Development of rapid guidelines: 1. Systematic survey of current practices and methods

A review and economic analysis of the dapivirine vaginal ring as HIV pre-exposure prophylaxis for women, to inform South African public-sector guidelines

BACKGROUND

South Africa has a high HIV incidence and oral pre-exposure prophylaxis (PrEP) is available as public-sector standard of care. Access to alternative prevention methods for women may further reduce HIV acquisition.

SETTING

South African public-sector.

METHODS

We performed a systematic search for high-quality up-to-date guidelines recommending dapivirine ring as PrEP using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-Adolopment process. We appraised the systematic review and randomised controlled trial (RCT) evidence underpinning the selected guideline's recommendations and conducted a cost-effectiveness analysis. The GRADE Evidence-to-Decision framework guided the adaptation of source guideline recommendations, according to our local context.

RESULTS

We identified the 2021 World Health Organization PrEP Guidelines, informed by two placebo-controlled RCTs, which were included in a contemporaneous systematic review. There were 23 fewer HIV acquisitions per 1000 clients with dapivirine ring versus placebo (95% confidence interval 10-34), with no increase in adverse events (moderate certainty evidence). We found no RCTs comparing dapivirine to oral PrEP, or amongst adolescent/pregnant/breastfeeding clients. Dapivirine is less cost-effective than oral PrEP at $14.59/ring, at the current price.

CONCLUSION

The source guideline recommendation was adapted for the local context. Dapivirine ring appears to be less efficacious than oral PrEP, although comparative studies are lacking. Data in adolescents and pregnancy are also lacking, currently limiting the use of dapivirine as an alternative for women unable to take oral PrEP. At the current price, dapivirine is not cost-effective and unaffordable for inclusion in the South African Essential Medicines List.

Evolution of National Guidelines on Medicines Used to Treat COVID-19 in Pregnancy in 2020-2022: A Scoping Review

The lack of inclusion of pregnant women in clinical trials evaluating the effectiveness of medicines to treat COVID-19 has made it difficult to establish evidence-based treatment guidelines for pregnant women. Our aim was to provide a review of the evolution and updates of the national guidelines on medicines used in pregnant women with COVID-19 published by the obstetrician and gynecologists' societies in thirteen countries in 2020-2022. Based on the results of the RECOVERY (Randomized Evaluation of COVID-19 Therapy) trial, the national societies successively recommended against prescribing hydroxychloroquine, lopinavir-ritonavir and azithromycin. Guidelines for remdesivir differed completely between countries, from compassionate or conditional use to recommendation against. Nirmatrelvir-ritonavir was authorized in Australia and the UK only in research settings and was no longer recommended in the UK at the end of 2022. After initial reluctance to use corticosteroids, the results of the RECOVERY trial have enabled the recommendation of dexamethasone in case of severe COVID-19 since mid-2020. Some societies recommended prescribing tocilizumab to pregnant patients with hypoxia and systemic inflammation from June 2021. Anti-SARS-CoV-2 monoclonal antibodies were authorized at the end of 2021 with conditional use in some countries, and then no longer recommended in Belgium and the USA at the end of 2022. The gradual convergence of the recommendations, although delayed compared to the general population, highlights the importance of the inclusion of pregnant women in clinical trials and of international collaboration to improve the pharmacological treatment of pregnant women with COVID-19.

Two Years of Experience and Methodology of Korean COVID-19 Living Clinical Practice Guideline Development

BACKGROUND

In Korea, during the early phase of the coronavirus disease 2019 (COVID-19) pandemic, we responded to the uncertainty of treatments under various conditions, consistently playing catch up with the speed of evidence updates. Therefore, there was high demand for national-level evidence-based clinical practice guidelines for clinicians in a timely manner. We developed evidence-based and updated living recommendations for clinicians through a transparent development process and multidisciplinary expert collaboration.

METHODS

The National Evidence-based Healthcare Collaborating Agency (NECA) and the Korean Academy of Medical Sciences (KAMS) collaborated to develop trustworthy Korean living guidelines. The NECA-supported methodological sections and 8 professional medical societies of the KAMS worked with clinical experts, and 31 clinicians were involved annually. We developed a total of 35 clinical questions, including medications, respiratory/critical care, pediatric care, emergency care, diagnostic tests, and radiological examinations.

