[Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment]. / Enuresis und nicht-organische (funktionelle) Harninkontinenz bei Kindern und Jugendlichen ­ klinische Leitlinie zur Diagnostik und Therapie.

Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment Abstract: Objective: Enuresis and daytime urinary incontinence are common disorders in children and adolescents and are associated with incapacitation and a high rate of comorbid psychological disorders. This interdisciplinary guideline summarizes the current state of knowledge regarding somatic and psychiatric assessment and treatment. We formulate consensus-based, practical recommendations. Methods: The members of this guideline commission consisted of 18 professional associations. The guideline results from current literature searches, several online surveys, and consensus conferences based on standard procedures. Results: According to the International Children's Continence Society (ICCS), there are four different subtypes of nocturnal enuresis and nine subtypes of daytime urinary incontinence. Organic factors first have to be excluded. Clinical and noninvasive assessment is sufficient in most cases. Standard urotherapy is the mainstay of treatment. If indicated, one can add specific urotherapy and pharmacotherapy. Medication can be useful, especially in enuresis and urge incontinence. Psychological and somatic comorbid disorders must also be addressed. Conclusions: The recommendations of this guideline were passed with a high consensus. Interdisciplinary cooperation is especially important, as somatic factors and comorbid psychological disorders and symptoms need to be considered. More research is required especially regarding functional (nonorganic) daytime urinary incontinence.

[Functional Constipation and Nonretentive Fecal Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment]. / Funktionelle (nicht-organische) Obstipation und Stuhlinkontinenz im Kindes- und Jugendalter: Klinische Leitlinie zur Diagnostik und Therapie.

Functional Constipation and Nonretentive Fecal Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment Abstract. Objective: Constipation and fecal incontinence are common disorders in children and adolescents and are associated with incapacitation and a high rate of comorbid psychological disorders. Functional constipation and nonretentive fecal incontinence can be differentiated according to the current Rome-IV classification systems. This interdisciplinary guideline aims to summarize the current state of knowledge regarding somatic and psychiatric assessment and treatment. It formulates consensus-based, practical recommendations. Methods: The members of the Guideline Commission consisted of 11 professional associations and a parental organization. The guideline was based on current literature searches, several online surveys, and consensus conferences based on standard procedures. Results: Functional constipation is much more common than nonretentive fecal incontinence. Constipation requires a detailed medical assessment to exclude somatic causes, especially in young children. Red flags are useful indicators of organic causes to be considered. Most cases of constipation are functional (approximately 95 %). Counseling, toilet training, disimpaction, and long-term oral laxatives, combined with cognitive-behavioral interventions, are most effective. The assessment and treatment of nonretentive fecal incontinence are similar. The rate of somatic factors is much lower (approximately 1 %). Laxatives can worsen outcomes and should be avoided. Comorbid psychological disorders are common (approximately 30 % to 50 %). They should be assessed and treated additionally according to evidence-based guidelines. Conclusions: The recommendations of this guideline were approved with a high consensus. Interdisciplinary cooperation is especially important, as somatic factors and comorbid psychological disorders and symptoms need to be considered. More research is required, especially regarding nonretentive fecal incontinence.

From conventional to living guidelines - faster updates for better informed guidance? A scoping review.

