Appraisal of clinical practice guidelines on the management of obstetric perineal lacerations and care using the AGREE II instrument

Regional and clinical guidelines for prevention and care of obstetric anal sphincter injuries - A critical frame analysis

OBJECTIVE

Policy documents govern how the prevention and care of obstetric anal sphincter injuries (OASIS) are implemented. Thus, in the absence of Swedish national guidelines on OASIS, differing views may be visible in the regional and local policy documents. Therefore, we aimed to analyse regional and local policies, guidelines, and care programs on the prevention of OASIS and care for OASIS-affected women in a Swedish context by applying a critical frame analysis inspired by Verloo.

DESIGN AND SETTING

A cross-sectional study of existing policy documents from Swedish healthcare regions was performed. The documents were analysed using Verloo's critical frame analysis.

FINDINGS

We found that OASIS was framed as a preventable problem addressed by skilled protective manoeuvres of the healthcare staff. Education, communication, and teamwork were three frames of crucial solutions to minimise the prevalence of OASIS. However, complicating power dimensions between professional groups and between professionals and birthing women were identified. Furthermore, several discursive struggles were found, predominantly regarding the scientific evidence for the suggested prevention and care.

CONCLUSION

The policy documents emphasised that OASIS is preventable, and improved education, communication, and teamwork could diminish the OASIS prevalence. Nevertheless, power dimensions and discursive struggles may challenge the preventive efforts. Furthermore, each Swedish region has the sovereignty to develop its policies, which was reflected in our findings and may imply inequities in care provision. Thus, there is an urgent need to develop comprehensive national high-quality guidelines of high quality for OASIS prevention and care so that all women giving birth have access to equal care and treatment in Sweden.

A rapid systematic review of postpartum bladder care guidelines and recommendations in the context of the COVID-19 pandemic

New pathways for the management of postpartum voiding dysfunction and postpartum urinary retention should be considered to shorten hospital stays and promote early discharge during the COVID-19 pandemic. This rapid systematic review aimed to identify relevant national and international guidelines, and summarise available recommendations on postpartum bladder care that are relevant to women's care and management at the time of the pandemic. We searched Medline, Embase and Cochrane from inception till September 2021. Hand-searching of national and international specialist societies' websites was performed. We identified one international technical consultation, one international society's report of recommendations and two national guidelines. Guidelines stated that postnatal women should not be left more than 6 hours without voiding and assessed for postpartum urinary retention. As the cut-off of 150 ml for the diagnosis of significant postvoid residual volume is commonly used with no reported adverse outcomes, it could be beneficial to adopt this instead of 100 ml as further unnecessary interventions can be avoided. Such changes can reduce the number of women staying in the hospital. Clean intermittent self-catheterisation for the management of postpartum urinary retention could be considered as an option during the COVID-19 pandemic aiming to shorten hospital stays and avoid further attendances. Optimised bladder care has become more relevant during the coronavirus pandemic by striving towards self-care, community-based and remote care. We propose consideration of intermittent self-catheterisation in cases of postpartum urinary retention enabling self-care and avoidance of hospital visits.

Evaluation of the Quality of COVID-19 Guidance Documents in Anaesthesia using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) Instrument

Background

Methods

Results

Conclusions

Post-repair laxative management in obstetric anal sphincter injury guidelines: A narrative review

BACKGROUND

Childbirth is a common factor which increases the risk of obstetric anal sphincter injuries (OASIS). Damage to the anal sphincters increases the risk of anal incontinence, which has a debilitating impact on the quality of life. Post-repair laxatives are prescribed in this group of women. However, there is no consensus regarding the type or frequency with which they are used, and available guidelines lack consistency and evidence to support the recommendations.

AIM

The aim was to review and compare the international, national and local Australian management guidelines for recommendations regarding laxative use in women after OASIS.

METHOD

An online literature search of medical and nursing databases such as PubMed, Embase, MEDLINE, CINAHL, Web of Science, Scopus and Cochrane was performed between January 2000 and October 2020. Full-text articles with MeSH headings and Text Words [TW] identified guidelines in the prevention, management and care of OASIS. The search terms included 'obstetric anal sphincter injury', 'OASIS', 'perineal tear', 'postpartum continence', 'bowel injury', 'aperient', 'laxative use' and 'bulking agents'.

RESULTS

Thirteen guidelines were included. Laxatives were recommended in most guidelines; however, there was a lack of consistency regarding the type of laxative used, frequency, dose and duration of use. Guidelines were based on historical evidence, with paucity of recently acquired data identified.

