based but actionable and responsive to varying patient
needs and preferences at the point of care.
All told, a single AGA guideline costs around $45,000 and
takes approximately 24 months to complete and publish.
Currently, the AGA is working to pilot new methods of shortening the time to publication through the development of
rapid reviews within a focused topic (e.g., opioid-induced
constipation).1 The development of each guideline requires
a team of one or more specially trained GRADE methodologists, two or more content experts, a medical librarian,
a panel of three or more guideline authors, two AGA staff
members, and the Clinical Guidelines Committee Chair.
Determining the guideline topics. Each AGA guideline begins as a simple idea submitted through the annual call for
topics, which is open to the public. At their annual meeting
at Digestive Disease Week®, the 15 members of the AGA
Institute Clinical Guidelines Committee (CGC) review the
entire list of submissions and rank a list of eight or more
topics that they believe are the most timely, relevant, and
impactful to the field of gastroenterology. This may include a
combination of completely new topics and updates of older,
out-of-date guidelines. The AGA Institute Governing Board
then determines a final list of four or more topics to immediately begin development.
Determining the focused questions. First, the entire team
of physician-authors determines a list of focused questions
that the guideline will address. This list of focused questions
is translated into a table of Population, Intervention, Comparison, Outcomes (PICOs) that operationalize the general
questions into search terms utilized by the medical librarian
to run the systematic search as well as define the final scope
of the guideline. The focused questions and related PICOs
are sent to the Governing Board for review and approval.
Developing the technical review. Over the next several
months, the methodologist and content experts meet on a
weekly basis to review the search results question-by-ques-
tion and develop the technical review of evidence that will
form the basis of the clinical recommendations. For each
PICO, the technical review assesses the entire body of evi-
dence and rates the overall quality of evidence gathered for
each outcome related to the PICOs (from “very low” to “low”
to “moderate” to “high”).
Rating the quality of evidence. Ratings of the quality of evidence for each PICO are based not only on the methodology
used in the scientific studies (e.g., whether each study is an
observational study or a randomized controlled trial) but
additional categories such as publication bias (i.e., whether
there is reason to believe there is a disproportionate representation of positive results in the literature) or indirectness
(i.e., how directly applicable the study population and interventions are to real-life clinical scenarios). In this way, outcomes informed by randomized controlled trials might be
“rated down” to a moderate quality of evidence because of
indirectness, whereas a body of evidence from observational
studies may be “rated up” because of large effect.
Drafting the clinical recommendations. The technical review presents the findings of the literature along with the
authors’ assessment of the evidence quality. At a face-to-face meeting, these results are presented by the technical
review authors to the guideline panel, who are responsible
for developing the official guideline document. The role of
the guideline panel is to understand the quality of evidence
and determine an ultimate list of clinical recommendations
and assign a strength (strong or conditional) to each recommendation, all while considering important factors such
as the balance between benefits and downsides, potential
variability in patients’ values and preferences, and impact
on resource utilization. Oftentimes, but not always, recommendations based on higher-quality evidence for which
most patients would request the recommended course
The development of each guideline requires a team of one or more specially
trained GRADE methodologists, two or more content experts, a medical librarian,
a panel of three or more guideline authors, two AGA staff members, and the
Clinical Guidelines Committee Chair.