A scoping review of evidence-based guidance and guidelines published by general practice professional organizations

Abstract Background General practitioners (GPs) need robust, up-to-date evidence to deliver high-quality patient care. There is limited literature regarding the role of international GP professional organizations in developing and publishing clinical guidelines to support GPs clinical decision making. Objective To identify evidence-based guidance and clinical guidelines produced by GP professional organizations and summarize their content, structure, and methods of development and dissemination. Methods Scoping review of GP professional organizations following Joanna Briggs Institute guidance. Four databases were searched and a grey literature search was conducted. Studies were included if they were: (i) evidence-based guidance documents or clinical guidelines produced de novo by a national GP professional organization, (ii) developed to support GPs clinical care, and (iii) published in the last 10 years. GP professional organizations were contacted to provide supplementary information. A narrative synthesis was performed. Results Six GP professional organizations and 60 guidelines were included. The most common de novo guideline topics were mental health, cardiovascular disease, neurology, pregnancy and women’s health and preventive care. All guidelines were developed using a standard evidence-synthesis method. All included documents were disseminated through downloadable pdfs and peer review publications. GP professional organizations indicated that they generally collaborate with or endorse guidelines developed by national or international guideline producing bodies. Conclusion The findings of this scoping review provide an overview of de novo guideline development by GP professional organizations and can support collaboration between GP organizations worldwide thus reducing duplication of effort, facilitating reproducibility, and identifying areas of standardization. Protocol registration Open Science Framework: https://doi.org/10.17605/OSF.IO/JXQ26.


Introduction
General practitioners (GPs) practice medicine in the setting of the community and the family, 1 and are responsible for providing comprehensive and ongoing care to every individual seeking medical support irrespective of their illness, sex, or age. 2 Internationally there are variations in healthcare structures and the cultural settings that GPs practice in, but there are also similar components.For example in many countries GPs act as gatekeepers, facilitating access to hospital and speciality care and certain diagnostic tests. 3Ps endeavour to use a patient centred approach to achieve shared decision making, through the integration of clinical evidence, clinical judgement, and patient priorities. 4,5][8][9][10] Clinical practice guidelines, being systematically developed statements, based on a comprehensive evaluation of evidence, aim to address this need and support practitioners' to make healthcare decisions. 11However, a review of 45 UK clinical practice guidelines reported a significant number of guideline recommendations were based on studies with little relevance to primary care. 124][15][16] High workload and time pressure are significant barriers to utilization of clinical guidelines, 17 however, despite these barriers, GPs are more likely to use guidelines that involved GP contributors during the development stage and where the evidence is applicable to primary care. 18vailability of resources and national guideline development agencies influence how GP professional organizations develop and disseminate clinical guidelines. 19National guideline agencies may approach GP organizations to endorse their guidelines. 202][23] Some GP organizations play a central role in developing de novo guidelines for GPs.For example, the Dutch College of GPs/Nederlands Huisartsen Genootschap (NHG) develop clinical guidelines which cover a range of primary care presentations. 24Assimilating how GP professional organizations develop and disseminate clinical guidelines for their members, would facilitate collaboration between GP organizations thus reducing duplication of effort and promoting a standardization of processes to support GPs in their clinical decision making. 25he aim of this scoping review was to identify what evidence-based guidance is published by GP professional organizations internationally to support GPs in their clinical decision making.The objectives were: (i) to identify the topics covered, (ii) to review the methods used to develop evidencebased guidance and/or clinical guidelines and how these guidance documents are structured, and (iii) to explore how evidence is disseminated to GPs.

Methods
This scoping review was preregistered on Open Science Framework and a study protocol has been published. 25iven that many GP guidelines may not be published as peer reviewed publications and the evident heterogeneity of nomenclature (e.g.guides versus guidance versus clinical guidelines), a combination of a bibliographic database search, grey literature search, and GP organization author contacts was conducted.

