. 2021 Dec 2;11(12):e053587. doi: 10.1136/bmjopen-2021-053587

Table 3.

Main steps of the adaptation process

Adaptation methodology/year	Selection of the scope and source CG(s)	Assessment of source materials	Decision-making process	External review and follow-up
ADAPTE 2010⁹	Determining the health question Search for existing CGs/other relevant documents Source CG(s) screening and selection	Source CG quality assessment Source CG currency assessment Source CG content assessment Source CG consistency assessment Acceptability and applicability of recommendations assessment	Review assessment Choosing between source CGs and recommendations	External review and acknowledgement of source CG(s) Consulting source CG(s)
Adopt–Contextualise–Adapt Framework 2016³⁶	Predefining CG topics ¹ Search for international existing CGs Source CG(s) selection by evaluating the implementability of the question to the target setting	Evaluation of methodological quality of the source CG(s) ^a Content review and recommendations and evidence summary Identifying recommendations relevant to steps along the patient journey Dealing with two or more relevant recommendations Supplementing with local evidence ^a	Developing composite recommendations ^α Decision making as adoption, contextualisation/adaptation according to the local context	Plan Implementation Focused public consultation Planning and evaluation of the CG adaptation roll out Establishing partnerships
ACP guidance statement 2019³⁴	Choosing topics with recommendation conflictions Search and selection of national-level source CG(s) within 5 years ²	Assessing quality and process transparency of source CG(s) Assessing the interpretation of the evidence (benefits, harms, costs, and patient values and preferences) Source evidence review ^b	Presenting evidence summary and proposing recommendations Reaching consensus by discussion or voting	Public panel review Peer review process Publication Financial support Reporting Updating
ASCO CG endorsement/adaptation methodology 2019³²	Based on the ASCO’s priority topics Selection of source CGs matched by criteria ³	Quality of source CGs appraisal using AGREE II ^c Content review with expert’s agreement on recommendations SRs appraisal using AMSTAR and search for new evidence (eg, when the evidence base is outdated.)	Evidence synthesis with a matrix containing recommendations and supporting evidence Independent evidence review by the expert panel Modification decision (eg, contextualisation, clarification, or new evidence addressing) made by the expert panel Full committee approval or voting for consensus	Review by applicant organisations of source CG(s) Peer review by journal Publication Derivative clinical tools/resources Updating
CCO endorsement protocol 2019³⁵	Defining key topics based on the release of well-known CGs that meet the interest of CCO or Defining key topics based on CG-related project and identify existing CG addressing CCO’s topic	Initial assessment and selection of source CG(s) ^d Source recommendations assessment ^e Likelihood of new evidence assessment (if so, a de novo development will start)	Review of the draft endorsement document by an expert panel Consensus and approval	Professional Consultation Final Publication Maintenance/Updating
DynaMed editorial methodology 2019³³	Based on the current existing topics of Dynamed Screening and selection of the best available evidence based on relevance and potential impact on clinical decision-making and patient care	Critically appraisal of source CGs regarding trustworthiness, relevance, and clinical value Rating of the strength of the recommendations (eg, net benefit, cost and burdens, and patients’ value) ^f Rating of potential source of bias and certainty of the evidence	Evidence reporting and review by clinicians Synthesis of multiple evidence reports ^β Based on conclusions of the overviewed evidence with direct links provided	Review by the editorial team, topic/section editors, and EBM experts Updating daily
DELBI 2019³⁸	Defining key questions before source CG selection ⁴ Systematic search for existing CGs Criteria description for source CG selection	Quality review of source CG(s) ^g Source recommendation review ^g Systematic update of searches for primary evidence	Describing the modifications of recommendations	External review CG adaptation process*
GRADE-ADOLOPMENT 2017⁴	CG topic and source CG selection⁵ Questions prioritisation by the panel from selected source CGs	Checking Evidence to Decision frameworks availability of source CGs Completing the GRADE Evidence to Decision frameworks Updating systematic reviews of health effects and identifying local data ^h	Preparing GRADE Evidence to Decisions frameworks and review by an expert panel Formulating recommendations through consensus or voting	NA
Piloted adaptation framework 2017⁸	CG topic prioritisation and Ministry of Health approval CG search from National guideline Clearinghouse	Source CG quality assessment ⁱ Identifying relevant recommendations from source CG(s) based on panel expertise and clinical practice settings	Adopted/adapted/new recommendations compilation Expert review	External review Online access for public consultation Updating
Adaptation experience 2019	Predefining health questions ⁶ Searching for existing CG ⁶	Source CG quality assessment using AGREE II ^j Identifying evidence from the most up-to-date CGs ^j Underlying evidence review ^j	Evidence review from source CG(s) Decision-making by national-level experts with no further details provided ^µ	National external review ƚ