OBJECTIVE: The goal of living guidelines is keeping recommendations in guidelines up-to-date as new evidence becomes available. This review aims at scoping the prevalence and formal characteristics of living guidelines in the field of medicine and explore differences between formats. METHODS: A selective search of living guidelines in MEDLINE via PubMed, Google Scholar and six relevant online repositories for guidelines (MAGICApp, AWMF, GIN, NICE, WHO-Iris, BIGG) was conducted. Authors and editors were contacted to receive previous non-living guideline versions. Living guidelines were subsequently analyzed according to pre-defined methodological criteria as described below (inter-comparison). Differences between living and their conventional (non-living) versions were assessed (intra-comparison). RESULTS: 83 living guidelines were identified and selected for further screening, out of which 26 were eligible for analysis. 61.5% were new publications (de-novo guidelines) and 38.5% updates of pre-existing guidelines. There are some concepts defining, for example, the update cycle (AWMF, maximum of 12 months) but not all living guidelines follow or refer to existing concepts. The analysis shows that living guidelines in line with the established standards for (non-living) clinical guidelines involve an evidence standard, an extensive consensus process (often in the form of a Delphi process), and the inclusion of stakeholders (patients/relatives) in the development process, despite the high frequency of updates. When comparing living and conventional guidelines with the descriptive approach changes were found in update frequency (being more frequent with living guidelines, annually at the latest) and publication format (towards more digital) and public consultation (living guidelines offered more possibilities), no substantial methodological differences were observed in the description of consensus processes, changes in number of recommendations, inclusion of patient representatives. Given the small number of comparable pairs, the results reflect a tendency in the analyzed sample. CONCLUSIONS: The definition and development of living guidelines varied. Standardization (i. e. in the form of a checklist, procedure template) is needed to assess quality of the living process.

Reporting guidelines for Delphi techniques in health sciences: A methodological review.

BACKGROUND: Delphi techniques are conducted across different subfields in the health sciences. The reporting practices of studies using Delphi techniques vary, and current reporting guidelines for Delphi techniques focus on individual subfields of the health sciences or on different aspects of research and are therefore of limited applicability. The aim of this article was to identify similarities, differences, and possible shortcomings of existing Delphi reporting guidelines and to draft an initial proposal for a comprehensively applicable reporting guideline. METHODS: A systematic literature search for reporting guidelines on Delphi studies was performed in existing data resources based on databases in the health sciences (Scopus, MEDLINE, CINAHL, Epistemonikos) including publications from 2016 to 2021. In June 2021, we conducted an additional search in PubMed and included further studies by contacting experts of the scientific Delphi expert network (DeWiss). Title and abstract screening of articles was performed, followed by a full-text screening of the articles included. We qualitatively and quantitatively evaluated, compared and contrasted the reporting guidelines identified using content analysis and discussed the results among the members of the Delphi expert network. RESULTS: We retrieved ten health science articles with reporting guidelines for Delphi studies. In analyzing them, we identified nine main categories (Justification, Expert panel, Questionnaire, Survey design, Process regulation, Analyses, Results, Discussion, Methods reflection & Ethics). The current reporting guidelines vary significantly, with only the aspect of consensus appearing in all of them. Frequency distributions show that most of the subcategories are only addressed in individual articles (e.g., meeting of participants, proceeding with the survey method, transfer of the results, validation, prevention of bias) and that epistemological foundations of the Delphi technique are rarely mentioned or reflected on. We drafted an initial proposal for Delphi reporting guidelines for the health science sector. DISCUSSION: A well-justified position concerning epistemological foundations of Delphi studies is necessary to make the quality of the process assessable and, along with the reporting of the process, to classify and compare study results. This will increase the acceptance of both the method in the health science sector and the results in medical practice. A Delphi reporting guideline must, above all, take into account the diversity of variants, subfield-related objectives and application areas, and their modifications of the Delphi technique in order to be comprehensively applicable in the health sciences. CONCLUSION: The results of our methodological review do not provide a final reporting guideline. The newly developed proposal is intended to encourage discussion and agreement in further analyses.

[Methodological Standard for the Development of Quality Indicators within Clinical Practice Guidelines - Results of a structured consensus process]. / Methodischer Standard für die Entwicklung von Qualitätsindikatoren im Rahmen von S3-Leitlinien ­ Ergebnisse einer strukturierten Konsensfindung.

