Clinical practice guidelines are seen as powerful tools to achieve effective and efficient care.¹ Many consider that they bridge the gap between the growing stream of research findings and actual clinical practice.^2,3 Both clinical practice guidelines (CPGs) and health technology assessments (HTAs) support the drive toward evidence based decision making, and both have their origin in concerns about the quality of care, inequalities in care provision, and increasing healthcare costs.^4–6

Many countries have built up experience in the development, appraisal, and implementation of clinical practice guidelines at professional, organizational, regional, and national levels.^7–9 National institutions, experts, and healthcare providers specialise in the guideline field and participate in supranational networks. However, no established forum for communication on an international level existed until recently. Thus, in different countries seeking similar goals and using similar strategies, efforts have been unnecessarily duplicated. As a consequence, financial and structural resources risk being wasted and activities may be managed in a suboptimal way. Active cooperation between national and international guideline organizations could yield substantial synergies and even savings. This could occur with the exchange of existing guidelines, systematic reviews and evidence reports, by joint development of methodology, collaboration in literature searches for revision of guidelines, and organizing joint peer review of draft guidelines.¹⁰

Against this background the establishment of an international guidelines network was proposed in 2001 and occurred one year later, building on existing partnerships. In this paper we describe the background, goals, and first achievements of the Guidelines International Network (“G-I-N”).

TOWARDS INTERNATIONAL COLLABORATION

Since the early 1990s many countries have established guideline development programmes. This has not ended concern about guideline quality, as methods of development differed across the programmes.^11–15 In Europe this has resulted in the Recommendation of the Council of Europe on Guidelines Methodology,¹⁶ in a generic methodology for guideline appraisal (AGREE instrument),¹⁷ and in efforts to adapt international methodology for regional guidelines systematically.^18–21 On the American continent the US-National Guideline Clearinghouse was established (www.guideline.gov)²² and a taxonomy for reporting guidelines has been proposed.²³ In Australia and New Zealand, as well as in Asia and Africa, activities aimed at the use of good CPGs are funded²⁴ or in development.²⁵

Effective collaboration in evidence based health care requires that the methodological principles are common. The AGREE Collaboration developed a core tool for guideline evaluation (box 1) and provided a platform for discussion that revealed an increased international consensus and willingness to work together.⁷

In two research projects funded by the European Union, the AGREE Collaboration demonstrated an increasing harmonisation of the methodologies used by guideline agencies and programs around the world and provided a forum for guideline developers, researchers, and implementers to meet and share ideas.⁷

Following completion of the first AGREE project in March 2001, participants recommended that an international forum for organisations and individuals working with guidelines should be established. Several AGREE participants also worked in HTA where international networking has supported development for two decades.²⁶ To complement this, one aim of the second AGREE project was to establish an international network of excellence for the research and implementation of guidelines. A multinational group of guideline experts agreed with the initiative and consented (1) to evaluate the level of interest in systematic networking and bring the results for discussion in an open forum; and, based on this assessment, (2) to decide whether to establish an international guidelines network covering the production, implementation, and evaluation of guidelines.

THE G-I-N INITIATIVE AND SURVEY

The foundation of the Network was initiated by a multinational steering group and coordinated by staff of the Scottish Intercollegiate Guidelines Network (SIGN; www.sign.ac.uk) and the German Agency for Quality in Medicine (AQuMed; www.azq.de). The steering group involved leaders from European, American and Oceanian guideline development organisations (www.g-i-n.net) who had established working relationships from the AGREE project (www.agreecollaboration.org).

A structured questionnaire was issued in spring 2002 by email to all known national organisations (n = 88, 32 countries including WHO) working in the field of guideline production, appraisal, implementation and/or research. The questions addressed different issues (domains) and projects of interest for the proposed network, including information sharing, research on guideline development, research on implementability, research on implementation, education/promoting best evidence, collaboration between network members, outreach of the network, membership, structure, funding, activities, and name of the network.²⁷ Each item was scored on a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree).¹⁷ The mean scores were calculated and items sorted by scores within each domain. Only domains and projects with a mean score higher than 2.9 were considered relevant.

The questionnaire was answered by 36 organisations (41% response rate) from 17 countries (Australia, Canada, Denmark, Finland, France, Georgia, Germany, Great Britain, Iceland, Ireland, Lithuania, Netherlands, Portugal, Serbia, Spain, Sweden, USA) and WHO. All responders agreed with the idea of establishing a worldwide guideline forum. There was a broad consensus on issues and projects of the proposed network (table 1), and on its structure and organization (table 2).