CONCLUSIONS

There is no consensus regarding an optimal laxative regime for women who sustain an anal sphincter injury after childbirth. Further research is required to develop evidence-based robust clinical guidelines regarding laxative use in women who sustain OASIS.

Outcome reporting in randomized controlled trials (RCTs) on the pharmacological management of idiopathic overactive bladder (OAB) in women; a systematic review for the development of core outcome sets (COS)

Introduction and hypothesis

Evidence on OAB management remains suboptimal and methodological limitations in randomized control trials (RCTs) affect their comparability. High quality meta-analyses are lacking. This study aimed to compare selection and reporting of outcomes and outcome measures across RCTs as well as evaluate methodological quality and outcome reporting quality as a first stage in the process of developing core outcome sets (COS).

Methods

RCTs were searched using Pubmed, EMBASE, Medline, Cochrane, ICTRP and Clinicaltrials.gov from inception to January 2020, in English language, on adult women. Pharmacological management, interventions, sample size, journal type and commercial funding were documented. Methodological and outcome reporting quality were evaluated using JADAD and MOMENT scores.

Results

Thirty-eight trials (18,316 women) were included. Sixty-nine outcomes were reported, using 62 outcome measures. The most commonly reported outcome domains were efficacy (86.8%), safety (73.7%) and QoL (60.5%). The most commonly reported outcomes in each domain were urgency urinary incontinence episodes (UUI) (52.6%), antimuscarinic side effects (76.3%) and change in validated questionnaire scores (36.8%).

A statistically significant correlation was found between JADAD and MOMENT (Spearman’s rho = 0.548, p < 0.05) scores. This indicates that higher methodological quality is associated with higher outcome reporting quality.

Conclusions

Development of COS and core outcome measure sets will address variations and lead to higher quality evidence. We recommend the most commonly reported outcomes in each domain, as interim COS. For efficacy we recommend: UUI episodes, urgency and nocturia episodes; for safety: antimuscarinic adverse events, other adverse events and discontinuation rates; for QoL: OAB-q, PPBC and IIQ scores.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-05040-1.

A meta-synthesis of qualitative studies on stress urinary incontinence in women for the development of a Core Outcome Set: A systematic review

OBJECTIVE

Given the high variation of perceptions of women with stress urinary incontinence (SUI), qualitative meta-synthesis in this field appears warranted. We aimed to synthesize evidence on women's experiences of SUI by analyzing qualitative data.

METHODS

A literature search of Medline, Embase, Scopus, PsycInfo, and CINAHL databases was performed by a CHORUS Working Group, from inception to August 2020. Qualitative studies on women's perspectives on SUI were included. Thematic analysis was used as a conceptual approach to analyze the data and develop a set of overarching themes. The quality of studies was assessed based on the Critical Appraisal Skills Program tool.

RESULTS

Seven studies were included. Six themes encompassing women's perspectives on SUI emerged: experiencing SUI, awareness of SUI, treatments for SUI, sexuality, communication, and psychosocial effects. The quality appraisal of the studies showed good coherence.

CONCLUSION

This study revealed six overarching themes, of which treatment had the highest prevalence. Assessment of women's perceptions of SUI in the context of a qualitative meta-synthesis may inform policy and practice around this condition, may guide and help set research priorities, and will ideally contribute to the development of a Core Outcome Set for SUI.

Outcome reporting in trials on conservative interventions for pelvic organ prolapse: A systematic review for the development of a core outcome set

BACKGROUND

Significant risk of bias and limitations in outcome selections in trials evaluating conservative treatments for the management of Pelvic Organ Prolapse (POP) have been highlighted and preclude comparability of outcomes, synthesis of primary studies and high quality evidence.

OBJECTIVES

As systematic review of the reported outcomes is the first step in the process of development of a Core Outcome Set (COS), we aimed to systematically review reporting of outcomes and outcome measures in Randomised Control Trials (RCTs) on conservative treatments for POP and develop an inventory of them for consideration as core outcome and outcome measures sets. We evaluated methodological quality, outcome reporting quality and publication characteristics and their associations among published RCTs.

STUDY DESIGN

Systematic review of RCTs identified from the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE and MEDLINE (Pubmed). RCTs evaluating the effectiveness of conservative interventions for the management of POP were considered for inclusion. Outcomes and outcome measures were obtained from the RCTs and an inventory was created. Outcomes were grouped in domains and themes. Methodological quality, outcome reporting quality and publication characteristics were evaluated and statistically analysed.

