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Original Research: Education, Research, And Quality Improvement |

Adaptation of Trustworthy Guidelines Developed Using the GRADE MethodologyFive-Step Adaptation Process for GRADE Guidelines: A Novel Five-Step Process

Annette Kristiansen, MD; Linn Brandt, MD; Thomas Agoritsas, MD; Elie A. Akl, MD, PhD, MPH; Eivind Berge, MD, PhD; Johan Bondi, MD, PhD; Anders E. Dahm, MD, PhD; Lars-Petter Granan, MD, PhD; Sigrun Halvorsen, MD, PhD; Pål-Andre Holme, MD, PhD; Anne Flem Jacobsen, MD, PhD; Eva-Marie Jacobsen, MD, PhD; Ignacio Neumann, MD; Per Morten Sandset, MD, PhD; Torunn Sætre, MD, PhD; Arnljot Tveit, MD, PhD; Trond Vartdal, MD, PhD; Gordon Guyatt, MD, FCCP; Per Olav Vandvik, MD, PhD
Author and Funding Information

From the Department of Internal Medicine (Drs Kristiansen, Brandt, and Vandvik), Innlandet Hospital Trust, Gjøvik, Norway; Institute for Health and Society (Drs Kristiansen, Brandt, and Vandvik), Faculty of Medicine, and Institute of Clinical Medicine (Dr Sandset), University of Oslo, Oslo, Norway; Department of Internal Medicine (Drs Kristiansen and Brandt), Diakonhjemmet Hospital, Oslo, Norway; Department of Clinical Epidemiology and Biostatistics (Drs Agoritsas, Akl, Neumann, and Guyatt), McMaster University, Hamilton, ON, Canada; Department of Internal Medicine (Dr Akl), American University of Beirut, Beirut, Lebanon; Department of Internal Medicine (Dr Berge), Oslo University Hospital, Ullevål, Oslo, Norway; Department of Surgery (Dr Bondi), Department of Medical Research (Dr Tveit), and Department of Internal Medicine (Dr Vartdal), Bærum Hospital, Vestre Viken Hospital, Drammen, Norway; Department of Hematology (Drs Dahm, Holme, Jacobsen, Sandset), Department of Physical Medicine and Rehabilitation (Dr Granan), Department of Pain Management and Research (Dr Granan), Division of Emergencies and Critical Care, Department of Cardiology B (Dr Halvorsen), Department of Obstetrics and Gynaecology (Dr Flem Jacobsen), and Center for Vascular Surgery (Dr Sætre), Oslo University Hospital, Oslo, Norway; Oslo Sports Trauma Research Center (Dr Granan), Norwegian School of Sport Sciences, Oslo, Norway; and Norwegian Knowledge Centre for the Health Services (Dr Vandvik), Oslo, Norway.

CORRESPONDENCE TO: Annette Kristiansen, MD, Department of Internal Medicine, Sykehuset Innlandet HF, Gjøvik, Norway; e-mail: annettekrist@gmail.com


Part of this article has been presented in poster form at the 2012 G-I-N Conference, August 22-25, 2012, Berlin, Germany.

FUNDING/SUPPORT: Innlandet Hospital Trust, the Southern and Eastern Norway Regional Health Authority, and the Norwegian Research Council have provided research grants. The Norwegian Medical Association has provided grants to support completion of the adaptation process.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(3):727-734. doi:10.1378/chest.13-2828
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BACKGROUND:  Adaptation of guidelines for use at the national or local level can facilitate their implementation. We developed and evaluated an adaptation process in adherence with standards for trustworthy guidelines and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, aiming for efficiency and transparency. This article is the first in a series describing our adaptation of Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines for a Norwegian setting.

METHODS:  Informed by the ADAPTE framework, we developed a five-step adaptation process customized to guidelines developed using GRADE: (1) planning, (2) initial assessment of the recommendations, (3) modification, (4) publication, and (5) evaluation. We developed a taxonomy for describing how and why recommendations from the parent guideline were modified and applied a mixed-methods case study design for evaluation of the process.

RESULTS:  We published the adapted guideline in November 2013 in a novel multilayered format. The taxonomy for adaptation facilitated transparency of the modification process for both the guideline developers and the end users. We excluded 30 and modified 131 of the 333 original recommendations according to the taxonomy and developed eight new recommendations. Unforeseen obstacles related to acquiring a licensing agreement and procuring a publisher resulted in a 9-month delay. We propose modifications of the adaptation process to overcome these obstacles in the future.

CONCLUSIONS:  This case study demonstrates the feasibility of a novel guideline adaptation process. Replication is needed to further validate the usefulness of the process in increasing the organizational and methodologic efficiency of guideline adaptation.

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