Scoping review study design
The scoping review was conducted in accordance with JBI methodology for scoping reviews [26][27][28] and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR). 29A scoping review was selected as it is designed to address a broad research question by mapping a body of literature in that area. 30,31The research team comprised researchers and knowledge users (GPs and Irish College of General Practitioners) and through regular meetings identified the specific research question, designed the search strategy, and synthesized the evidence.
Eligibility Articles were included where they were an evidencebased guidance document or clinical guideline (henceforth "guideline") produced by a national GP professional organization, either de novo (new and updated versions) or through adaptation (Table 1).These guidelines had to support GPs clinical decision making and patient clinical care and be published in the last 10 years for currency.For the purposes of this scoping review "published" refers to guidelines that are made freely available by GP professional organizations on their website or through peer reviewed publication.It does not include guidelines that are collaborations with or endorsed by other, non GP organizations.No language restrictions were applied.English versions were sought on the organizations websites or translated via Google translate.

Search strategy
The search strategy (Appendix 1) was developed in consultation with an information specialist (PM), and applied to 4 bibliographic databases (Medline, Embase, Cochrane Library, and Scopus).The search was conducted on 12 April 2021.

Grey literature search
In addition to NHS evidence and Guideline central, websites of included organizations were searched for clarification regarding the production method of de novo guidelines.This search was not exhaustive, e.g. if additional de novo guidelines were discovered from the organization websites these were not charted as per the database search.
Screening and data extraction Two reviewers (SD and EOB) screened titles for eligibility, a third reviewer (EW) resolved conflicts.One reviewer (EOB) completed the data charting, with 20% checked by the second reviewer (SD).
Quality appraisal and analysis Consistent with established scoping review methodology, 26 we did not appraise the risk of bias of included studies, nor did we summarize the data quantitatively (meta-analysis).Findings were synthesized narratively with descriptive statistics (e.g.frequencies and percentages).
GP professional organizations were contacted to provide supplementary information.A total of 39 organizations were contacted through professional links via the Irish College of General Practitioners (n = 6) and links with the European Society for Quality and Safety in Practice (n = 33).GP professional organizations were invited to provide additional information regarding their published guidelines (see Appendix 2) which was based on the inclusion criteria for the review (Table 1).Responses were collected using Survey Monkey, transferred to Excel, and data analysed using descriptive statistics.The purpose was to clarify methods of guideline production and publication within GP organizations included in the scoping review and identify any other relevant publications.

Search results
A total of 14,142 titles and abstracts were identified after duplicates removed.Of these, 125 articles full texts were assessed for eligibility with 60 full texts guidelines being included (Appendix 3 and Fig. 1) from 6 organizations.Findings

Key messages
• GP professional organizations produce de novo clinical guidelines.• Mental health is the most common de novo guideline category.
• Dissemination occurs via downloadable pdfs and peer review publication.
• GP professional organizations also collaborate on and endorse other guidelines.
from the websites of included organizations revealed that additional de novo guidelines not retrieved from the database search were also available.The 60 identified guidelines from the database search are therefore a subset of de novo guidelines from the included organizations.
Of the 39 GP professional organizations contacted to provide supplementary information, 13 responded, representing input from 12 unique GP professional organizations (Appendix 4).Four of these 12 organizations met the inclusion criteria; being national organizations and producing evidence-based de novo guidelines.Eight organizations were excluded based on production method, members only access or being a regional organization (Table 2).Guideline topics covered in the questionnaire included all methods of production.These findings were documented for the purposes of comparison and context, although they were outside the inclusion criteria of de novo production.Of the 6 organizations identified in the database search, 4 responded to the contact for supplementary information and 2 did not.).From these organizations, 60 guidelines were included, 12 of which were in English and all others were translated (from German or Dutch to English) or accessed in English from the organizations website.Figure 2 shows the number of guidelines retrieved from the search for each organization, the majority were from NHG (n = 38).

Guideline topics
Across the 6 organizations and 60 included guidelines, topics were distributed across 19 clinical categories (Table 3).Mental health comprised the most guidelines (n = 7), addressing broad categories such as anxiety, 32 depression, 33 sleep problems, 34 and addiction management. 35,36wo organizations covered very specific guidelines such as managing medically unexplained physical symptoms and somatoform disorder 37 and depression following coronary syndrome. 38In the cardiovascular disease category, chest pain, 39 atrial fibrillation, 40,41 venous leg ulcers, 42 and venous thromboembolism 43 were identified.Atrial fibrillation is one of only 3 de novo guidelines retrieved from the AAFP 41 ; other AAFP guidelines such as cholesterol management and management of hypertension are produced in collaboration with other specialties or by endorsing external organizations such as the US preventive services task force.Chronic disease management, pain management, and preventive care were the top 3 categories (all methods of production) identified from GP organizations (Appendix 4).All organizations identified in the scoping review produce guidelines by collaboration with external organizations and the RACGP, AAFP, and CFPC all endorse guidelines developed by external organizations.

