Methods underpinning national clinical guidelines for hypertension: describing the evidence shortfall

Postpartum care indications and methodological quality:a systematic review of guidelines

Background

The coverage of postpartum care is not ideal, and has not been used very well due to not enough attention being paid to the puerperal women and newborns, especially in developing countries. Practice guidelines on postpartum care provide beneficial practice guidance and help to reduce maternal mortality. However, little is known about the credibility and consistency of those guidelines. This systematic review was conducted to summarize main postpartum care indications and appraise methodological quality of guidelines.

Methods

Seven literature databases and guideline development institutions and organizations of obstetrics and maternity care were searched. Two reviewers independently assessed guideline quality using the AGREE II instrument, and synthesized consistent and non-consistent recommendations using the content analysis approach.

Results

Twenty-nine guidelines were included and a total of eight postpartum care indications were identified. Most guidelines focused on care indications and interventions including exclusive breastfeeding, maternal nutrition, home visit, infant or newborn care and sexuality, contraception, and birth spacing. However, indications such as pain or weight management, pelvic floor muscle training, abdominal rehabilitation, and mental health got less attention. Additionally, the overall quality of all involving postpartum care guidelines is relatively good and acceptable.

Conclusions

Guidelines developed by NICE, RANO, and WHO indicated higher methodological quality. For postpartum care indications, most guidelines are incomplete. Variation in practice guidelines for postpartum care recommendations exists. In the future, implementation research into shared decision-making, as well as further high-quality research to broaden the evidence base for postpartum care indications is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-021-01629-4.

Methods for the evaluation of biomarkers in patients with kidney and liver diseases: multicentre research programme including ELUCIDATE RCT

Background

Protein biomarkers with associations with the activity and outcomes of diseases are being identified by modern proteomic technologies. They may be simple, accessible, cheap and safe tests that can inform diagnosis, prognosis, treatment selection, monitoring of disease activity and therapy and may substitute for complex, invasive and expensive tests. However, their potential is not yet being realised.

Design and methods

The study consisted of three workstreams to create a framework for research: workstream 1, methodology – to define current practice and explore methodology innovations for biomarkers for monitoring disease; workstream 2, clinical translation – to create a framework of research practice, high-quality samples and related clinical data to evaluate the validity and clinical utility of protein biomarkers; and workstream 3, the ELF to Uncover Cirrhosis as an Indication for Diagnosis and Action for Treatable Event (ELUCIDATE) randomised controlled trial (RCT) – an exemplar RCT of an established test, the ADVIA Centaur® Enhanced Liver Fibrosis (ELF) test (Siemens Healthcare Diagnostics Ltd, Camberley, UK) [consisting of a panel of three markers – (1) serum hyaluronic acid, (2) amino-terminal propeptide of type III procollagen and (3) tissue inhibitor of metalloproteinase 1], for liver cirrhosis to determine its impact on diagnostic timing and the management of cirrhosis and the process of care and improving outcomes.

Results

The methodology workstream evaluated the quality of recommendations for using prostate-specific antigen to monitor patients, systematically reviewed RCTs of monitoring strategies and reviewed the monitoring biomarker literature and how monitoring can have an impact on outcomes. Simulation studies were conducted to evaluate monitoring and improve the merits of health care. The monitoring biomarker literature is modest and robust conclusions are infrequent. We recommend improvements in research practice. Patients strongly endorsed the need for robust and conclusive research in this area. The clinical translation workstream focused on analytical and clinical validity. Cohorts were established for renal cell carcinoma (RCC) and renal transplantation (RT), with samples and patient data from multiple centres, as a rapid-access resource to evaluate the validity of biomarkers. Candidate biomarkers for RCC and RT were identified from the literature and their quality was evaluated and selected biomarkers were prioritised. The duration of follow-up was a limitation but biomarkers were identified that may be taken forward for clinical utility. In the third workstream, the ELUCIDATE trial registered 1303 patients and randomised 878 patients out of a target of 1000. The trial started late and recruited slowly initially but ultimately recruited with good statistical power to answer the key questions. ELF monitoring altered the patient process of care and may show benefits from the early introduction of interventions with further follow-up. The ELUCIDATE trial was an ‘exemplar’ trial that has demonstrated the challenges of evaluating biomarker strategies in ‘end-to-end’ RCTs and will inform future study designs.