RESULTS

An evidence-based search for treatments began in March 2021 and monthly updates were performed. It was expanded to other areas, and the search interval was organized by a steering committee owing to priority changes. Evidence synthesis and recommendation review was performed by researchers, and living recommendations were updated within 3-4 months.

CONCLUSION

We provided timely recommendations on living schemes and disseminated them to the public, policymakers and various stakeholders using webpages and social media. Although the output was successful, there were some limitations. The rigor of development issues, urgent timelines for public dissemination, education for new developers, and spread of several new COVID-19 variants have worked as barriers. Therefore, we must prepare systematic processes and funding for future pandemics.

Management of Multisystem Inflammatory Syndrome in Children: Decision-Making Regarding a New Condition in the Absence of Clinical Trial Data

Multisystem inflammatory syndrome in children (MIS-C) is a new illness that evolved during the COVID-19 pandemic with initial reports of severe disease including use of extracorporeal membrane oxygenation and death. Institutions rapidly assembled task forces to develop treatment algorithms. At the national/international levels, collaboratives and associations assembled consensus writing groups to draft guidelines. These guidelines and algorithms were initially on the basis of expert opinion and small case series. Some groups used the Delphi approach, and the resultant guidelines often mimicked those for other conditions that resembled MIS-C, like Kawasaki disease (KD). For instance, intravenous immunoglobulin (IVIG), a known effective treatment for KD, was recommended for MIS-C. Early in the pandemic many favoured IVIG over steroids as first-line therapy. As evidence evolved so did some guidelines, which now endorse the dual use of IVIG with steroids as first-line therapy. In contrast, withholding immunotherapy became an option for some MIS-C patients with mild symptoms. Herein, we review guidelines and discuss the evidence informing early recommendations, how this has evolved, the role and limitations of expert opinion and observational data, and the importance of leveraging existing research infrastructures, such as the intensive care unit collaborative (Overcoming COVID-19 surveillance registry), and the International Kawasaki Disease Registry. Finally, we discuss strategies to rapidly develop, deploy, and adapt clinical trials evaluating the treatment of such rare conditions in children, which might include alternatives to conventional clinical trial design. The emergence of MIS-C during the COVID-19 pandemic has highlighted unmet needs regarding research of a new condition.

The GIN-McMaster guideline tool extension for the integration of quality improvement and quality assurance in guidelines: a description of the methods for its development

BACKGROUND AND OBJECTIVES

Our objective was to develop an extension of the widely used GIN-McMaster Guideline Development Checklist and Tool for the integration of quality assurance and improvement (QAI) schemes with guideline development.

METHODS

We used a mixed-methods approach incorporating evidence from a systematic review, an expert workshop and a survey of experts to iteratively create an extension of the checklist for QAI through three rounds of feedback. As a part of this process, we also refined criteria of a good guideline-based quality indicator.

RESULTS

We developed a 40-item checklist extension addressing steps for the integration of QAI into guideline development across the existing 18 topics and created one new topic specific to QAI. The steps span from 'organization, budget, planning and training', to updating of QAI and guideline implementation.

CONCLUSION

The tool supports integration of QAI schemes with guideline development initiatives and it will be used in the forthcoming integrated European Commission Initiative on Colorectal Cancer. Future work should evaluate this extension and QAI items requiring additional support for guideline developers and links to QAI schemes.

Recent Advance in Clinical Practice Guideline Development Methodology

Clinical practice guidelines (CPG) can be defined as systematically developed recommendations and related content obtained by reviewing scientific evidence, which help healthcare providers make decisions. CPG is one of the most powerful tools that helps clinicians make evidence-based decisions in practice. Methodologies in areas essential for CPG development, such as for systematic review, risk of bias (ROB) assessment, adaptation, and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations, are rapidly developing. Therefore, they must be well-understood and applied to evidence-based CPG development. In this regard, it is necessary to learn about the updates and changed in the methodologies for CPG development. This manuscript covers the following CPG development methodologies: (1) main principles of CPG, (2) managing conflict of interest, (3) considering patient value and preference, (4) determination of key questions, (5) ROB assessment, (6) adaptation, (7) rapid guideline development, (8) living guideline development, and (9) GIN-McMaster Guideline Development Checklist.

Systematic review and critical evaluation of quality of clinical practice guidelines on the management of SARS-CoV-2 infection in pregnancy

OBJECTIVE

To systematically identify and critically assess the quality of clinical practice guidelines for the management of SARS-CoV-2 infection in pregnancy.