Methods of development of de novo guidelines
All 60 included guidelines contained explicit descriptions of the evidence-based methods involved in their development.A total of 57 guidelines from the 6 organizations followed a similar process of development, outlined in Table 4.In summary, this process involves topic identification and formation of a working group comprising of GPs and other medical specialists, allied health professionals, scientific experts, and patients as appropriate.Once conflicts of interest are declared, guideline-specific questions are formulated.A systematic literature search is conducted, by either an evidence team or member of the working group, depending on the organization and funds available.For example, the RACGP utilize the PEER team while the NHG utilize a methodologist employed by the college.Following the search, recommendations are developed using an approach such as GRADE, utilizing the evidence synthesized, 92 however use of the GRADE process

Inclusion criteria Excluded
National GP professional organization may depend on external funding. 74The final steps of consensus, review and guideline publication is carried out by all 6 organizations.There was 1 guide from the RACGP 91 which was distinguished from a guideline, as there was no formulation of weighted recommendations.This was explicitly stated as part of the method of production.Two guidelines were developed using the ADAPTE process, 66,93 examining currently available international and/or national guidelines as a basis for recommendations, with the remainder of the process following the organizations de novo production method.Guideline updating processes varied across the 6 organizations.Five of the organizations updated guidelines after a predefined time period, ranging from 3-5 years (RACGP, AAFP, and Domus Medica) to 5-10 years (NHG and the CFPC).The guidelines and web resources from DEGAM did not contain this information. 39,47,49,55,71,76,79,81,83In addition to the timeframes specified, the 5 organizations state that guideline updating can be prompted by a change in the evidence and/or national guideline updating on a particular topic.The method is a modified version of the original evidence-based approach (Table 4).

Structure and dissemination of guidelines
All 6 organizations make guidelines available in downloadable portable document format (Pdf) directly from their organizations website.The length of guideline Pdf's varied from 30 to 150 pages depending on the topic.Five organizations also provided a summary version of the guideline to accompany the Pdf.DEGAM, NHG, and CFPC provide a summary infographic. 39,47,49,55,71,76,79,81,83Websites of NHG, RACGP, and AAFP provide summary versions, but the full version can only be downloaded as a Pdf.Five organizations provide patient information material.For Modus Medica, only the guideline was available via open access, all other material was accessible only to members.Patient information leaflets differ between organizations, e.g.NHG support a dedicated website for patients (https://www.gpinfo.nl/),while the CFPC refers to patient information within their guidelines and also signposts to external patient support groups.
In terms of dissemination, in addition to publishing the full guideline on the organizations website, 3 organizations (CFPC, AAFP, and DEGAM) publish full guidelines, and 1 (NHG) publishes a summary, in their organizations journal.The included Belgium guideline was published in a peer reviewed journal. 66Continuing medical education meetings are used for dissemination by CFPC, AAP, NHG, and RACGP.The NHG, RACGP, and CFPC use webinars and e-learning modules, while the NHG and RACGP use periodicals and workshops (Table 5).In the DEGAM guideline on Dementia the strategy for dissemination is described and includes GPs involved in developing the guideline and the publication media drive on completion of a guideline. 76Although beyond the scope of this review, of note, clinical decision support systems are used by the CFPC and NHG as a form of implementation, while NHG also use financial incentives and continuing medical education credits.

Summary of principal findings
This scoping review included 6 GP professional organizations that publish a range of guidelines for frontline GPs with explicit methods of development and recommendations.Topics cover a wide range of clinical areas including mental health, cardiovascular care, neurology, pregnancy and women's health and preventive care.These guidelines are available on organizations websites as downloadable Pdfs, with summary documents and patient information.Dissemination strategies include peer reviewed publications, webinars, and continuing medical education meetings.