The results of the survey were discussed in summer 2002 during an international symposium which was arranged before an HTA congress and attended by 200 experts from 30 countries.²⁸ Based on the survey results and the discussion, the steering group prepared a position paper outlining goals, structures, and key points of an international guidelines network for action and acceptance as a new organisational entity.²⁹

FOUNDATION, MEMBERSHIP AND ACTIVITIES OF THE NETWORK

In November 2002 the steering committee consented to the main objectives, areas of interest, and possible working agenda for the network (box 2) and founded the forum under the name of “Guidelines International Network (G-I-N)”. Information about the network and invitations to join the Network as founder members were issued to over 100 organisations in 34 countries. The Network was formally constituted as a Scottish Guarantee Company and recognised as a Scottish charity in February 2003. The logo of the Network is shown in fig 1.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

 Logo of G-I-N.

The membership is open to organisations and individuals involved in developing, disseminating, implementing, or evaluating clinical practice guidelines or otherwise active in the field of clinical practice guidelines. The eligible organisations are non-profit distributing bodies that work in accordance with international standards for CPGs and are transparent about their sources of funding.

Between December 2002 and March 2003 a total of 37 organisations agreed to become founder members of G-I-N and paid an inception subscription in addition to an annual fee to fund the Network’s start up costs. By June 2004, 52 organisations from 27 countries had joined the Network including institutions from Oceania, North America, and Europe, and WHO (box 3).

In the first year the activities of the Network focused on establishing the legal and organisational framework, acquiring members, presenting G-I-N at international conferences, and developing the website.

In line with the survey results, the website is the key tool supporting the Network’s activities and communication. The cornerstone of the website is a searchable database where members can search for published and planned guidelines and related documents (such as evidence tables, search strategies, patient information). The development tools and training materials are open to the public. By May 2004 more than 2200 items of information about guidelines and their development had been uploaded by G-I-N members.

FUTURE PLANS

Over the next 3 years the Guidelines International Network intends to work with its members on developing methodology for guideline development, adaptation and implementation as well as updating and exchanging search strategies and evidence tables to underpin the guidelines.

Since the inception of the Network, members have been actively looking for ways to share the information stored on the website. These include the identification of shared priorities for guideline development topics (for example, screening and risk assessment of cardiovascular disease), the use of existing guidelines for local adaptation,³⁰ and the establishment of a standard architecture to facilitate the sharing and implementation of guidelines.³¹ The work is carried out by different task forces consisting of 4–6 active members. The Network also arranges at least one annual meeting to bring the guideline community together for discussion and review of cutting edge topics related to guideline development and implementation.

DISCUSSION

The proliferation of guidelines and concerns about their quality have led to the development of international collaboration between organisations and individuals active in the field of guidelines. The fast growth of the Guidelines International Network confirms that structured international partnership is needed.

It is important to note and learn from the challenges experienced in the first years of the Network. The diversity and cultural differences in guideline development programmes and their support have continued to present obstacles that are necessary to overcome. Many current and potential Network members are supported under different funding mechanisms, some more stable than others. Issues such as the role of industry in supporting guideline programmes are challenging, not only to the Network but to other international consortiums such as the Cochrane Collaboration and Health Technology Assessment International (HTAi). The Network has decidedly moved toward supporting developing organisations through training, partnerships and subsidised fees to conferences, to reduce the need for industry support. Language barriers continue to be a challenge but can be overcome. The lingua franca is English but resources are provided in multiple languages when possible. It is imperative that the true meaning or validity of a guideline or supporting document transcends translations, and care has been taken to ensure this.

Some Network members come from more mature programmes with long experience. The challenge of the Network is to provide a useful forum and resource for these more evolved programs. The Network Working Groups have met this challenge by convening around topic areas that are complex and ripe for investigation, harmonisation, or evaluation—for example, electronic architecture of guidelines, guideline adaptation, optimal issues in guideline updating, evidence grading. Finally, implementation of guidelines is a global issue. The Network recognises the importance of this crucial area and the work that needs to be done to increase the uptake and use of guidelines.³² This will be a continued focus of the Network for years to come.

In due course it will be important to evaluate the actual impact of the Network on programmes seeking to promote health care quality. Furthermore, links to other international activities and networks of evidence based medicine, continuous professional development and healthcare quality must be established and strengthened in order to guarantee sustainability of this initiative.