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AAN Systematic Review and Guideline Development Process

The Guideline Development Subcommittee (GDS) follows a well-defined process for the development of an evidence-based guideline, starting from an evidence-based systematic review. The AAN process is designed to rigorously evaluate the strength of the evidence and formulate explicit practice recommendations to improve patient outcomes. Each systematic review and practice guideline is the culmination of the generous donation of time, energy, and expertise of topic experts and methodology experts and is made possible by financial support from the AAN.

Full process

Access the 2011 AAN Guidelines Process Manual and recently approved amendments:

Suggested citation: American Academy of Neurology. 2011. Clinical Practice Guideline Process Manual, 2011 ed. St. Paul, MN: The American Academy of Neurology.

Process summary

The following stages make up the AAN systematic review and guideline development process:

Select guideline topic
AAN members, committees, and sections are encouraged to submit guideline topic nominations at any time. To submit a topic nomination to the GDS, download the template and email the completed document to guidelines@aan.com. For your reference, a sample proposal on Huntington’s disease can be downloaded. Nominations are reviewed quarterly and can be emailed to guidelines@aan.com at any time.

GDS members review nominated topics on the basis of the following criteria:

  • AAN members' needs
  • Prevalence of condition
  • Health impact of condition for the individual and others
  • Socioeconomic impact
  • Extent of practice variation
  • Quality of available evidence
  • External constraints on practice
  • Urgency for evaluation of new practice technology
Form a systematic review author panel

When a guideline topic is selected, the GDS selects a lead author and forms an author panel without conflicts. Patients and patient advocates are also considered panel members.

Develop clinical questions

Each guideline should address one or more specific, answerable clinical questions. A clinical question should have the following three basic components:

  • The type of patient
  • The type of exposure that the patient experiences (risk factor, intervention, diagnostic test)
  • A comparator exposure
  • The outcomes to be addressed
Draft the protocol and submit for public comment

When the panel has been formed and the clinical questions identified, the panel must write a draft protocol, including the following sections:

  • Introduction to the topic
  • Background information and justification for pursuing the topic
  • Panel formation
  • Clinical questions
  • Proposed search strategy
  • Conflicts of interest
Review the literature

The author panel critically assesses the topic through analysis of the medical literature. MEDLINE, EMBASE, and other pertinent databases are searched. Panel members review the identified articles on the basis of a priori inclusion and exclusion criteria and pertinence to the topic as drafted in the protocol. Selected articles are rated on the basis of quality of study design.

Summarize the evidence

The author panel reviews the articles selected for inclusion, classifies them according to the AAN methodology, and summarizes the evidence as a systematic review. Upon initial approval of the summarization of the evidence from the GDS, the manuscript will be made available for public comment.

Hold second public comment period (systematic review)

When the systematic review has been drafted, the AAN will post the manuscript online at www.aan.com for 30 days. AAN members, nonmembers, patients, industry, professional medical societies, and other members of the public are able to review and comment on the draft document. The response form seeks qualitative and quantitative responses regarding the following:

  • The perceived overall value of the systematic review
  • Clarity of the systematic review and suggestions for improvement
  • Timeliness of the systematic review and suggestions for improvement
  • Importance of the clinical questions addressed and suggestions for improvement
  • Comprehensiveness of the literature review and suggestions for additional data to be analyzed and included
  • Clarity and conciseness of conclusions and suggestions for improvement
  • Format of the systematic review and suggestions for improvement
Obtain AAN approval

Following the systematic review public comment period, the manuscript must receive approval from the GDS, the AAN Practice Committee, and the AAN Board of Directors.

Write the guideline

Members of the GDS and authors of the systematic review will determine whether there is enough evidence to support the development of a clinical practice guideline. If guideline development is approved, the following steps take place.

Form a guideline author panel

When the GDS approves the topic, the Subcommittee selects a lead author without conflicts and forms an author panel wherein at least more than half of the panel members do not have conflicts. Patients and patient advocates are also considered panel members.