Comparison with previous literature
To our knowledge, this review is the first to map guidelines published by GP professional organizations internationally to support GPs in their clinical decision making.Mental health topics were the top clinical category for de novo guideline production.Mental health conditions are a common presenting condition to general practice 96 and a more significant challenge now due to the COVID-19 pandemic. 97ental health is a leading cause of significant morbidity 98 and clinical importance is one of the criteria supporting the need for guideline development. 99While, GPs dealing with mental health issues may require access to psychologists and psychiatrists, 100 they remain the first point of care and need diagnostic and therapeutic tools to deal with such presentations.In this context, the updated NHG guidelines on Depression, e.g. now includes these tools as well as website links to online learning modules for GP members to upskill in the delivery of such care. 33Chronic health conditions were the main clinical category from GP organizations and   topics such as COPD, 78 asthma, 80 depression, 33 obesity, 65 and chronic kidney disease 71 were all included guidelines from the review.The complexity of this care is a considerable challenge for frontline GPs, especially as these patients may suffer from multiple chronic conditions. 14GPs play a central role in the coordination of this care and for this GP-specific guidance is required. 15DEGAM and RACGP publish multimorbidity guidelines on their websites.In addition to guidelines, the literature emphasizes the importance of GPs unique relationships with their patients, the need for policies and "models of practice" that allow nurturing of this relationship in order to manage such complex care. 101he findings of this review are consistent with existing literature on guideline development, structure, and updating. 99,102,103Each organization has a transparent production method and the de novo process aligns with the Institute of Medicine standards for the development of trustworthy guidelines and the Guideline International Network key components for guideline development. 104,105Governance structures and access to government and other national guideline producing bodies, 19 as well as resources, a need for information sharing and a drive to reduce duplication of effort, all influence the choice of the guideline development process. 106The review findings reflect this, as in addition to producing de novo guidelines, all included organizations, produce guidelines by collaborating with other specialities and 50% endorse guidelines from other non GP guideline producing organizations.Guidelines are also developed by adaptation of other available guidelines, 107 2 such guidelines are included in this review. 59,66The review findings also support other recent literature from Belgium on the quality of evidence-based medicine resources in primary care, 108 which suggests that being concise, of direct clinical relevance and adapted to the local situation is essential for evidence-based medicine resources. 108ecent literature on guideline dissemination focussing on the format and language of guidelines outlines the importance of document structure in helping improve their use in practice.Being user friendly, especially relating to the length of the document and how information is visualized is important

Mental health (n = 7)
Problem drinking 35 Anxiety 32 Depression 33 Medically unexplained physical symptoms 37 Sleep problems 34 Depression post coronary syndrome 38 Opioid use disorder 36 Cardiovascular disease (n = 6) Atrial fibrillation 40,41,44 Chest pain 39 Venous leg ulcers 42 Venous thromboembolism 43 Neurology (n = 5) Facial paralysis 45 Head injury 46 Stroke 47,48 Acute dizziness 49 Pregnancy and women's health (n = 5) Preconception care 50 Contraception 51 Menopause 52 Vaginal bleeding 53 Labour and delivery after CS 54 Preventive care (n = 5) Cardiovascular prevention 55 Lipid guidelines 56 Risk prevention (SNAP) 57 Smoking cessation 58 Preventive activities in GP 59 Sexual health and GU (n = 4) STD c onsultation 60 Female urinary incontinence 61 Sexual problems 62 Male micturition problems 63 Paediatrics (n = 4) ADHD 64 Obesity 65 Prolonged cough 66 Asthma 67 Renal and GIT (n = 4) Acute diarrhoea 68 Gastric symptoms 69 Diverticulitis 70 Chronic kidney disease 71 Musculoskeletal (n = 3) Lumbosacral radicular syndrome 72 Hand and wrist symptoms 73 Osteoarthritis 74 Care of the elderly(n = 3) Delirium 75 Dementia 76,77 Respiratory (n = 3) COPD 78 Acute cough 79 Asthma 80 Endocrine (n = 2) Thyroid disorders 81,82 ENT (n = 2) Sore throat 83,84 Rheumatology and Food allergy 85 Polymyalgia rheumatic 86 Dermatology and immunology (n = 1) Infectious diseases (n = 1) Influenza pandemic 88 Ophthalmology (n = 1) Visual symptoms 89 Cannabinoids 90 Genomics 91 for end-users. 109Wide variation in the length of guideline pdf documents is evident in this review.Although summary pdfs and summarized website versions of guidelines are available, quick access to pertinent information such as using visual aids and hyperlinks may help to improve their implementation in practice. 110The findings of the review show that multiple dissemination strategies are used, including education tools, infographics, patient information, and a publicity drive at the time of guideline publication.The importance of these strategies is highlighted by the findings of a recent Cochrane review of tools to promote uptake of guidelines, where provision of education materials likely improves adherence to guidelines. 111