The criteria or clarification for topic/scope/questions selection and source CG screening: 1: Quote: ‘At that time we have identified the top of the conditions for stroke and low back pain. We look at the literature, even at that time, there were so many CGs published already for those two topics.’ (Participant 10) 2: Sources were from PubMed and GIN library in the last five years or current practice, and Web of science. 3: Criteria are: high-quality CG developers, detailed CoI management, and financially independence; or applicant organisations’ preferable. 4: Quote: ‘If the CG adaptation groups plan to develop a new CG, they will search for the existing evidence from published CGs first.’ (Participant 06) 5: Assessed the relevance to stakeholders, proposed by a professional group or prioritised by stakeholders; In addition, GRADE approach and Evidence to Decision frameworks availability are required. 6: Quote: ‘A lot of kind of process will be in a national process, and there will be specific health questions and PICOs. Then we will be asked to conduct SRs. We do have in that particular process is that the SR would include first to look at what CGs are out there, and then we will look at what SRs are out there before we conduct our systematic review.’ (Participant 09)
The considerations or clarifications for the assessment of source materials: a: Quote: ‘We quickly appraise source CGs using AGREE II to ensure the source CG you are basing on are good quality; … To adapt, we update the search and include new evidence. …It means you take evidence surrounded for instance in the local context settings, there might be a new paper has been published locally, not internationally, but it answers the questions the local context actually asked. Then the recommendation could change.’ (Participant 10) b: Quote: ‘We will look at the evidence and do the assessment ourselves. If we do the quality assessment, we look at the systematic review, and if the systematic review doesn’t make sense, we will look at the primary studies.’ (Participant 07) c: Quote: ‘We do not have a numeric cut-off for AGREE II.’ (Participant 02) d: Criteria: Scope, relevance, and timing, quality and methods, resource availability; acceptability; e: Interpretation and justification, applicability/relevance, qualifications & clarifications. f: Quote: ‘If we see many CGs agree, and we know the evidence is high quality, we don’t need to go into a lot of greater depth because everything is pointing into the right direction. If we see the CGs are disagreeing, then we may have to evaluate and see why they are disagreeing and that where we checked the currency of the content to help us to understand the disagreement.’ (Participant 01) g: Quote: ‘We don’t have a critical cut off to choose which CG to use, we do prioritise by the quality of the CG. The CG adaptation group will create CG synopses, prefer methodologically sound recommendations. …The adaptation group should be transparent if they have appropriate changes in the recommendations when the adaptation process and provide the scientific rationale behind the change.’ (Participant 03) h: We conducted rapid SRs of patient’s value, cost-effectiveness; We considered local data suggested by panel members (patients’ value and preference, cost, resource use, population prevalence and incidence). i: Quote: ‘We request the adaptation group to assess the quality of the CGs using the AGREE II instrument. We do not have a cut-off of the AGREE score, because sometimes there are few source CGs for the consideration of adaptation. … If there are no clear answers for several questions in the source CG(s), they looked at existing Cochrane SRs but do not conduct a new one. No cost-effectiveness evidence was searched, but patients’ values and preferences, yes.’ (Participant 08) j: Quote: ‘If there is a CG of good quality, those are the recommendations. So, if I see a CG from NICE, or from European, our society will have both or do an AGREE appraisal. If there are good quality, I transparently put in my review about what the quality it was, and I pooled out the recommendations that could be relevant for that health question. And then I also look at the underlying evidence from those CGs, also the SRs, that independent of pooling out the if possible, a GRADE evidence table, or something that explains the magnitude of the effect and the certainty of evidence.’ (Participant 09)
The considerations or clarifications for the decision-making process: α: Quote: ‘In the most recent CG we published, we extracted the source recommendations from the source CGs, we have developed composite recommendations, which is the new recommendation based on the other CG have said…’ (Participant 10) β: ‘Current evidence, current CGs, and clinical expertise’s recommendations to support clinical decision making’. µ: Quote: ‘For people who work in the CG adaptation group they have any Evidence to Decision framework, so they will look at the quality of evidence from source CGs or other SRs.’ (Participant 09)
The considerations or clarifications for the external review process: * Quote: ‘Our organisation doesn’t do for the CG adaptation group, but they do the external review process by themselves’. (Participant 03) ƚ Quote: ‘The national group I am referring to send the adapted CG out for comment, feedback, and input as external review. We don’t have a specific small external review team broadly.’ (Participant 10)

DELBI is a CG assessment tool used by adaptation group to inform CG adaptation.

ACP, American College of Physicians; ADAPTE, Resource Toolkit for Guideline Adaptation; AGREE II, Appraisal of Guidelines for Research & Evaluation II; ASCO, American Society of Clinical Oncology; CCO, Cancer Care Ontario; CGs, clinical guidelines; CoI, conflict of interest; DELBI, German Instrument for Methodological Guideline Appraisal; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; NA, not applicable; NICE, National Institute for Health and Care Excellence; SR, systematic review.