BACKGROUND: Recommendations of evidence- and formally consensus-based clinical practice guidelines (CPGs) represent a valuable source of quality indicators (QIs). Nevertheless, a standardized methodological procedure for developing QIs in the context of CPGs does not yet exist in Germany for all CPGs. For this reason, a methodological standard for the guideline-based development of QIs (QI Standard) was developed based on a structured consensus process involving multiple key stakeholders. METHODS: The proposed content of the QI Standard was derived from evidence, drawing upon results of reviews and qualitative studies, and considered German manuals for guideline-based QI development of two guideline programs. A multi-perspective consensus panel, broadly representing key stakeholders from the German healthcare system with expertise in CPGs and/or quality management, was nominated to vote on recommendations for guideline-based development of QIs. The iterative, structured consensus process included a two-stage online survey based on the Delphi method ("preliminary voting") and a moderated final stakeholder conference where all those recommendations were definitely included in the QI Standard that received approval of more than 75 % (consensus criterion) of the consensus panel. RESULTS: Based on the agreed QI Standard, the QI development process starts with a criteria-based selection of "potential" QIs which - in case of adoption - are published in CPGs as "preliminary" QIs and can achieve the status "final" after successful testing. The QI Standard is composed of a total of 30 recommendations, which are allocated to six areas: A) preparatory work steps for the guideline-based recommendation of QIs, B) QI development group and cooperation with the CPG group, C) development of potential QIs, D) critical appraisal of potential QIs, E) formal adoption and publication as well as F) piloting/testing of preliminary QIs and conversion into final QIs. DISCUSSION: Before the QI Standard can be recommended for implementation in future CPGs, it should have been successfully tested in selected German CPG projects. In addition to methodological requirements for the QI development, it must be ensured that guideline groups have adequate resources for the implementation of the QI Standard. CONCLUSION: By using the QI Standard, scientifically sound and healthcare-relevant QIs can be expected.

Ernährungsmanagement bei mangelernährten Kindern in der häuslichen Pflege - Empfehlungen aus einer settingspezifischen Leitlinie.

Nutritional management in malnourished children and adolescents in home care - recommendations from a setting-specific evidence-based guideline Abstract. Background: Malnutrition in children is an underestimated phenomenon that is frequently unrecognized and therefore not adequately treated. If the treatment is inadequate, malnutrition can lead to a variety of negative consequences for the childrens' development. Corresponding guidelines for malnutrition for pediatric nursing in home care settings are lacking. Aim: The aim of this paper is to present the nutritional management of malnourished children, which was elaborated in the course of developing a setting-specific guideline for pediatric home care. Methods: The developed guideline is based on the approach described by the Scientific Medical Societies Working Group. This approach encompasses a) forming a group of experts, b) defining clinical questions, c) searching the literature, d) evaluating and synthesizing the literature, and d) formulating recommendations. Parents were included to rate the relevance of the recommendations. Results: The nutrition management involves a detailed nutritional assessment, subsequent oral, enteral or parenteral interventions, weight monitoring and a re-assessment of the child's nutritional status. Nurses, as well as parents/legal guardians, play essential roles in planning and implementing nutrition management in the home care setting. Conclusions: The use of the guideline may contribute to the early detection of causes for malnutrition and adequate multidisciplinary treatment of children with suspected or identified malnutrition in the home care setting.

[Development of guideline-based quality indicators: a qualitative study on barriers and facilitating factors from the perspective of S3-guideline authors]. / Entwicklung leitlinienbasierter Qualitätsindikatoren: eine qualitative Studie zu Barrieren und förderlichen Faktoren aus der Sicht von S3-LeitlinienautorInnen.

