Quality of pediatric clinical practice guidelines

Nutrition guidelines for preterm infants: A systematic review

BACKGROUND

There is no consensus on optimal nutrition for preterm infants, leading to substantial practice variation. We aimed to assess the quality of nutrition guidelines for preterm infants, the consistency of recommendations, and the gaps in recommendations.

METHODS

We searched databases and websites for nutrition guidelines for preterm infants before first hospital discharge, which were endorsed, prepared, or authorized by a regional, national, or international body, written in English, and published between 2012 and 2023. Two reviewers independently screened articles and extracted the recommendations. Four reviewers appraised the included guidelines using Appraisal of Guidelines, Research, and Evaluation II.

RESULTS

A total of 7051 were identified, with 27 guidelines included, 26% of which were high in quality. Most guidelines lacked stakeholder involvement and rigor of development. We found considerable variation in recommendations, many of which lacked details on certainty of evidence and strength of recommendation. Recommendations for type of feed and breastmilk fortification were consistent among high-quality guidelines, but recommendations varied for intakes of almost all nutrients and monitoring of nutrition adequacy. Different guidelines gave different certainty of evidence for the same recommendations. Most gaps in recommendations were due to very low certainty of evidence.

CONCLUSION

Future development of nutrition guidelines for preterm infants should follow the standard guideline development method and ensure the rigorous process, including stakeholders' involvement, to improve the reporting of strength of recommendation, certainty of evidence, and gaps in recommendation. Evidence is needed to support recommendations about macro and micronutrient intakes, breastmilk fortification, and markers on adequacy of intake of different nutrients.

Development, Evaluation, and impLemenTation for guideline adaptation: a quality improvement protocol for the DELTA study in global health practice

BACKGROUND

Guideline adaptation is an emerging field to provide more appropriate recommendations for local clinical practice quality and to promote global health equity. However, its utilization status, adaptation procedures, and related materials remain to be studied.

METHODS

This study developed a quality improvement protocol for a study as the Development, Evaluation, and impLemenTation for guideline Adaptation (DELTA) study. Current adapted clinical practice guidelines (CPGs) will be systematically searched. Their characteristics, utilization status, and adaptation procedures will be extracted, compared, and analyzed. Whether these adapted CPGs rigorously followed the instruments and steps of adaptation frameworks will also be appraised. In addition, the advantages and limitations of current adaptation methods and their suitable application situations will be analyzed. In addition, future perspectives as DELTA series and DELTA system, aiming for comprehensively evaluating current needs for guideline adaptation and developing a unified framework and related materials were proposed to improve the acceptability, applicability, and implementation of guideline adaptation in clinical practice. The DELTA series are divided into four phases: phase I in analyzing status, characteristics, and procedures and completeness of adapted CPGs; phase II in analyzing differences, heterogeneity, and implementation between adapted and original CPGs; and phase III in collecting, analyzing, and comparing all available adaptation materials. With these research bases, an international working group will be established in phase IV and will develop unified guideline adaptation materials after Delphi consensus, including adaptation frameworks, appraisal tools and checklists, registries, and databases.

DISCUSSION

Guideline adaptation has been advanced as an efficient way to guide local clinical practice. However, it still faces several major challenges. The proposed DELTA study, series, and system will further contribute to this emerging topic.

TRIAL REGISTRATION

 This study has been registered by the PROSPERO international database. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=400170 .

A systematic review of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal syndrome in pediatric intensive care

Introduction

This systematic review aimed to evaluate the quality of clinical practice guidelines (CPGs) and recommendations for managing pain, sedation, delirium, and iatrogenic withdrawal syndrome in pediatric intensive care (PICU). The objectives included evaluating the quality of recommendations, synthesizing recommendations, harmonizing the strength of the recommendation (SoR) and the certainty of evidence (CoE), and assessing the relevance of supporting evidence.

Methods

A comprehensive search in four electronic databases (Medline, Embase.com, CINAHL and JBI EBP Database), 9 guideline repositories, and 13 professional societies was conducted to identify CPGs published from January 2010 to the end of May 2023 in any language. The quality of CPGs and recommendations was assessed using the AGREE II and AGREE-REX instruments. Thematic analysis was used to synthesize recommendations, and the GRADE SoR and CoE harmonization method was used to interpret the credibility of summary recommendations.