Conclusions

The limitations in the programme were principally that, during the collection and curation of the cohorts of patients with RCC and RT, the pace of discovery of new biomarkers in commercial and non-commercial research was slower than anticipated and so conclusive evaluations using the cohorts are few; however, access to the cohorts will be sustained for future new biomarkers. The ELUCIDATE trial was slow to start and recruit to, with a late surge of recruitment, and so final conclusions about the impact of the ELF test on long-term outcomes await further follow-up. The findings from the three workstreams were used to synthesise a strategy and framework for future biomarker evaluations incorporating innovations in study design, health economics and health informatics.

Trial registration

Current Controlled Trials ISRCTN74815110, UKCRN ID 9954 and UKCRN ID 11930.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 3. See the NIHR Journals Library website for further project information.

Appraisal of clinical practice guidelines on the management of hypothyroidism in pregnancy using the Appraisal of Guidelines for Research and Evaluation II instrument

PURPOSE

This study aimed to systematically evaluate the quality of guidelines for the management of hypothyroidism in pregnancy.

METHOD

Systematic searches were conducted to identify hypothyroidism in pregnancy guidelines published in electronic databases and developers' websites. Four reviewers independently evaluated eligible guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Agreement among reviewers was measured using the intraclass correlation coefficient (ICC). The number of recommendations, strength of recommendations, and levels of evidence were determined. The software used for analysis was SPSS version 12.0.

RESULTS

Nine guidelines met the inclusion criteria and were appraised. The scope and purpose (65%) and clarity of presentation (70%) domains achieved relatively high scores, whereas the stakeholder involvement (41%), rigor of development (33%), applicability (36%), and editorial independence (31%) domains yielded low scores. The American Thyroid Association (ATA) guideline ranked the highest, whereas the 2012 Chinese Society of Endocrinology (CSE) guideline ranked the lowest among all the guidelines. The British Thyroid Association (BTA) and ATA guidelines were strongly recommended as dependable and helpful references to aid clinical decisions for medical providers, whereas the CSE guideline was not recommended. Most recommendations of the guidelines were relatively consistent. However, the nine guidelines varied with respect to their recommendations on thyroid scanning, dose of levothyroxine (L-T4) treatment, and target thyroid-stimulating hormone(TSH) level of L-T4 therapy.

CONCLUSIONS

The quality of the guidelines on the management of hypothyroidism in pregnancy is highly variable. Additionally, these guidelines need significant improvement, especially in the rigor of development and applicability domains. Some improvements should be made to promote the development and implementation of guidelines, for example, conducting a comprehensive search strategy to include more potential evidence and establishing a standard grading system to evaluate the quality of evidence.

International Variation in Asthma and Bronchiolitis Guidelines

BACKGROUND AND OBJECTIVES

Guideline recommendations for the same clinical condition may vary. The purpose of this study was to determine the degree of agreement among comparable asthma and bronchiolitis treatment recommendations from guidelines.

METHODS

National and international guidelines were searched by using guideline databases (eg, National Guidelines Clearinghouse: December 16-17, 2014, and January 9, 2015). Guideline recommendations were categorized as (1) recommend, (2) optionally recommend, (3) abstain from recommending, (4) recommend against a treatment, and (5) not addressed by the guideline. The degree of agreement between recommendations was evaluated by using an unweighted and weighted κ score. Pairwise comparisons of the guidelines were evaluated similarly.

RESULTS

There were 7 guidelines for asthma and 4 guidelines for bronchiolitis. For asthma, there were 166 recommendation topics, with 69 recommendation topics given in ≥2 guidelines. For bronchiolitis, there were 46 recommendation topics, with 21 recommendation topics provided in ≥2 guidelines. The overall κ for asthma was 0.03, both unweighted (95% confidence interval [CI]: -0.01 to 0.07) and weighted (95% CI: -0.01 to 0.10); for bronchiolitis, it was 0.32 unweighted (95% CI: 0.16 to 0.52) and 0.15 weighted (95% CI: -0.01 to 0.5).