BACKGROUND: Evidence-based and formally consensus-based clinical practice guidelines (S3-CPGs) are a valuable source for the development of quality indicators (QIs) in Germany. While deriving QIs from guideline recommendations is a mandatory part of the development of S3-CPGs within the National Program for Disease Management Guidelines (DMGP) and the German Guideline Program in Oncology (GGPO), there is no such obligation in the guideline program of the Association of the Scientific Medical Societies in Germany (AWMF) (MS program). Despite that, several S3-CPGs in the MS program have been published with QIs in the last years while some DMGP and one GGPO S3 guidelines have failed to meet this requirement. From the perspective of the guideline authors of all three mentioned programs, the present qualitative study examined why S3-CPGs do or do not contain QIs and explored the factors perceived by authors as either facilitating or hampering in the QI development process. METHODS: Semi-structured interviews were conducted with authors of 22 S3-CPGs, 11 of which represented guidelines containing QIs and 11 of which represented guidelines without QIs. Authors of guidelines containing QIs (n=11) were asked about the perceived decisive reasons for formulating QIs and about facilitators and barriers during the QI development process. Authors of guidelines without QIs (n=11) gave reasons for not formulating QIs. Interviews were analyzed using structuring qualitative content analysis. RESULTS: Within the MS program, not formulating QIs was mainly attributed to the lack of a mandatory requirement and to insufficient funding of guideline projects. Amongst DMGP authors, a low priority of QI development prevailed, which was, for example, due to already existing QIs or to their lacking implementation. In the GGPO guideline examined, not formulating QIs was due to the guideline topic (prevention) - for this topic, there was a lack of suitable evidence and data sources. If QIs were developed, the most important facilitating factor in the development process, across all programs, was the methodological support provided by the guideline program. Important hampering factors included the additional time required for QI development and concerns regarding the implementation of many potential QIs, especially due to a lack of data availability. DISCUSSION: For regular development of QIs within S3-CPG projects, the incorporation of such a requirement in the guideline program is a necessary, but not a sufficient, condition. Other pivotal factors include systematic methodological support, adequate financial and staff resources and the perceived meaningfulness and relevance of guideline-based QI development, measured in terms of the actual implementation of already existing QIs. CONCLUSION: The study reveals starting points for measures to strengthen the consideration of QI development in German S3-CPG projects, especially within the MS program. Without substantial structural changes, especially of the resources of guideline groups, and without an overall concept covering the entire process from QI development to QI implementation, guideline-based QI development will remain heavily dependent on the (self-)motivation of guideline groups.

[(How) Are quality indicators for measuring and appraising the quality of healthcare derived from evidence-based clinical practice guidelines? A review]. / (Wie) Erfolgt die Ableitung von Qualitätsindikatoren zur Messung und Bewertung der Versorgungsqualität im Rahmen von S3-Leitlinien? Eine Übersichtsarbeit.

BACKGROUND: Evidence-based and formally consensus-based clinical practice guidelines (CPGs) offer potential for the development of quality indicators (QIs). Although QIs are recommended as part of some CPGs, there is no accepted gold standard for the specific development process of guideline-based QIs. The purpose of this review, which is embedded in a mixed-methods research project, was to analyze the current state of methodological approaches for QI development in German CPGs to derive insights for the development of a national evidence-guided and consensus-based standard for guideline-based development of QIs. METHODS: In order to identify valid CPGs containing recommendations for QIs, a search was carried out (July 31, 2016) via the guideline database of the German Association of the Scientific Medical Societies (AWMF). Based on a stratified random sample per guideline program (guidelines published by medical societies, National Program for Disease Management Guidelines (DMG), and the German Guideline Program in Oncology [GGPO]), 11 CPGs were selected. With regard to QIs, the specific development methodology, indications on their psychometric properties and how the quality of care should be examined by recommended QIs were extracted and compared by using the guideline documents. RESULTS: In 35 of the 109 (16/85 medical societies, 4/8 DMG, 15/16 GGPO) (32 %) valid CPGs, a total of 372 QIs were recommended. Based on 11 randomly selected guidelines (5 published by medical societies, 1 DMG, 5 GGPO; a total of 109 QIs), the QI development methodology was inconsistent in all five medical societies guidelines (including QI presentation, usage and selection of guideline recommendations for QI derivation) compared to DMG and GGPO. Based on all 109 QIs, 2 (2 %) were presented as a quantitative measure with a reference range, and quality objectives were formulated for 17 (16 %). There was no guideline explicitly reporting about the results of a pilot study or data-based analysis of the psychometric properties of the recommended QIs. The GGPO guideline documents were the only ones providing information on the assessment of the quality of care based on recommended QIs. DISCUSSION: The usage of the QI manuals of the DMG and GGPO leads to a largely standardized development of guideline-based QIs. In the CPGs of the medical societies - if at all - QIs are developed inconsistently and mostly unsystematically. Due to largely missing reference ranges and quality objectives, the identified QIs cannot yet be used to transparently identify potential quality deficits in health care. This requires results of pilot studies and further development of guideline-based QI. CONCLUSIONS: A standard for QI development is needed for German guideline authors to seize the opportunity and develop clinically relevant, widely accepted and evidence-based QIs in the guideline development process. In addition, it must be ensured that appropriate structures are used or set up in order to be able to apply the recommended QIs in the German healthcare system.