Results

A total of 18 CPGs and 170 recommendations were identified. Most CPGs were of medium-quality, and three were classified as high. A total of 30 summary recommendations were synthesized across each condition, focused on common management approaches. There was inconsistency in the SoRs and CoE for summary recommendations, those for assessment showed the highest consistency, the remaining were conditional, inconsistent, inconclusive, and lacked support from evidence.

Conclusion

This systematic review provides an overview of the quality of CPGs for these four conditions in the PICU. While three CPGs achieved high-quality ratings, the overall findings reveal gaps in the evidence base of recommendations, patient and family involvement, and resources for implementation. The findings highlight the need for more rigorous and evidence-based approaches in the development and reporting of CPGs to enhance their trustworthiness. Further research is necessary to enhance the quality of recommendations for this setting. The results of this review can provide a valuable foundation for future CPG development.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274364, PROSPERO (CRD42021274364).

The quality of diagnostic guidelines for children in primary care: A meta-epidemiological study

AIM

To determine the quality of paediatric guidelines relevant to diagnosis of three of the most common conditions in primary care: fever, gastroenteritis and constipation.

METHODS

We undertook a meta-epidemiological study of paediatric guidelines for fever, gastroenteritis and gastroenteritis. We systematically searched MEDLINE, Embase, Trip Database, Guidelines International Network, the National Guideline Clearinghouse and WHO from February 2011 to September 2022 for guidelines from high-income settings containing diagnostic recommendations. We assessed the quality of guideline reporting for included guidelines using the AGREE II tool.

RESULTS

We included 16 guidelines: fever (n = 7); constipation (n = 4) and gastroenteritis (n = 5). The overall quality across the three conditions was graded moderate (median AGREE II score 4.5/7, range 2.5-6.5) with constipation guidelines rated the highest (median 6/7), and fever rated the lowest (median 3.8/7). Major methodological weaknesses included consideration of guideline applicability. Half of the guidelines did not report involving parent representatives, and 56% did not adequately declare or address their competing interests.

CONCLUSIONS

Substantial variations exist in the quality of paediatric guidelines related to the diagnosis of primary care presentations. Better quality guidance is needed for general practitioners to improve diagnosis for children in primary care.

Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis

Background

Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings.

Methods

A literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal).

Results

From 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%.

Conclusions

The review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].

Adapting global evidence-based practice guidelines to the Egyptian healthcare context: the Egyptian Pediatric Clinical Practice Guidelines Committee (EPG) initiative

Background

In Egypt, academic organizations, professional societies, and research groups develop clinical practice guidelines (CPGs) in order to improve patient quality care and safety. Although important improvements have been made over the past years, many of these consensus-based guideline documents still lack the transparency and methodological rigor of international standards and methodologies recommended by reference evidence-based healthcare and guideline organizations like the Guidelines International Network.

Main body of the abstract

In the Egyptian Pediatric Clinical Practice Guidelines Committee (EPG), we have adopted one of the CPG formal adaptation methodological frameworks named the 'Adapted ADAPTE', relevant CPG resources (e.g., the Appraisal of Guidelines for Research and Evaluation or AGREE II Instrument), and involved key stakeholders including clinical and healthcare topic experts and guideline methodologists in producing 32 trustworthy national evidence-based CPGs and one protocol customized to the healthcare context and services provided for Egyptian children. An EPG online website was launched to make these CPGs available and accessible as CPG summaries for pediatricians and relevant healthcare providers.

Short conclusion

The lessons learned, enablers, challenges, and solutions relevant to Egyptian National Pediatric CPGs identified in this paper could be used to address and enrich the debate on pediatric high-quality CPGs, especially for countries of similar contexts and systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42269-023-01059-0.

The Consistency between Registered Acupuncture-Moxibustion Clinical Studies and Their Published Studies and Update Status of Registered Information

BACKGROUND

Few studies have analyzed the consistency between registered acupuncture-moxibustion clinical studies and their published research results as well as their update status of registered information.

METHODS

We searched for acupuncture-moxibustion clinical studies that were registered at the World Health Organization International Clinical Trials Registry Platform between 2013 and 2015 and collected data regarding their characteristics and update status. Published results of these registered studies were identified and compared with registered information.