Strengths and limitations
The challenge in this review was to map the landscape of information being produced given the fact that not all GP professional organizations publish their guidelines in peer reviewed journals and also the heterogeneity of the nomenclature for this search.Contacting GP organizations and conducting an extensive grey literature search which included website searches of key organizations helped address this.However, completing a more exhaustive website search (including those organizations whose guidelines were not freely available) and mapping a complete topic list of de novo guidelines from each organization would allow a more detailed comparison of specific guideline recommendations, although that was outside the scope of this review.This scoping review was limited to de novo production of guidelines, this excluded certain national GP organizations that develop guidelines in association with national bodies.This decision was based on the varying number of GPs that are members of these national bodies and if those GP members represent their organization.Furthermore, in choosing to map the de novo production of guidelines, the full breadth of activity undertaken by GP organizations in terms of guidelines for use in clinical practice was not captured in this review.A good example of this are the AAFP guidelines on Cholesterol Management and Management of Hypertension, both excluded but very relevant for use in GP.The authors believe it is important to map what guidelines GP professional organizations are producing, given the specific challenges for GPs identifying guidelines that are relevant to general practice, as most are single disease focussed, may not account for the patient perspective, and may not consider the challenges relating to cost and resources for general practice. 112s this was a scoping review, we did not quality appraise included guidelines so we were not in a position to comment on the overall quality of the included guidelines.

Research implications
There is scope for further research to map guidelines being published by GP organizations worldwide regardless of the production method.This would facilitate a broader understanding of the complex nature of guidelines necessary for GPs working on the frontline in any given healthcare system.Implementation strategies were beyond the scope of this review but we did note that in general these were not identified as part of the guidelines identified.There is a gap in the evidence on which type of implementation strategies are effective, [113][114][115] and although there is some literature in general practice on these strategies, 116 there is a need for further research on the type and effectiveness of implementation strategies, e.g.use of financial or other incentives to encourage uptake.International GP organizations would be well placed to collaborate on such research.

Clinical and policy implications
This review shows that international GP organizations, despite working in different healthcare systems, with different governance structures, produce guidelines with similar topics, methods, and dissemination strategies for use by their members.The standard transparent approach to production methods can facilitate a standardization across GP organizations thus promoting sharing of resources, but this needs to be balanced with the need for local relevance to improve the success of guideline implementation. 117Emerging evidence on the effectiveness of guideline implementation in terms of improving patient outcomes, may influence policy around the use of alternative strategies to support the use of guidelines in practice.

Conclusion
This scoping review has highlighted specific de novo guideline production in GP professional organizations worldwide.There is substantial overlap in the areas of methods of production and publication and some variation in clinical topics and dissemination methods.Overall it indicates there is potential for collaboration between GP organizations worldwide to reduce duplication of effort, facilitate reproducibility, and identify areas of standardization internationally.Furthermore, there is an opportunity for leading guideline producing GP organizations to collaborate with countries where the focus remains on secondary/specialist care, helping to strengthen primary care in these countries.

The 6
organizations included were from the Netherlands (The Dutch College of General Practitioners [NHG]), Germany (the German College of General Practitioners and Family Practitioners [DEGAM]), Belgium (Belgian Society for General Practitioners/Family Physicians [Domus Medica]), the United States (the American Association of Family Practitioners [AAFP]), Canada (the College of Family Physicians of Canada [CFPC]), and Australia (the Royal Australian College of GPs [RACGP]

Fig. 1 .
Fig. 1.PRISMA flow diagram of articles retrieved for scoping review on evidence-based guidance documents or clinical guidelines produced by general practice professional organizations, 2010-2021.

Fig. 2 .
Fig. 2. Number of de novo guidelines retrieved from the database search for each general practice professional organization.The number of de novo guidelines found on each organizations website shown for comparison.

Table 1 .
Summary of the eligibility criteria for the review.

Table 2 .
Summary of excluded organizations from those contacted.

Table 3 .
Summary of guidelines per clinical category.

Table 4 .
Summary of methods of guideline development and updating.

Table 5 .
Summary of guideline structures and modes of dissemination. ).mp.