[Increasing the efficiency of guideline production: a narrative review]. / Effizientere Leitlinienerstellung ­ eine narrative Übersichtsarbeit.

BACKGROUND: The development of high-quality clinical practice guidelines is laborious and time-consuming. New methods have become available to streamline this process. However, the awareness of these methods should be improved. METHODS: Selective literature search in PubMed/MEDLINE und Embase. RESULTS: Simple tools such as surveys or voting systems can facilitate the organization, planning and communication. Adequate methods should be used to prioritize all potential questions that should be addressed in the guideline. Published or ongoing international guidelines and systematic reviews can be used meaningfully for the planned guideline. In the case of guideline updates, it should be determined whether all parts of the guideline require an update of the evidence. The need for an update should be investigated. The concept of living guidelines has the biggest potential to provide gains in efficiency. Living guidelines are continuously updated based on new evidence instead of being regularly updated at a predefined time. CONCLUSIONS: New methods allowing for more efficient guideline production have been developed and, in part, already been introduced. Before starting with the production of a guideline (or its update), the potential advantages and disadvantages/risks of the corresponding methods should be balanced.

[The diagnostics of autism spectrum disorder in children, adolescents and adults: Overview of the key questions and main results of the first part of the German AWMF-S3 - clinical guideline]. / Diagnostik von Autismus- Spektrum-Störungen im Kindes-, Jugend- und Erwachsenenalter: Überblick zu den wesentlichen Fragestellungen und Ergebnissen des ersten Teils der S3-Leitlinie.

The diagnostics of autism spectrum disorder in children, adolescents and adults: Overview of the key questions and main results of the first part of the German AWMF-S3 - clinical guideline Abstract. Background: Autism spectrum disorders (ASD) include ICD-10 diagnoses of childhood autism, Asperger syndrome, and atypical autism; there is a lifetime prevalence of ~1 %. The aim of the evidence-based clinical guideline (AWMF-S3-Guideline) is to summarize the current evidence concerning diagnostic and therapeutic processes for professionals working in healthcare and social welfare and to provide consensus on clinical recommendations. The present study summarizes the most important results of the diagnostic part of this guideline. Method: The guideline group comprised 14 clinical and scientific expert associations from the German healthcare system, in addition to representatives of relatives and patients. Recommendations were based on results of a systematic literature search, data extraction, the evaluation of study quality, and, if possible, meta-analytic aggregation of included data in combination with the clinical expertise of the respective representatives. Consensus-based recommendations were determined via nominal group technique. Results: The AWMF-S3-Clinical Guideline, Diagnostic Part, summarizes current research on this topic. The main focus is put on the question of obligatory versus redundant diagnostic procedures. After a general introduction to the clinical picture of ASD, essential aspects like obtaining the medical history, the effective use of screening and diagnostic instruments, medical examination, the full diagnostic work-up as well as communicating the diagnostic results to relatives and patients are described in detail. We also conducted a meta-analysis on the stability of early diagnosis. Conclusion: This first part of the ASD guideline offers users the opportunity to inform themselves about the background of ASD as well as evidence-based and broadly consented information on the correct diagnostic process of ASD from infancy to adulthood.