RESULTS

A total of 425 registered acupuncture-moxibustion clinical studies were included; 379 (89.2%) of them were interventional studies, and the remaining 46 (10.8%) were observational studies. Forty-six studies (10.8%) were found to have published results, and 51 published articles were identified. Overall, 73.2% (311) of registered studies did not update the research status in time; 46.6% (198) stopped updating before recruiting; 21.6% (92) stopped updating after recruiting; and 4.9% (21) stopped updating after completion. Regarding the 46 studies with published results, 29 (63.0%) were considered to be affected by reporting bias. These reporting biases predominantly involved the omission of some predefined outcomes or endpoints (16 studies), contradictions regarding descriptions of sample sizes (9 studies), discrepancies in treatment measurements or group distribution (7 studies), and inconsistent treatment durations (4 studies). When compared with other studies, significant and various reporting biases could also be commonly found in fields other than acupuncture-moxibustion.

CONCLUSIONS

There were many discrepancies between registered information and published reports on acupuncture-moxibustion, which could also be commonly observed in other fields. Moreover, a large proportion of registered studies did not update their research status in time. Efforts should be made to improve the reporting quality and timely updates.

Hintergrund

Es gibt nur wenige Studien, in denen die Übereinstimmung zwischen den registrierten klinischen Studien zur Akupunktur und Moxibustion mit den veröffentlichten Studienergebnissen und dem Aktualisierungsstand der Informationen im Register untersucht wurde.

Methoden

Wir suchten nach klinischen Studien zur Akupunktur und Moxibustion, die zwischen 2013 und 2015 auf der International Clinical Trials Registry Platform der Weltgesundheitsorganisation registriert wurden, und erhoben Daten zu ihren Merkmalen und ihrem Aktualisierungsstand. Die veröffentlichten Ergebnisse der registrierten Studien wurden identifiziert und mit den Informationen im Register verglichen.

Ergebnisse

Insgesamt wurden 425 registrierte klinische Studien zur Akupunktur und Moxibustion eingeschlossen, davon waren 379 (89,2 %) Interventionsstudien und die restlichen 46 (10,8 %) waren Beobachtungsstudien. Es wurden 46 Studien (10,8 %) mit veröffentlichten Ergebnissen gefunden und 51 veröffentlichte Artikel identifiziert. Insgesamt wurde bei 73,2 % (311) der registrierten Studien der Forschungsstand nicht zeitnah aktualisiert; bei 46,6 % (198) wurde die Aktualisierung vor der Rekrutierung eingestellt; bei 21,6 % (92) wurde die Aktualisierung nach der Rekrutierung eingestellt und bei 4,9 % (21) wurde die Aktualisierung nach Abschluss der Studie eingestellt. Von den 46 Studien mit veröffentlichten Ergebnissen wurden 29 (63,0 %) als von Publikationsverzerrung betroffen angesehen. Diese Publikationsverzerrung betraf vor allem die Auslassung einiger vordefinierter Zielkriterien oder Endpunkte (16 Studien), Widersprüche bei der Beschreibung des Stichprobenumfangs (9 Studien), Diskrepanzen bei den Behandlungsmessungen oder der Gruppenverteilung (7 Studien) und Inkonsistenzen bei der Behandlungsdauer (4 Studien). Beim Vergleich mit anderen Studien wurden auch in anderen Bereichen als Akupunktur und Moxibustion häufig signifikante und unterschiedliche Publikationsverzerrungen festgestellt.

Schlussfolgerungen

Es bestanden zahlreiche Diskrepanzen zwischen den Informationen im Register und den veröffentlichten Berichten über Akupunktur und Moxibustion, die auch in anderen Bereichen häufig zu beobachten waren. Darüber hinaus wurde bei einem Großteil der registrierten Studien der Forschungsstand nicht zeitnah aktualisiert. Es sollten Anstrengungen unternommen werden, um die Qualität der Berichterstattung und die zeitnahe Aktualisierung zu verbessern.

Methodological rigor and reporting quality of clinical practice guidelines for adults hospitalized with bacterial pneumonia: a scoping review protocol

OBJECTIVE

This scoping review will present a profile of methodological rigor and reporting quality of clinical practice guidelines for adults hospitalized with bacterial pneumonia.

INTRODUCTION

An ideal clinical practice guideline is evidence-based and the product of a rigorous and robust literature-vetted process, yet reports show that rigor is not being achieved. Moreover, a new vulnerable population has been identified due to COVID-19, increasing the need for high quality clinical practice guidelines. Preliminary searches yielded no scoping or systematic reviews on methodological rigor and reporting quality of clinical practice guidelines used for managing bacterial pneumonia in hospitalized adults.