DATA SOURCES

Medline, Scopus, and ISI Web of Science databases were searched until February 15, 2022.

STUDY ELIGIBILITY CRITERIA

Inclusion criteria were clinical practice guidelines on the management of SARS-CoV-2 infection in pregnancy. The risk of bias and quality assessments of the included clinical practice guidelines were performed using the Appraisal of Guidelines for REsearch and Evaluation II tool, which is considered the gold standard for quality assessment of clinical practice guidelines. To define a clinical practice guideline as of good quality, we adopted the cutoff score proposed by Amer et al: if the overall clinical practice guideline score was >60%, it was recommended.

METHODS

The following clinical points related to the management of pregnant women with SARS-CoV-2 infection were addressed: criteria for maternal hospitalization, recommendations for follow-up fetal growth scan, specific recommendations against invasive procedures, management of labor, timing of delivery, postpartum care, and vaccination strategy.

RESULTS

A total of 28 clinical practice guidelines were included. All recommended hospitalization only for severe disease; 46.1% (6/13) suggested a fetal growth scan after SARS-CoV-2 infection, whereas 23.1% (3/13) did not support this practice. Thromboprophylaxis with low-molecular-weight heparin was recommended in symptomatic women by 77.1% (7/9) of the clinical practice guidelines. None of the guidelines recommended administering corticosteroids only for the presence of SARS-CoV-2 infection in preterm gestation, unless specific obstetrical indication exists. Elective induction of labor from 39 weeks of gestation was suggested by 18.1% (2/11) of the clinical practice guidelines included in the present review, whereas 45.4% (5/11) did not recommend elective induction unless other obstetrical indications coexisted. There were 27% (3/11) of clinical practice guidelines that suggested shortening of the second stage of labor, and active pushing was supported by 18.1% (2/11). There was general agreement among the clinical practice guidelines in not recommending cesarean delivery only for the presence of maternal infection and in recommending vaccine boosters at least 6 months after the primary series of vaccination. The Appraisal of Guidelines for REsearch and Evaluation II standardized domain scores for the first overall assessment of clinical practice guidelines had a mean of 50% (standard deviation±21.82%), and 9 clinical practice guidelines scored >60%.

CONCLUSION

A significant heterogeneity was found in some of the main aspects of the management of SARS-CoV-2 infection in pregnancy, as reported by the published clinical practice guidelines.

Methodology and experiences of rapid advice guideline development for children with COVID-19: responding to the COVID-19 outbreak quickly and efficiently

BACKGROUND

Rapid Advice Guidelines (RAG) provide decision makers with guidance to respond to public health emergencies by developing evidence-based recommendations in a short period of time with a scientific and standardized approach. However, the experience from the development process of a RAG has so far not been systematically summarized. Therefore, our working group will take the experience of the development of the RAG for children with COVID-19 as an example to systematically explore the methodology, advantages, and challenges in the development of the RAG. We shall propose suggestions and reflections for future research, in order to provide a more detailed reference for future development of RAGs.

RESULT

The development of the RAG by a group of 67 researchers from 11 countries took 50 days from the official commencement of the work (January 28, 2020) to submission (March 17, 2020). A total of 21 meetings were held with a total duration of 48 h (average 2.3 h per meeting) and an average of 16.5 participants attending. Only two of the ten recommendations were fully supported by direct evidence for COVID-19, three recommendations were supported by indirect evidence only, and the proportion of COVID-19 studies among the body of evidence in the remaining five recommendations ranged between 10 and 83%. Six of the ten recommendations used COVID-19 preprints as evidence support, and up to 50% of the studies with direct evidence on COVID-19 were preprints.

CONCLUSIONS

In order to respond to public health emergencies, the development of RAG also requires a clear and transparent formulation process, usually using a large amount of indirect and non-peer-reviewed evidence to support the formation of recommendations. Strict following of the WHO RAG handbook does not only enhance the transparency and clarity of the guideline, but also can speed up the guideline development process, thereby saving time and labor costs.

International alliance and AGREE-ment of 71 clinical practice guidelines on the management of critical care patients with COVID-19: a living systematic review

OBJECTIVE

We aimed to systematically identify and critically assess the clinical practice guidelines (CPGs) for the management of critically ill patients with COVID-19 with the AGREE II instrument.

