When is good, good enough? Methodological pragmatism for sustainable guideline development.

Background: Continuous escalation in methodological and procedural rigor for evidence-based processes in guideline development is associated with increasing costs and production delays that threaten sustainability. While health research methodologists are appropriately responsible for promoting increasing rigor in guideline development, guideline sponsors are responsible for funding such processes.
Discussion: This paper acknowledges that other stakeholders in addition to methodologists should be more involved in negotiating trade-offs between methodological procedures and efficiency in guideline production to produce guidelines that are 'good enough' to be trustworthy and affordable under specific circumstances. The argument for reasonable methodological compromise to meet practical circumstances is consistent with current implicit methodological practice. This paper proposes a conceptual tool as a framework to be used by different stakeholders in negotiating, and explicitly reporting, reasonable compromises for trustworthy as well as cost-worthy guidelines. The framework helps fill a transparency gap in how methodological choices in guideline development are made. The principle, 'when good is good enough' can serve as a basis for this approach. The conceptual tool 'Efficiency-Validity Methodological Continuum' acknowledges trade-offs between validity and efficiency in evidence-based guideline development and allows for negotiation, guided by methodologists, of reasonable methodological compromises among stakeholders. Collaboration among guideline stakeholders in the development process is necessary if evidence-based guideline development is to be sustainable.