcomes. Feedback was incorporated to quantify related DTs using empirical studies and modelling. Preliminary thresholds were piloted and will be finalized through consensus at an in-person panel meeting.

Results: We used the WHO elimination threshold and the EU average incidence (4 and 10 cervical cancer cases per 100,000 person-years respectively) as references to calculate incidence reduction aligned with global public health goals. Colposcopy DTs used EU screening reports. Related DTs were defined considering logical constraints and using empirical studies and modelling to ensuring consistency. Heterogeneity in time horizons and metrics remains a limitation.

Conclusions: Establishing DTs ensures consistent expert judgments, enhances transparency, helping end-users to understand the rationale behind judgements made in the EC-CvC.

Background: Although deprescribing is considered an integral part of good prescribing, it has not been systematically addressed in clinical practice guidelines (CPG) until recently. Moreover, making recommendations for the discontinuation of a diverse group of medicines such as antidepressants can be challenging.
Objective: to describe the decision-making process about clinical areas in an antidepressant deprescribing CPG
Methods: Following the GuiaSalud methodology, a multidisciplinary working group was formed, which included primary and hospital healthcare professionals and patients. Decisions were made through consensus in a series of meetings. We conducted a scoping review (ScR) to overview the availbale evidence following the Joanna Briggs Institute methodology. We searched four databases in August 2024. The eligibility criteria were any evidence synthesis (ES) document including recommendations for adults on antidepressants in discontinuing treatment.
Results: The ScR included 21 ES and 39 recommendations documents. Four themes were identified in the ES: consequences of withdrawal, impact of interventions, perspectives and implementation issues. The recommendations were related to elective/mandatory discontinuation conditions, good prescribing, deprescribing guidance, shared decision-making and values, and follow-up. The working group met four times and agreed on the following clinical areas: i) identification of conditions for antidepressant deprescribing; ii) barriers and facilitators; iii) deprescribing approaches; and iv) interventions for symptoms arising from withdrawal.
Discussion: A ScR aimed to inform how the topic has been approached can support the GPC panel regarding the agreement on the main relevant clinical areas. Besides, multidisciplinarity in the panel is key in deprescribing guidelines to ensure all perspectives are considered.

Background:
Rating the importance of health outcomes for guideline development and decision making is particularly challenging for new, complex conditions like post COVID-19 condition (PCC), and may differ between key interest groups.

Objective:
To describe the outcome importance rating results from the Canadian Guidelines for Post COVID-19 Condition (CAN-PCC), and to assess differences between subgroups of responders.

Methods:
CAN-PCC sent an outcome importance rating survey with health outcome descriptors for standardization to all collaborators, including patients, healthcare professionals, policymakers, and researchers. Rating results were collected on a 9-point Likert scale, whereby scores 1-3 were not important, 4-6 important but not critical, and 7-9 critical for decision making. Median (25th-75th) percentile was calculated overall and for subgroups. For group comparisons with medians falling in different decision-making categories, Chi-square test was used for critically vs not critically important, as few ratings were in the lowest range (1-3).

Results:
The survey received 100 responses for 130 outcomes. Overall, 70 outcomes were rated critically important, including eight outcomes with a median score 9, and only one outcome had a median score below 4. When testing subgroup differences for statistical significance, PCC patients rated 23 outcomes higher, healthcare professionals rated 2 outcomes lower, people with disability rated 6 outcomes higher, and people <24 years rated 4 outcomes lower than their counterparts.

Discussion:
The CAN-PCC survey identified outcomes for which key interest groups assigned different importance in health decision making. Further research will need to explore reasons and assess applicability to other outcomes and conditions.

Background
The neuroprotective benefits of magnesium sulphate (MgSO4) for fetal neuroprotection (preterm cerebral palsy (CP) prevention) were first confirmed in a 2009 Cochrane review. In 2010 Australian and New Zealand (ANZ) National Health and Medical Research Council-endorsed clinical practice guidelines (CPG) ‘Antenatal Magnesium Sulphate Prior to Preterm Birth for Neuroprotection of the Fetus, Infant and Child’ were released.

