Table 1 Overview of the various steps included in the adaptation process

1

Selection of a guideline topic from the database of EBM Guidelines

From the database of more than 1000 EBM Guidelines a shortened list was generated from which GP-trainees could select a topic. This list was designed to prevent GP-trainees from choosing unsuited topics based on relevance for primary care and availability of trustworthy evidence

2

Identification and framing of the health questions addressed in the EBM Guideline

EBM Guidelines do not provide a list of addressed health questions. We therefore instructed GP-trainees to identify them based on the recommendations formulated by EBM Guidelines. We also instructed them to frame the health question using the PICO or PIPOH format

3

Performing a literature search, including source CPGs

GP-trainees were instructed to perform a literature search for source CPGs on the guideline topic

4

Assessment of the quality of source CPGs using the AGREE II instrument and selection of one or more source CPGs based on this assessment

Each of the source CPGs was assessed for quality using the AGREE II instrument [12]. Only those source CPGs rated as high quality using this instrument were considered as source CPG for further adaptation

5

Identification of recommendations in the source CPGs

For each source CPG, all recommendations related to the formulated health questions were inventoried in the matrix

6

Assessment of currency, consistency and applicability of recommendations in the source CPGs

All of the inventoried recommendations were assessed for currency, consistency and applicability. A literature search for more recent primary studies not included in the evidence review of the source CPG was performed to assess whether the recommendations were sufficiently up to date. Additionally, for each recommendation an evaluation of the consistency between the recommendation and the cited evidence was made. Finally, based on own experience and knowledge of the healthcare system, an assessment of the local applicability of the recommendation was made

7

Formulating (adapted) recommendations based on the results of the previous step and grading of the recommendations

Based on the previous assessments, recommendations from the source CPGs were either adopted without changes, adapted with changes or omitted. GP-trainees graded the evidence and the recommendations using GRADE.

8

Comparison of the newly formulated (adapted) recommendation with the recommendations in the EBM Guideline

These recommendations (adapted from source CPGs) were then compared with the recommendations formulated by EBM Guidelines. Any inconsistencies were documented including the underlying rationale

9

Proposal of amendments to recommendations in the EBM Guideline based on the comparison

When GP-trainees encountered inconsistencies between their adapted recommendations and the recommendations in the EBM Guideline, they were instructed to propose an amendment to the EBM Guideline. Inconsistencies due to new evidence or flaws in the evidence review were relayed back to the editorial board of EBM Guidelines. Inconsistencies due to applicability, differences in practice, preferences or regulations resulted in an amended recommendation on the EBPracticeNet website.

10

Implementation of the (adapted) recommendation and evaluate the implementation as part of a quality improvement strategy

GP-trainees were instructed to evaluate the applicability and implementability of the (adapted) recommendations through a quality improvement strategy. The purpose for this task was to provide more information on the applicability of the recommendations and to document barriers or facilitators to adherence to the recommendations. Sometimes this step resulted in an amendment to the recommendations to improve applicability