[Barriers and facilitators for the development of sex/gender sensitive clinical practice guidelines: A qualitative interview study]. / Barrieren und Förderfaktoren für die Entwicklung von geschlechtersensiblen medizinischen Leitlinien ­ Eine qualitative Befragung.

INTRODUCTION: Sex and gender health research evaluates biological and psychosocial differences between women and men which can influence the development, progress and experience of diseases. However, despite the increasing body of evidence about relevant differences between women and men regarding healthcare, the prevention, management and treatment of many common diseases do not yet reflect the knowledge of sex/gender characteristics. Furthermore, in the development of clinical practice guidelines, which are a valuable tool for knowledge transfer between scientific evidence and healthcare, sex/gender factors are only rarely explicitly and systematically considered. The goal of the current study therefore is to identify barriers and facilitators for the consideration and integration of sex/gender differences into guidelines, to create a basis for potential solutions and tools to increase the development of sex/gender sensitive guidelines in the future. METHODS: Barriers and facilitators for the development of sex/gender sensitive guidelines were identified by conducting semi-structured interviews with twelve experts in national and international guideline development (guideline authors and coordinators), as well as gender experts (female: n=8). The selection of experts followed a purposeful sampling strategy and the interview data was analyzed using the qualitative content analysis according to Mayring. RESULTS: The views on barriers and facilitators were allocated to and summarized in five categories with ten subcategories. The identified barriers mainly addressed the increasing complexity of guidelines, the lack of availability and quality of sex/gender sensitive evidence, and the shortage of resources. In addition, barriers were identified in an individual/professional context, such as deficiencies in awareness/knowledge about relevant sex/gender differences. The results of facilitating factors showed that experts see political policies and standards from guideline organizations as support for the consideration of sex/gender factors in guideline development. CONCLUSION: The perspective of experts illustrates that besides organizational and political inventions, individual and social factors should also be addressed in order to achieve behavioral change.

[Simple guideline-oriented supportive tools in primary care: Effects on adherence to the S3/NV guideline unipolar depression]. / Niederschwellige leitlinienorientierte supportive Materialien (NILS) in der primärärztlichen Versorgung: Effekte auf die Orientierung an der S3/NV-Leitlinie Unipolare Depression.

Simple guideline-oriented supportive tools in primary care: Effects on adherence to the S3/NV guideline unipolar depression Objectives: Does the provision of supportive tools improve guideline-oriented recognition and treatment of patients with depression in primary care? METHODS: In a nested intervention study, as part of a larger epidemiological study program in German primary care, 46 randomly drawn practices received tools to facilitate identification and treatment decisions.Pre-post effects were compared to 42 matched control practices without intervention. RESULTS: The proportion of correctly identified depression cases was similar in the intervention (47.2%) and the control group (42.3%, p = 0.537). Compared to controls, practitioners in the intervention group rated their competence in case identification and treatment at post-intervention more positively (p = 0.016). No effects were observed regarding the usage of the tools, practitioners' attitudes towards national depression guidelines, and depression treatment procedures. CONCLUSIONS: Since provision of guideline-oriented tools did not improve recognition and quality of treatment, delineation of alternative strategies for enhanced guideline adherence in primary care for depression is warranted.

[Needs assessment to improve the applicability and methodological quality of a German S3 guideline]. / Bedarfsanalyse zur Verbesserung der Anwendbarkeit und methodischen Qualität einer S3-Leitlinie.