INCLUSION CRITERIA

This review will consider current national and international clinical practice guidelines for management of hospitalized adult patients with either suspected or confirmed primary bacterial pneumonia. The review will include adult patients with multiple diagnoses if there is a clearly delineated clinical practice guideline for pneumonia.

METHODS

A 3-step search strategy will be conducted using JBI methodology for scoping reviews. After an initial MEDLINE search for keywords, a broad search of 7 databases, 1 simultaneous platform, gray literature, specialty organizations, and international guideline groups will be conducted from 2017 to the present, in any language. Reference lists will be screened for additional sources. A 2-step screening process will be used to identify eligible clinical practice guidelines. Three reviewers will independently extract data using a standardized form. Domain scores will be analyzed and presented as percentages, and the results will be interpreted as map trends.

DETAILS OF THIS REVIEW PROJECT ARE AVAILABLE AT

Open Science Framework https://osf.io/eucqy/.

Availability and implementation of guidelines in European child primary health care: how can we improve?

BACKGROUND

Clinical guidelines are important for providing high-quality child primary health care. We aimed to assess the availability, use and achieved delivery of guidelines in the European Union (EU).

METHODS

We used a case study design to ascertain expert views on guidelines in six countries representing the EU. The experts completed an online questionnaire (response 49%), asking about their perception of guideline availability and implementation regarding three topics that represent prevention and care, i.e. vaccination, assessment of mental health and asthma care.

RESULTS

According to the respondents all countries had guidelines available for asthma care. For vaccination and mental health assessment respondents agreed to a lesser degree that guidelines were available. Implementation of guidelines for vaccination was mostly perceived as intended, but implementation of the guidelines for mental health assessment and asthma care was limited. Notable barriers were complexity of performance, and lack of training of professionals and of financial resources. Important facilitators for guideline implementation were the fit with routine practice, knowledge and skills of professionals and policy support. We found no clear relationship of guideline availability and implementation with type of child primary health care system of countries, but strong governance and sufficient financial resources seemed important for guideline availability.

CONCLUSIONS

Availability and implementation of clinical guidelines in child primary health care vary between EU countries. Implementation conditions can be strongly improved by adequate training of professionals, stronger governance and sufficient financial resources as facilitating factors. This can yield major gains in child health across Europe.

Variation in Current Guidelines for Fluoride Varnish Application for Young Children in Medical Settings in the United States

Background

The United States Preventive Services Task Force recommends that medical providers apply fluoride varnish (FV) to the teeth of all children under 6 years of age, but fewer than 10% of eligible children receive FV as recommended. Prior studies suggest that variation in clinical guidelines is associated with low uptake of other evidence-based health-related interventions, but consistency of national guidelines for the delivery of FV in medical settings is unknown.

Methods

Eligible guidelines for application of FV in medical settings for children under 6 years of age were published in the past 10 years by national pediatric or dental professional organizations or by national public health entities. Guidelines were identified using the search terms fluoride varnish + [application; guidelines, or recommendations; children or pediatric; American Academy of Pediatrics (AAP); American Academy of Pediatric Dentistry] and a search of Guideline Central. Details of the guidelines were extracted and compared.

Results

Ten guidelines met inclusion criteria. Guidelines differed in terms of periodicity recommendations and whether FV was indicated for children with a dental home or level of risk of dental caries.

Conclusion

Numerous recommendations about FV delivery in medical settings are available to pediatric medical providers. Further study is warranted to determine whether the variation across current guidelines detected in this study may contribute to low FV application rates in medical settings.

Quality of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal in pediatric intensive care: a systematic review protocol

INTRODUCTION

Inadequate management of pain and sedation in critically ill children can cause unnecessary suffering and agitation, but also delirium and iatrogenic withdrawal. It is, therefore, important to address these four interrelated conditions together. Some clinical practice guidelines (CPGs) are available for the management of pain and sedation, and a few for delirium and iatrogenic withdrawal in the paediatric intensive care unit; none address the four conditions altogether. Critical appraisal of the quality of CPGs is necessary for their recommendations to be adopted into clinical practice. The aim of this systematic review is to identify and appraise the quality of CPGs and recommendations for management of either pain, sedation, delirium and iatrogenic withdrawal.