Develop the recommendations

Authors of the guideline take the evidence into account when developing the recommendations, but through a modified form of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, now also consider the following:

  • Clinical importance of an effect
  • Variation in patient preferences
  • Cost
  • Availability
  • Feasibility
  • Value of benefit relative to the risk
  • Confidence in the evidence
  • Strength of principle-based inferences
  • Evidence from other, related, conditions
  • Deductive inferences from other premises

Read the Elements of Recommendations

Hold guideline public comment period

When the guideline has been drafted, the AAN will post the manuscript online at www.aan.com for 30 days. AAN members, nonmembers, patients, insurance and pharmaceutical companies, other professional medical societies, and other members of the public are able to review and comment on the draft document. The response form seeks qualitative and quantitative responses regarding the following:

  • The perceived overall value of the guideline
  • Clarity of the guideline and suggestions for improvement
  • Timeliness of the guideline and suggestions for improvement
  • Clarity and conciseness of recommendations and suggestions for improvement
  • Format of the guideline and suggestions for improvement
Obtain AAN approval

Before being published as an AAN evidence-based guideline, the manuscript must receive approval from the GDS, the AAN Practice Committee, Neurology, and the AAN Board of Directors.

Updating AAN systematic reviews and guidelines

Guidelines are updated or affirmed every two years or earlier on the basis of the availability of new evidence. As of 2012, AAN systematic reviews and guidelines include the projected date when the document will be formally reviewed and considered for update or affirmation of currency.

* All AAN guideline authors are required to complete the AAN Conflict of Interest Reporting Form. AAN staff, the systematic review and guideline leadership, and the GDS leadership review the completed forms and manage conflicts of interest by balancing the panel, limiting and potentially preventing participation, and providing strong oversight. In addition, the following paragraphs are included in every AAN systematic review and guideline.

Systematic review

The American Academy of Neurology is committed to producing independent, critical, and truthful systematic reviews (SR). Significant efforts have been made to minimize the potential for conflicts of interest to influence the conclusions of this SR. The AAN has gone to significant lengths to keep separate those who have a financial stake in the success or failure of the products appraised in the SRs. Conflict of interest forms were obtained from all authors and reviewed by the process outlined in the AAN Guideline Development Process Manual prior to initiation of this document. The AAN forbids commercial participation in, or funding of, guideline projects. Drafts of the review protocol and the full systematic review have been submitted for public comment period whereby individuals provided critique, criticism, and suggestions to improve the development of this SR.

Clinical practice guidelines

The American Academy of Neurology is committed to producing independent, critical, and truthful clinical practice guidelines (CPGs). Significant efforts have been made to minimize the potential for conflicts of interest to influence the recommendations of this CPG. To the extent possible, the AAN keeps separate those who have a financial stake in the success or failure of the products appraised in the CPGs and the developers of the guidelines Conflict of interest forms were obtained from all authors and reviewed by the process outlined in the AAN Guideline Development Process Manual prior to initiation of this document. The AAN forbids commercial participation in, or funding of, guideline projects. The penultimate draft of this CPG was submitted for a 30-day public comment period whereby individuals provided critique, criticism, and suggestions to improve the development of this CPG.

Publication disclaimers

Clinical practice guidelines, practice advisories, systematic reviews and other guidance published by the American Academy of Neurology and its affiliates are assessments of current scientific and clinical information provided as an educational service. The information: 1) should not be considered inclusive of all proper treatments, methods of care, or as a statement of the standard of care; 2) is not continually updated and may not reflect the most recent evidence (new evidence may emerge between the time information is developed and when it is published or read); 3) addresses only the question(s) specifically identified; 4) does not mandate any particular course of medical care; and 5) is not intended to substitute for the independent professional judgment of the treating provider, as the information does not account for individual variation among patients. In all cases, the selected course of action should be considered by the treating provider in the context of treating the individual patient. Use of the information is voluntary. AAN provides this information on an “as is” basis, and makes no warranty, expressed or implied, regarding the information. AAN specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. AAN assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.

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