STUDY DESIGN AND SETTING

We searched Medline, CINAHL, EMBASE, CNKI, CBM, WanFang, and grey literature from November 2019 - November 2020. We did not apply language restrictions. One reviewer independently screened the retrieved titles and abstracts, and a second reviewer confirmed the decisions. Full texts were assessed independently and in duplicate. Disagreements were resolved by consensus. We included any guideline that provided recommendations on the management of critically ill patients with COVID-19. Data extraction was performed independently and in duplicate by two reviewers. We descriptively summarized CPGs characteristics. We assessed the quality with the AGREE II instrument and we summarized relevant therapeutic interventions.

RESULTS

We retrieved 3,907 records and 71 CPGs were included. Means (Standard Deviations) of the scores for the 6 domains of the AGREE II instrument were 65%(SD19.56%), 39%(SD19.64%), 27%(SD19.48%), 70%(SD15.74%), 26%(SD18.49%), 42%(SD34.91) for the scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, editorial independence domains, respectively. Most of the CPGs showed a low overall quality (less than 40%).

CONCLUSION

Future CPGs for COVID-19 need to rely, for their development, on standard evidence-based methods and tools.

QUALITY APPRAISAL OF CLINICAL PRACTICE GUIDELINES ON PROVISION OF DENTAL SERVICES DURING THE FIRST MONTHS OF THE COVID-19 PANDEMIC

Objectives

To evaluate the quality of clinical practice guidelines (CPGs) on dental services provision during the first months of the COVID-19 pandemic.

Materials and methods

We systematically searched in MEDLINE, EMBASE, LILACS, Epistemonikos, Trip databases, websites of CPG developers, compilers of CPGs, scientific societies and ministries of health to identify documents with recommendations intended to minimize the risk of COVID-19 transmission during dental care. Reviewers independently and in duplicate assessed the included CPGs using the AGREE II instrument. We calculated the standardized scores for the 6 domains and made a final recommendation about each CPG. The inter-appraiser agreement was assessed using the intraclass correlation coefficient (ICC).

Results

Twenty-three CPGs published were included. Most of the CPGs were from America (n = 15) and Europe (n = 6). The overall agreement between reviewers was very good (ICC = 0.93; 95%CI 0.87-0.95). The median score for each domain was the following: Scope and purpose 67% (IQR 20%); Stakeholder involvement 33% (IQR 14%); Rigour of development 13% (IQR 13%); Clarity of presentation 64% (IQR 31%); Applicability 19% (IQR 17%) and Editorial independence 8% (IQR 8%). Twenty two guidelines were not recommended by the reviewers. Only one of the CPGs was recommended with modifications. The median overall rate was 3 (IQR 1). All CPGs were classified as low quality.

Conclusions

The overall quality of CPGs on dental services provision during the first months of the COVID-19 pandemic was low, which makes its implementation difficult for clinicians and policy makers. Therefore, it is critical that developers are transparent and forthcoming about the difficulties that have arisen during the CPG development process.

How trustworthy guidelines can impact outcomes

PURPOSE OF REVIEW

If developed using rigorous methods and produced in a timely manner, clinical practice guidelines have the potential to improve patient outcomes. Although the COVID-19 pandemic has highlighted the challenges involved in generating reliable clinical guidance, it has also provided an opportunity to address these challenges.

RECENT FINDINGS

New research addressing drugs for COVID-19 is being produced at unprecedented rates. Incorporating this new knowledge into patient care can be daunting for the average clinician. In collaboration with the BMJ and MAGIC, the WHO has developed a living guideline initiative with the goal of providing rapid and trustworthy clinical guidance in response to practice-changing evidence. As new evidence becomes available, it is incorporated into a living network meta-analysis that informs these guidelines, which are iteratively updated. Until this point, the group has generated guidelines addressing the use of corticosteroids, remdesivir, hydroxychloroquine, lopinavir/ritonavir, and ivermectin for COVID-19.

SUMMARY

We provide an example of how rapid and rigorous guidelines can be accomplished, even in the setting of a pandemic, capitalizing on expertise, large and dedicated teams, and focused scope. We highlight the benefits of multifaceted knowledge dissemination through multiple formats to ensure global dissemination and in order to maximize impact.