CONCLUSIONS

Less agreement was found in national and international guidelines for asthma than for bronchiolitis. Additional studies are needed to determine if differences are based on patient preferences and values and economic considerations or if other recommendation-level, guideline-level, and condition-level factors are driving these differences.

Tools for assessing the content of guidelines are needed to enable their effective use--a systematic comparison

Background

To ensure that clinical practice guidelines (CPGs) form a sound basis for decision-making in health care, it is necessary to be able to reliably assess and ensure their quality. This results in the need to assess the content of guidelines systematically, particularly with regard to the validity of their recommendations.

The aim of the present analysis was to determine the suitability and applicability of frequently used assessment tools for evidence syntheses with regard to the assessment of guideline content.

Methods

We conducted a systematic comparison and analysis of established tools for the assessment of evidence syntheses (guidelines, systematic reviews, health technology assessments). The tools analyzed were: ADAPTE, AGREE II, AMSTAR, GLIA and the INAHTA checklist. We analyzed methodological steps related to the assessment of the reliability and validity of guideline recommendations. Data were extracted and analyzed by two persons independently of one another.

Results

Widely used tools for the methodological assessment of evidence syntheses are not suitable for a comprehensive content-related assessment. They remain mostly at the level of assessment of the documentation of processes. Some tools assess selected content-related aspects, but operationalization is either unspecific or lacking.

Conclusion

None of the tools analyzed enables the structured and comprehensive assessment of the content of guideline recommendations with special regard to their reliability and validity. All tools contribute towards the judicious use of evidence syntheses by supporting their systematic development or assessment. However, further progress is needed, particularly with regard to the assessment of content quality. This includes comprehensive operationalization and documentation of the assessment process to ensure reliability and validity, and therefore to enable the effective use of trustworthy guidelines in the health care system.

Electronic supplementary material

The online version of this article (doi:10.1186/1756-0500-7-853) contains supplementary material, which is available to authorized users.

Guidelines for therapeutic drug monitoring of vancomycin: a systematic review

BACKGROUND AND OBJECTIVE

Despite the availability of clinical practice guidelines (CPGs) for therapeutic drug monitoring (TDM) of vancomycin, vancomycin serum concentrations still do not reach therapeutic concentrations in many patients. Thus, we sought to systematically review the quality and consistency of recommendations for an international cohort of CPGs regarding vancomycin TDM.

METHODS

PubMed, Embase, guidelines' websites and Google were searched for CPGs for vancomycin TDM. Two independent assessors rated the quality of each CPG using the Appraisal of Guidelines for Research & Evaluation II (AGREEII) instrument and data were independently extracted.

RESULTS

Twelve guidelines were evaluated and the overall quality of guidelines for vancomycin TDM was moderate. The highest score was recorded in the domain of clarity of presentation, and the lowest score was recorded in the domain of rigor of development and stakeholder involvement. The specific recommendations for vancomycin TDM were moderately consistent and guidelines varied in trough concentration monitoring, frequency of TDM, and serum concentration targets.

CONCLUSION

The overall guideline quality for vancomycin TDM was not optimal and effort is needed to improve guideline quality, especially in the domain of rigor of development and stakeholder involvement.

Systematic review of clinical practice guidelines in the diagnosis and management of thyroid nodules and cancer

BACKGROUND

Given the uncertainties regarding thyroid nodule assessment and management, physicians require systematically and transparently developed recommendations. This systematic review assesses the quality and consistency of the recommendations of international clinical practice guidelines (CPGs) for the diagnosis and management of thyroid nodules and cancer to assist physicians in making appropriate recommendations.

METHODS

The CPGs on the management of thyroid nodules and cancer published before June 2013 were retrieved. All the reviewed guidelines were in English. Four reviewers independently assessed the rigor of guideline development by using the Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument, and their reported evidence was evaluated.