RESULTS

Twenty-five trials (3179 women) were included and reported 31 outcomes and 50 outcome measures. Reporting rates of the outcomes investigated ranged between 4% and 56%. The most commonly reported outcome domains were patient reported symptoms, stage of POP expressed as POP-Q stage, and quality of life. Univariate analysis demonstrated no significant correlations of methodological and outcome reporting parameters.

CONCLUSIONS

There is a need to increase comparability of RCTs. Reporting standardized outcomes included in a COS for conservative interventions for POP will facilitate the comparability across RCTs. While the process of developing COS is in progress, we propose the interim use of the three most commonly reported outcomes in each domain: patient-reported outcomes (symptom distress including bowel and urinary symptoms, sexual function), stage of prolapse and quality of life parameters using validated questionnaires (Pelvic Floor Distress Inventory 20 (PFDI-20), Pelvic Floor Impact Questionnaire/Health related quality of life (PFIQ-7/HRQOL) and Pelvic Organ Prolapse Impact Questionnaire (POPIQ-7).

Systematic review and appraisal of clinical practice guidelines on pelvic organ prolapse using the AGREE II tool

AIMS

To systematically evaluate the content and quality of national and international clinical guidelines on pelvic organ prolapse (POP).

METHODS

We searched medical databases and organizations websites, to identify national and international guidelines on diagnosis and management of POP. Five authors independently assessed guidelines using the validated AGREE II tool. Its six domains include (1) scope and purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity of presentation, (5) applicability, and (6) editorial independence.

RESULTS

Eight guidelines met the inclusion criteria. Three hundred and thirteen different recommendations were identified. One hundred and ninety-nine recommendations were comparable across guidelines. Thirty-one recommendations were not supported by research evidence. Assessment by history and physical examination using the POP quantification system and consideration of imaging were recommendations featuring in all guidelines. Conservative treatment recommendations namely pelvic floor muscle training and vaginal pessaries were also found in all guidelines. Regarding surgical management, patient counseling, treating only symptomatic POP, consideration of apical fixation during surgical treatment, and use of biological or synthetic implants in recurrent cases were recommendations in all guidelines. Overall, the highest median scores were in the domains "scope and purpose" and "rigor of development". The lowest median score was for applicability (28.3%). Although the median score of "editorial independence" was high (85.4%), variability was also substantial (interquartile range: 12.5-100).

CONCLUSION

We identified variations in quality and deficiencies in certain areas, especially "applicability" and "editorial independence." Improvements in these key domains may enhance the quality and clinical impact of clinical practice guidelines.

Evaluation of clinical practice guidelines (CPG) on the management of female chronic pelvic pain (CPP) using the AGREE II instrument

Introduction and hypothesis

Variations in guidelines may result in differences in treatments and potentially poorer health-related outcomes. We aimed to systematically review and evaluate the quality of national and international guidelines and create an inventory of CPG recommendations on CPP.

Methods

We searched EMBASE and MEDLINE databases from inception till August 2020 as well as websites of professional organizations and societies. We selected national and international CPGs reporting on the diagnosis and management of female CPP. We included six CPGs. Five researchers independently assessed the quality of included guidelines using the AGREE II tool and extracted recommendations.

Results

Two hundred thirty-two recommendations were recorded and grouped into six categories: diagnosis, medical treatment, surgical management, behavioural interventions, complementary/alternative therapies and education/research. Thirty-nine (17.11%) recommendations were comparable including: a comprehensive pain history, a multi-disciplinary approach, attributing muscular dysfunction as a cause of CPP and an assessment of quality of life. Two guidelines acknowledged sexual dysfunction associated with CPP and recommended treatment with pelvic floor exercises and behavioural interventions. All guidelines recommended surgical management; however, there was no consensus regarding adhesiolysis, bilateral salpingo-oophorectomy during hysterectomy, neurectomy and laparoscopic uterosacral nerve ablation. Half of recommendations (106, 46.49%) were unreferenced or made in absence of good-quality evidence or supported by expert opinion. Based on the AGREE II assessment, two guidelines were graded as high quality and recommended without modifications (EAU and RCOG). Guidelines performed poorly in the “Applicability”, “Editorial Independence” and “Stakeholder Involvement” domains.

Conclusion

Majority of guidelines were of moderate quality with significant variation in recommendations and quality of guideline development.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04848-1.

