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We finally excluded from the analysis four items (B13-B16, Additional File ), as they were deemed to be more related to guideline development.We assessed the guideline-updating process of responding institutions by comparing the number of years developing CPGs (≤ 10 years of experience or 10 years of experience), contact source, and number of guidelines published per year using Fisher's exact test (alpha was set at 0.05).Clinical practice guidelines (CPGs) have become increasingly popular, and the methodology to develop guidelines has evolved enormously.However, little attention has been given to the updating process, in contrast to the appraisal of the available literature.

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Thirty-six institutions (92%) reported that they update their guidelines.Following these objectives, a common methodology for producing, implementing , and updating CPGs has been developed [].Within this context, we conducted an international survey with the aim of identifying current practices in guideline updating, exploring the need for standardization, and, ultimately, improving the guideline-updating process.We calculated absolute frequencies and proportions for all items.We evaluated nonresponding institutions and compared their contact source (Guidelines International Network, National Guideline Clearinghouse, or expert committee), country, and number of CPGs produced with responding institutions using Fisher's exact test or Mann-Whitney U test (alpha was set at 0.05).We sent an email to each institution through the address identified via the internet.

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