RESULTS

Ten eligible guidelines were included: nine had been developed by professional organizations, and the remaining guideline was endorsed by an independent regional body. Three guidelines achieved a score of greater than 50% in all six AGREE-II domains. Guidelines scored highest on the measurement of 'scope and purpose' (≥61.1% for eight CPGs) and lowest on the measurement of 'applicability' (≤38.5% for five CPGs). The overall quality ranged from 3.0 to 6.25 on a seven-point scale on the AGREE-II tool. Most CPG recommendations on the management of thyroid cancer were relatively consistent. Guidelines varied regarding the indication of fine-needle aspiration for thyroid nodules, as well as in their suggestions for postoperative radioiodine ablation.

CONCLUSIONS

Our analysis showed that the current CPGs varied in methodological quality. More effort is needed to improve the quality of recommendations on the diagnosis and management of thyroid nodules and cancer.

A systematic review of recent clinical practice guidelines on the diagnosis, assessment and management of hypertension

BACKGROUND

Despite the availability of clinical practice guidelines (CPGs), optimal hypertension control is not achieved in many parts of the world; one of the challenges is the volume of guidelines on this topic and their variable quality. To systematically review the quality, methodology, and consistency of recommendations of recently-developed national CPGs on the diagnosis, assessment and the management of hypertension.

METHODOLOGY/PRINCIPAL FINDINGS

MEDLINE, EMBASE, guidelines' websites and Google were searched for CPGs written in English on the general management of hypertension in any clinical setting published between January 2006 and September 2011. Four raters independently appraised each CPG using the AGREE-II instrument and 2 reviewers independently extracted the data. Conflicts were resolved by discussion or the involvement of an additional reviewer. Eleven CPGs were identified. The overall quality ranged from 2.5 to 6 out of 7 on the AGREE-II tool. The highest scores were for "clarity of presentation" (44.4%-88.9%) and the lowest were for "rigour of development" (8.3%-30% for 9 CGPs). None of them clearly reported being newly developed or adapted. Only one reported having a patient representative in its development team. Systematic reviews were not consistently used and only 2 up-to-date Cochrane reviews were cited. Two CPGs graded some recommendations and related that to levels (but not quality) of evidence. The CPGs' recommendations on assessment and non-pharmacological management were fairly consistent. Guidelines varied in the selection of first-line treatment, adjustment of therapy and drug combinations. Important specific aspects of care (e.g. resistant hypertension) were ignored by 6/11 CPGs. The CPGs varied in methodological quality, suggesting that their implementation might not result in less variation of care or in better health-related outcomes.

CONCLUSIONS/SIGNIFICANCE

More efforts are needed to promote the realistic approach of localization or local adaptation of existing high-quality CPGs to the national context.

Remarkable differences between three evidence-based guidelines on management of obstructive sleep apnea-hypopnea syndrome

OBJECTIVES/HYPOTHESIS

The aim of this study was to compare available guidelines for the diagnosis and treatment of patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) regarding their content, conclusions on the available evidence, and recommendations.

STUDY DESIGN

Literature review/systematic review.

METHODS

We retrieved guidelines from Embase, PubMed, Web of Science, and Web sites of several health care improvement centers and with a Google Scholar search. We appraised the quality of selected guidelines according to the Appraisal of Guidelines for Research and Evaluation instrument. For similar clinical questions we compared the conclusions, the attached levels of evidence, and the references used. If differences were found, we checked search strategies, appraisal criteria, and publication date as possible sources for these differences.

RESULTS

We selected the guidelines on diagnosis and treatment of OSAHS of the Scottish Scottish Intercollegiate Guidelines Network, the Dutch Institute for Healthcare Improvement, and the Institute for Clinical Systems Improvement in the United States for this comparison. For similar clinical questions these three guidelines showed conflicting conclusions (11%-18%), differences in attached levels of evidence (32%-62%), and remarkable discrepancies in cited studies. A plausible reason for these differences is the citation preference for articles from members of the guidelines workgroup and from their own country. Despite different publication dates, more recent guidelines fail to cite earlier published guidelines.

CONCLUSIONS

Despite the generally accepted approach regarding the development of evidence-based guidelines, remarkable differences exist between guidelines from different countries on the same clinical subject.

The basis for monitoring strategies in clinical guidelines: a case study of prostate-specific antigen for monitoring in prostate cancer

BACKGROUND

The volume of published literature on the evaluation and use of tests for monitoring purposes is sparse. Our aim was to determine the extent to which recommendations for monitoring prostate-specific antigen to detect recurrent prostate cancer consider key factors that should inform rule-based strategies for monitoring.