BACKGROUND: Clinical practice guidelines can change the practice in healthcare only if their recommendations are implemented in a comprehensive way. The German S3 guideline "Local Therapy of Chronic Wounds in Patients with Peripheral Vascular Disease, Chronic Venous Insufficiency, and Diabetes" will be updated in 2017. The emphasis here is on the guideline's validity, user-friendliness and implementation into practice. Therefore, the aim was to identify the improvements required in regard to the guideline's methods and content presentation. METHODS: The methodological approach used was the critical appraisal of the guideline according to established quality criteria and an additional stakeholder survey. Both were conducted between August and November 2016. The guideline and its related documents were reviewed independently by two researchers according to the criteria of the "Appraisal of Guidelines for Research and Evaluation" (AGREE-II). Published reviews and peer reviews by external experts and organisations were also taken into account. For the stakeholder survey, a questionnaire with open questions was distributed by e-mail and via the Internet to health professionals and organisations involved in the care of patients with leg ulcers in Germany. The questions were aimed at amendments and new topics based on the stakeholders' experience in inpatient and outpatient care. In addition, the survey focused on gathering suggestions to improve the applicability of the guideline. Suggested new topics and amendments were summarised thematically. The stakeholders' suggestions to improve the applicability, the results of the critical appraisal and the relevant aspects of the external reviews were then summarised according to the AGREE-II domains and presented in a cause and effect diagram. RESULTS: 17 questionnaires (out of 864 sent out by e-mail) were returned. Due to high practice relevance, the stakeholders suggested an expansion of the inclusion criteria to patients with infected wounds and pressure ulcers. They also proposed that plastic surgical procedures, several specific wound products and complementary measures should be included. The guideline is of high methodical quality with respect to the systematic synthesis and the formal expert recommendations. From both the stakeholders' and reviewers' perspectives, the guideline should be more in line with what guideline users regarded as key issues. The recommendations should be more action-oriented. Implementation concepts should be provided to teach, implement and evaluate the guideline in healthcare facilities. The updating process should also follow current standards for guideline development, for systematic reviews and for managing conflict of interests. CONCLUSION: The guideline is of high methodological quality but currently difficult to implement in clinical practice. The structured evaluation clearly reflects not only the potential for improvement but also provides a transparent theoretical framework for experts and scientific medical societies involved in the guideline updating process. Although some valuable insights were gained from the stakeholders' perspective, the representativeness is limited by the low response rate.

[How to develop Choosing Wisely recommendations for internal medicine]. / Praktisches Vorgehen bei der Entwicklung von "Klug-entscheiden"-Empfehlungen.

"Choosing Wisely" is an initiative of the German Society of Internal Medicine with the aim to provide recommendations for diagnostic and therapeutic procedures that are of clear medical and scientifically proven benefit, but are rather underused in daily practice. As such, these positive recommendations are indicative of an undersupply. On the other hand, the German Society of Internal Medicine also developed "negative recommendations", pointing out diagnostic and therapeutic procedures that are frequently used but for which there is little or no scientific evidence. They indicate oversupply. So far, the various internal medicine societies have each developed five positive and five negative recommendations, and there are more to come.

A guideline for adults with an indwelling urinary catheter in different health care Settings - methodological procedures / Eine institutionsübergreifende Leitlinie für erwachsene Personen mit Blasenkatheter ­ methodisches Vorgehen

Background: People with an indwelling urinary catheter often suffer from complications and health care professionals are regularly confronted with questions about catheter management. Clinical guidelines are widely accepted to promote evidence-based practice. In the literature, the adaptation of a guideline is described as a valid alternative to the development of a new one. Aim: To translate a guideline for the care for adults with an indwelling urinary catheter in the acute and long term care setting as well as for home care. To adapt the guideline to the Swiss context. Method: In a systematic and pragmatic process, clinical questions were identified, guidelines were searched and evaluated regarding clinical relevance and quality. After each step, the next steps were defined. Results: An English guideline was translated, adapted to the local context and supplemented. The adapted guideline was reviewed by experts, adapted again and approved. After 34 months and an investment of a total of 145 man working days, a guideline for the care for people with an indwelling urinary catheter is available for both institutions. Conclusions: Translation and adaptation of a guideline was a valuable alternative to the development of a new one; nevertheless, the efforts necessary should not be underestimated. For such a project, sufficient professional and methodological resources should be made available to achieve efficient guideline work by a constant team.