METHODS AND ANALYSIS

Researchers will conduct a systematic review in electronic databases (Medline ALL (Ovid), Embase.com, CINAHL with Full Text (EBSCO), JBI EBP Database (Ovid)), guideline repositories and websites of professional societies to identify CPGs published from 2010 to date. They will then combine index and free terms describing CPGs with pain, sedation, delirium and withdrawal. The researchers will include CPGs if they can be applied in the paediatric intensive care population (newborns to 18 years old) and include recommendation(s) for assessment of at least one of the four conditions. Two independent reviewers will screen for eligibility, complete data extraction and quality assessments using the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence instruments. Researchers will report characteristics, content and recommendations from CPGs in tabulated forms.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. Results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021274364.

Quality of recent clinical practice guidelines in anaesthesia publications using the Appraisal of Guidelines for Research and Evaluation II instrument

Clinical practice guidelines are a valuable resource aiding medical decision-making based on scientific evidence. In anaesthesia, guidelines are increasing in both number and scope, influencing individual practice and shaping local departmental policy. The aim of this review is to assess the quality of clinical practice guidelines published in high impact anaesthesia journals over the past 5 yr using the internationally validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. A literature search was conducted in Scopus to identify all guidelines published in the top 10 anaesthesia journals as per Clarivate Analytics Impact Factor from 2016 and 2020. Fifty-one guidelines were included for analysis by five independent appraisers using AGREE II. Each guideline was assessed across six domains and 23 items. Individual domain scores were calculated with a threshold agreed via consensus to represent high-quality guidelines. There was a significant increase in overall score over time (P=0.041), driven by Domain 3 (Rigour of Development, P=0.046). The raw overall score for Domain 3, however, was low. The other domains performed as expected based on previous studies, with Domains 1, 4, and 6 achieving high scores and Domains 2 and 5 incurring poor ratings. Most guidelines studied involved international collaboration but emerged from a single professional society. Use of an appraisal tool was stated as high but poorly detailed. The improvement in the overall score of guidelines and rigour of development is promising; however, only seven guidelines met high-quality criteria, suggesting room for improvement for the overall integrity of guidelines in anaesthesia.

Characteristics and conflicting recommendations of clinical practice guidelines for COVID-19 management in children: A scoping review

BACKGROUND

Clinical practice guidelines (CPGs) are statements that should be rigorously developed to guide clinicians' decision-making. However, given the scarce evidence for certain vulnerable groups like children, CPGs' recommendations formulation could be challenging.

METHODS

We conducted a scoping review of CPGs for COVID-19 management in children. Documents were included if they claimed to be a "clinical practice guideline", published between January and October 2021, and described the process followed to issue their recommendations. We assessed the quality using the "Appraisal of Guidelines for Research and Evaluation II" (AGREE-II) and described how the recommendations were reached.

RESULTS

We found five CPGs that fulfilled our inclusion criteria. The median score on the overall AGREE-II evaluation was 61% (range: 49%-72%), and the score on the third domain referred to the rigor of methodological development was 52% (range: 25%-88%). Recommendations for remdesivir, tocilizumab, and intravenous immunoglobulin were heterogeneous across CPGs (in favor, against, no recommendation), as well as the methodologies used to present the evidence, perform the benefits/harms balance, and issue the recommendation.

CONCLUSIONS

Heterogeneous recommendations and justifications across CPGs were found in the three assessed topics. Future CPGs should describe in detail their evidence-to-decision process to issue reliable and transparent recommendations.

Pediatric quality measures: The leap from process to outcomes

Value-based reimbursement arrangements tie financial incentives to achieving quality measures to ensure savings are not from withholding care. For patients and their families, the delivery of high-quality care is simply the expectation. Defining and measuring pediatric quality, however, is not standardized which has led to a large proliferation of metrics across multiple stakeholders. The majority of these measures are process rather than outcomes metrics often chosen for the ease at which the data can be obtained. In order to drive greater value, outcomes measures should be preferentially selected. However, measuring outcomes in children presents multiple unique challenges. Compared to adults, children are generally healthier, their outcomes may take more time to manifest, and their clinical variability is greater. Another challenge is the amount of healthcare data being generated by providers, provider networks, payors, government agencies, and many others. This should help in understanding pediatric quality outcomes, but the massive volume of data requires new analytic tools. Artificial intelligence techniques such as machine learning offer faster, more precise, and larger scale evaluation of quality outcomes. Its implementation necessitates identifying expertise in the way of data scientists as well as additional infrastructure components to evaluate data governance, security, regulatory compliance, and ethics. Despite these prerequisites, much progress is being made in outcome insights that drive value benefiting children and families.