In reply: I thank Hill and colleagues1 for their interest in my article.2 The approach of the Australian Living Evidence Collaboration (ALEC) is impressive and one that guideline developers should aspire to. It is my understanding that the ALEC receives considerable funding from federal and state governments and several charitable foundations. In contrast, the Paediatric Improvement Collaborative (PIC) receives a fraction of ALEC's budget to produce clinical practice guidelines (CPGs). The “iron triangle” refers to the three key constraints that can affect a project.3 These are cost, time and quality. It is almost impossible to change one without affecting the others or damaging the quality of the overall project. The approach of PIC CPG development is based on evidence-based medicine (EBM), as described by Sackett and colleagues as the integration of clinical expertise with the best available clinical evidence from systematic research.4 There are almost 150 PIC CPGs available as point-of-care guidelines for clinicians caring for children, and between 30 and 40 new and updated CPGs are published each year. Within the constraints of the current resources, it is not feasible to use GRADE methods and maintain this output. The current PIC approach to the development of national paediatric CPGs prioritises EBM, collaboration and quality. Significant investment in infrastructure and capacity is required to sustain, and ideally, enhance the process.
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To the Editor: It is encouraging to hear the collaborative effort in paediatric clinical practice guidelines (CPGs).1 CPGs provide a critical tool for clinicians, health administrators and policy makers. We strongly agree that nationally coordinated efforts for evidence synthesis are clearly needed, which can be adapted if required. Starr1 also makes important points around suboptimal adherence to CPGs, including lack of currency and concerns on evidence quality. Evidence is rapidly evolving and previous analysis found that one in five clinical practice recommendations were out of date within three years.2 Fortunately, Australia has pioneered living guideline methods, which use frequent (1–3 monthly) surveillance systems and rapid response pathways using robust Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods to ensure recommendations are up to date.3 This new model is clearly feasible and has demonstrated an increase in trust, frequency of access and intention to apply advice by stakeholders, in areas as diverse as coronavirus disease 2019 and stroke.4, 5 Our experience, contrasting to Starr's, is that this approach is feasible and helpful to develop living guidelines that use reliable GRADE methods and meet National Health and Medical Research Council standards. Living methods (using GRADE) are now considered the gold standard by leading guideline developers such as the National Institute for Health and Care Excellence in England and the World Health Organization. Unfortunately, in Australia there is no national agency to prioritise what guidelines should be developed, let alone sustainable funding to ensure they are kept up to date. We agree with Starr that this must urgently change and call on all governments to invest in CPG infrastructure and capacity. In an age of widespread misinformation and disinformation, it is crucial that Australian clinicians, patients and policy makers have access to reliable, up-to-date, evidence-based information to enable the best possible health care decisions.
All authors are members of the Australian Living Evidence Collaboration Strategic Advisory Committee.
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