[Obligation of guideline recommendations: Perception survey among guideline developers]. / Verbindlichkeit von Empfehlungsformulierungen in Leitlinien: Survey zur Wahrnehmung unter Leitlinienentwicklern.

INTRODUCTION: Specific recommendations form the centerpiece of medical guidelines. The intended strength of a recommendation is usually expressed by the use of different wordings. Recent investigations showed that guideline users (recipients) interpret the binding character of wordings in different ways. The perception of different wording and their binding character of the strength of guideline recommendations among guideline developers (sender) have so far not been investigated in the German-speaking area. METHODS: German-speaking guideline developers were invited online and at specialist meetings to participate in a survey investigating 13 different terms used in guideline recommendations. The aim was to measure their perceived binding character on a visual analog scale (VAS: 0-100). Additional demographic and occupational data were collected. The results were compared with data from a previous survey among guideline users. RESULTS: Overall, 136 guideline developers with an average of 4.2 (median 3) guideline (co-) authorships participated in the survey. While guideline developers interpreted the two imperative recommendations "must" and "must not" with a similarly high level of obligation, the level of obligation was not rated homogenously for strong and weak recommendations like "shall" or "should". Two out of five negative formulations were perceived as more binding than their corresponding positive formulations. In comparisons with the ratings of the guideline users the terms "darf nicht" (must not), (-5.8 VAS, p≤0.0001) and "muss" (must), (-2.9 VAS, p≤0.0006) were perceived as less binding by the guideline developers, as was "sollte nicht"(should not) (-6.6 VAS, p≤0.0001) and "kann nicht empfohlen werden" (cannot be recommended) (-9.4 VAS, p≤0.0001). Only "soll" (shall) was perceived as more binding (+8.7 VAS, p≤0.0001). DISCUSSION: The current survey demonstrates that guideline developers perceive the binding character of terms used in guideline recommendations in a similar way as it was found for guideline users in a previous survey. Negative recommendations are more often rated as more binding by guideline developers as the corresponding positive terms. The discordant ratings by the guideline developers can be explained by their methodological knowledge regarding formulations of recommendations. It would be desirable that efforts be made to identify wordings in guidelines which better discriminate the intended level of obligation of guideline recommendations with regard to these results.

[The German Guideline Program in Oncology (GGPO): A central core of an evidence-based, patient-centered interdisciplinary oncology?]. / Das Leitlinienprogramm Onkologie (OL): Nukleus einer evidenzbasierten, patientenorientieren, interdisziplinären Onkologie?

In 2008, the German Guidelines Program in Oncology (GGPO) was launched to promote the development and updating of evidence-based multidisciplinary practice guidelines. This paper describes the organizational structures and methods as well as the embeddedness of the program within a comprehensive strategy to enhance quality of cancer care. Using the example of the German Cancer Plan we argue that the GGPO guidelines are not only an instrument to transfer and exchange knowledge, but also provide an important basis for further initiatives in the field of quality improvement. It is illustrated what was achieved in the first seven years of the GGPO and which challenges will dominate the next years.

[New Aspects and Controversies in the Current European and American Hypertension Guidelines]. / Die aktuellen europäischen und amerikanischen Hypertonie-Leitlinien.

At the end of 2013, the long-awaited guidelines of the Eighth Joint National Committee (JNC8) were published. These guidelines developed nine specific recommendations for the management of arterial hypertension. The harmonization of blood pressure treatment thresholds and goals represents a convenient simplification for the practicing physician. However, the recommendations did not come without controversy. Especially the raise of the treatment goal in patients aged 60 years or older was criticized. In this and other aspects, the 2013 guidelines of the European Society of Cardiology and European Society of Hypertension (ESC/ESH 2013) share a different point of view. The article tries to summarize the different viewpoints and to provide an overview over the increasing number of hypertension guidelines.