Evaluation of guidelines on the use of vaginal mesh implants for pelvic organ prolapse using the AGREE II instrument

OBJECTIVE

To systematically evaluate the content and quality of national and international guidelines on vaginal mesh procedures for pelvic organ prolapse (POP).

METHODS

We searched PubMed, Medline, Web of Science, and ScienceDirect from inception to March 2020 and organizations' websites. The quality of the guidelines was assessed independently by six appraisers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

RESULTS

Five guidelines were included. Most guidelines recommended individualized treatments, clinical observation, and conservative treatment for asymptomatic women discouraging the use of mesh. Vaginal pessary and pelvic floor muscle training are unanimously considered effective treatments. Only two guidelines recommended weight loss. Each guideline recommended patient counseling supported by data on success rates and complications. Most guidelines highlighted the importance of a specialist experienced surgeon, multidisciplinary teams, and national/international registries. All guidelines highlighted potential benefits of the use of mesh and reported possible complications. The overall quality rating ranged between 4.2 and 6.3, suggestive of moderate to high quality. The highest mean score (92.5%) pertained to "Scope and Purpose" and "Clarity of Presentation", and the lowest to "Editorial Independence" (18%). Three out of five guidelines were "strongly recommended" by the appraisers.

CONCLUSION

Although most guidelines were of moderate to high quality, methodological applicability, stakeholder involvement, and editorial independence were domains with low scores.

Clinical practice guidelines for the nutritional risk screening and assessment of cancer patients: a systematic quality appraisal using the AGREE II instrument

PURPOSE

To evaluate the quality of published clinical practice guidelines (CPGs) regarding the nutritional risk screening and assessment of cancer patients and to identify high-quality CPGs for clinical healthcare professionals.

METHODS

Guidelines for the nutritional risk screening and assessment of cancer patients were comprehensively searched in eight electronic databases, including The Lancet, PubMed, Cochrane Library, Excerpta Medica dataBASE (EMBASE), Web of Science, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBMdisc), and Wan Fang Data, through August 2020. Six relevant guideline databases, including the National Comprehensive Cancer Network (NCCN), the National Guideline Clearinghouse (NGC), the Guideline International Network (GIN), the New Zealand Guidelines Group (NZGG), the China Guideline Clearinghouse (CGC), and Medlive, and relevant nutrition society websites, were also searched through August 2020. The methodological quality of the included CPGs was appraised independently by three assessors using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II) tool.

RESULTS

Seven CPGs were located, and the domain with the highest percentage was "clarity of presentation" (85.44%), while the domain with the lowest percentage was "applicability" (40.26%). From the AGREE II results, two guidelines were rated as "strongly recommended," three were assessed as "recommended with modifications," and two were deemed as "not recommended."

CONCLUSION

Considering that the two "strongly recommended" guidelines were developed within the American and European contexts, translation, validation, and cultural adaptation are recommended prior to implementing these guidelines in other countries or healthcare contexts to improve their effectiveness and sensitivity for local cancer patients.

TRIAL REGISTRATION

PROSPERO registration of the study protocol: CRD42020177390 (July 5, 2020).

Review of available national guidelines for obstetric anal sphincter injury

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injuries (OASIs) are the most severe form of perineal trauma with potentially devastating effects on a mother's quality of life. There are various national guidelines available for their management. The aim of this study was to review and compare recommendations from published national guidelines regarding management and prevention of OASI.

METHODS

We searched the PUBMED, EMBASE, MEDLINE, CINAHL and COCHRANE databases from January 2008 till October 2019 using relevant Medical Subject Headings (MeSH), including all subheadings. The guideline characteristics were mapped and methodological quality assessed with the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool by three independent reviewers. To compare the methodological quality of the guidelines, the interpretation of the six domain scores were taken into consideration. By consensus of the authors, a score of 70% was taken as a cut-off, and scores above this were considered 'high quality'.

RESULTS

Thirteen national guidelines on perineal trauma were included and analysed. Nine of these were specific to OASI. There is wide variation in methodological quality and evidence used for recommendations. AGREE scores for overall guideline assessment were > 70% in eight of the guidelines, with Australia-Queensland, Canada, the UK and USA scoring highest.

CONCLUSIONS

The wide variation in methodological quality and evidence used for recommendations suggests that there is a need for an agreed international guideline. This will enable healthcare practitioners to follow the same recommendations, with the most recent evidence, and provide evidence-based care to all women globally.