Objective
This presentation will profile past, current and future activities focused on building trust in the MgSO4 for preterm CP prevention science, through CPG dissemination, implementation and monitoring across ANZ; and will discuss international implications.

Methods
Over the last 15 years, ANZ activities included:
• A three-year implementation project ‘WISH’ (Working to Improve Survival and Health for babies born preterm) (2011-2014), supporting 25 tertiary maternity hospitals. This comprised dissemination of ‘Guideline Action Packs’, unit-level surveys, and provider-level interviews.
• Cochrane overviews of reviews, highlighting MgSO4 to be one of only two CP prevention strategies supported by high-certainty evidence (2017-2018)
• Adoption of a routine data collection item ‘Magnesium sulphate’ by the ANZ Neonatal Network to assess use and population-level impacts (CP trends) (2012-2020).
• Updating the ‘Magnesium sulphate for neuroprotection of the fetus’ Cochrane review (2024).

Discussion for scientific abstracts
Ongoing activities to build further confidence in MgSO4 for CP prevention include an update to the associated individual participant data meta-analysis (2025-2026), a scoping review of evidence and CPGs from low- and middle-income countries (2024-2025), and planned cost-effectiveness and implementation strategies reviews. Together, these will inform potential ANZ and international CPG updates.

Background: Clinical Practice Guidelines (CPGs) are a cornerstone of medicine, however, encouraging their use is challenging, particularly in resource-constrained regions, where physicians preclude their use with the assumption that they are not contextually relevant.
Objective: To develop, implement a comprehensive strategy to increase uptake of locally adapted CPGs in Pakistan.
Methods: Centre for Clinical Best Practices at Aga Khan University developed locally relevant guidelines, in collaboration with US GRADE Network, and published a three-volume CPG manual, covering 135 common diseases. The guidelines were adapted into multiple formats: a free web and mobile application, video lecture series, a physical manual ensuring easy access for healthcare practitioners nationwide.
To encourage uptake, committee consisting of internal and external members was formed, their expertise and networks utilized for dissemination. Through collaborative efforts, Pakistan Medical and Dental Council (national physician licensing and undergraduate medical education regulatory body) supported dissemination in medical universities, and College of Physicians and Surgeons Pakistan ( which oversees postgraduate medical training) facilitated physician training in CPGs. Partnerships with federal and provincial ministries, Pakistan Armed Forces, leading medical societies ensured broad reach and effective implementation of guidelines.
Results: Application of these strategies led to an increase in web and mobile application user base by 994%: 600 users in September 2024 to 6,829 in February 2025. A significant proportion of users (51%) were from AKUH, remainder from institutions across Pakistan. 64% were medical graduates, 12% holding master’s degree,1.63% PhD holders.
These approaches increased CPG uptake while accessibility through digital formats further boosted usage.

Background:

Living recommendations are updated as and when new relevant clinical evidence is available. At present, the stability of living recommendations across multiple updates is yet to be established, and there is a risk that the direction of recommendations may change following inclusion of new evidence.

Objective:

The objective is to determine the probability of living recommendations changing direction following the inclusion of new clinical evidence, and whether any of the recommendations changed direction more than once (i.e. flip-flopped).

Methods:

A retrospective review of three Australian living guidelines (COVID-19, stroke and inflammatory arthritis) was conducted to quantify and characterise all instances in which evidence from a new clinical trial was used to update a living recommendation. Changes were categorized based on impact on the recommendation.

Results:

Over a cumulative life of 13 years, there were a total of 247 new recommendations added and 241 individual updates across the three living guidelines. The majority of updates did not result in a change in strength or direction of recommendation, however there were 26 instances in which a recommendation changed direction from ‘for’ to ‘against’ or vice versa. No recommendations changed direction more than once.

Discussion:

The present analysis suggests that living recommendations change direction infrequently and instances in which a recommendation changes direction twice (i.e. flip-flops) is likely rare. Guideline users can be confident that the decisions they make today won’t suddenly change following updates to living recommendations.