METHODS

We reviewed the recommendations made in clinical guidelines for the repeated measurement of prostate-specific antigen in men who have received primary treatment for localized prostate cancer. We assessed the guidelines using the Appraisal of Guidelines for Research and Evaluation Framework.

RESULTS

We identified guidelines and statements of best practice from nine organizations. We saw considerable inconsistency in recommendations for testing for prostate-specific antigen as a form of monitoring. Recommendations on when to test appeared to be almost exclusively determined using standard follow-up schedules rather than any scientific basis. Recommendations on when to take action were primarily based on consensus statements or retrospective case series. Eight of the nine guidelines acknowledged the potential presence of measurement variability, but they did not attempt to account for the effect of such variability on the interpretation of the results of tests for prostate-specific antigen. Many recommendations were made with few or no supporting references; however, a variety of papers were cited across guidelines. Of 48 papers cited, 29.1% (14/48) were reviews; the remaining 70.8% (34/48) of papers cited were primary studies.

INTERPRETATION

A systematic approach to the development of monitoring schedules using prostate-specific antigen in guidelines for prostate cancer is lacking, due to inadequacies in the available evidence and its use.

[Improved effectiveness in the management of cardiovascular risk among type 2 diabetic patients in primary health care]

OBJECTIVES

To determine the impact of the implementation of a guidelines in the assessment of cardiovascular risk in high-risk patients (type 2 diabetes) in health centres, and to analyse the appropriateness of antihypertensive and antiplatelet treatment in diabetic patients.

DESIGN

Quasi-experimental, non-randomised, prospective study with concurrent control group. PLACEMENT: Two health centres in Málaga.

PARTICIPANTS

General practitioners of the two centres.

INTERVENTIONS

The guideline was implemented through a multifaceted intervention in family physicians in the experimental centre.

MAIN OUTCOMES

Rate of cardiovascular risk assessment in high risk population. Secondary: appropriateness of antihypertensive and antiplatelet treatment.

RESULTS

Large differences were detected in the cardiovascular risk assessment, improving in the experimental group (74.36% vs. 7.63%; RR = 9.74; 95% CI, 5.15-18.43; P = .0001). Similarly, the antiplatelet use was more in line with the guidelines recommendations in the intervention group (51.28% vs. 36.44%; RR = 1.407; 95% CI, 1.04-1.89; P = .026), and in antihypertensive drugs, although with no statistical significance (80% vs. 66.27%; RR = 1.207; 95% CI, 0.99-1.46).

CONCLUSIONS

A multifaceted intervention for the implementation of a guideline for the management of high risk cardiovascular patients, improves the adherence to effective interventions by family physicians.

Communication between secondary and primary care following self-harm: are National Institute of Clinical Excellence (NICE) guidelines being met?

BACKGROUND

Most patients contact their general practitioner (GP) following presentation to an Emergency Department (ED) after a self-harm incident, and strategies to help GPs manage these patients include efficient communication between services. The aim of this study was to assess the standard of documentation and communication to primary care from secondary care as recommended by the National Institute of Clinical Excellence (NICE) guidelines on the short-term management of people who self-harm.

METHODS

An audit of medical records (ED and Psychiatric) on people aged 16 years and over who had presented to the ED following self-harm, benchmarked according to government guidelines, was performed. Data were collected over a 4-week period at a general teaching hospital.

RESULTS

We collected data on 93 consecutive episodes of self-harm; 62% of episodes were communicated to primary care, 58% of these communications were within 24 h and most within 3 days. Patient identifying details and follow-up arrangements were specified in most cases. Communication via psychiatric staff was most detailed. ED clinicians provided few communications and were of limited content. Communication with the patient's GP was not made in half of those cases seen by a mental health specialist.

CONCLUSION

Government guidelines are only partially being met. Reliance on communication by ED staff would leave a substantial proportion of patients discharged from the ED with no or minimal communication to primary care. Psychiatric services need to improve the rate of communication to the patient's GP following assessment A national sample of National Health Service (NHS) trusts would establish if this is a problem elsewhere.