Recommendations for Safe Dental Care: A Systematic Review of Clinical Practice Guidelines in the First Year of the COVID-19 Pandemic

In the context of a pandemic, the rapid development of clinical practice guidelines (CPGs) is critical to guide dental staff towards the safe provision of dental care; detailed knowledge of the recommendations will help to achieve the intended results. We carried out a systematic review of the recommendations in clinical practice guidelines (CPGs) on the provision of dental care issued during the first year of the COVID-19 pandemic. A systematic database search was performed in MEDLINE, EMBASE, LILACS, Epistemonikos, and Trip databases to identify documents with recommendations intended to minimize the risk of COVID-19 transmission during dental care. The selection process and data extraction were carried out by two researchers independently. The majority of CPGs recommended the use of rubber dam, high-volume evacuator, mouthwash prior to dental care, four-handed work, and mechanical barriers. The use of aerosol-generating equipment should be avoided whenever possible. In aerosol-generating procedures, the use of a N95 respirator (or similar) is recommended, in addition to a face protector, an impermeable disposable apron/gown, a cap, and gloves. The CPGs developed during the first year of the pandemic offer recommendations which guide dental staff in providing safe dental care, minimizing exposure to SARS-CoV-2 and reducing the risk of COVID-19 infection in the clinical environment. Such recommendations must, however, be updated as new evidence arises.

Rapid and Living Guidance for COVID-19

In their article, Qaseem and colleagues reported how the American College of Physicians responded to the urgent need for guidance during the COVID-19 pandemic by producing living, rapid practice points. The editorialists discuss the challenges of developing high-quality, up-to-date evidence-based recommendations and how rapid and living reviews and guidelines are important additions to the tools we have available to translate research evidence into improved health outcomes.

The Development of Living, Rapid Practice Points: Summary of Methods From the Scientific Medical Policy Committee of the American College of Physicians

In response to the COVID-19 pandemic, the Scientific Medical Policy Committee (SMPC) of the American College of Physicians (ACP) began developing "practice points" to provide clinical advice based on the best available evidence for the public, patients, clinicians, and public health professionals. As one of the first organizations in the United States to develop evidence-based clinical guidelines, ACP continues to lead and advance the science of evidence-based medicine by implementing new methods to rapidly publish practice points and maintain them as living advice that regularly assesses and incorporates new evidence. The overarching aim of practice points is to answer targeted key questions for which there is a timely need to synthesize evidence for decision making. The SMPC believes these methods can potentially be adapted to address various clinical and public health topics beyond the COVID-19 pandemic. This article presents an overview of the SMPC's living, rapid practice points development process, which includes a rapid systematic review, use of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method, use of stringent policies on the disclosure of interests and management of conflicts of interest, incorporating a public (nonclinician) perspective, and maintenance of the documents as living through ongoing surveillance and synthesis of new evidence as it emerges.

Recommendations on off-label use of intravenous azithromycin in children

OBJECTIVE

Intravenous azithromycin (AZM) has been widely used in children worldwide, but there still remains much concern regarding its off-label use, which urgently needs to be regulated. Therefore, we developed a rapid advice guideline in China to give recommendations of rational use of intravenous AZM in children.

METHODS

This guideline focuses on antimicrobial therapy with intravenous AZM in children. The Delphi research method was used to select questions. A systematic literature review was also conducted. Data were pooled and ranked according to the GRADE system. Recommendations were developed based on expert clinical experience, patients' values and preferences, and evidence availability. After an external review, the recommendations were revised and approved.

RESULTS

This guideline included eighteen recommendations that covered four domains: (a) Indications: the treatment of pneumonia caused by atypical but common pathogens, such as Mycoplasma pneumoniae, Chlamydia trachomatis or Chlamydophila pneumoniae and Legionella pneumophila, more typical bacteria as well as the treatment of bronchitis of presumed bacterial aetiologies; (b) Usage and dosage: administration route, infusion concentrations, treatment duration, course of sequential treatment, and dosage stratified by age; (c) Adverse reactions and treatment: the management of gastrointestinal reactions, arrhythmias, pain or phlebitis at the infusion site, and anaphylaxis; and (d) Special population: children with renal or liver dysfunction, congenital heart disease, and obesity. This guideline will hopefully help promote a rational use of intravenous AZM in children worldwide.

CONCLUSION

This guideline has summarised the evidence and has developed recommendations on the use of intravenous AZM in children worldwide. Further attention and well-designed researches should be conducted on the off-label use of intravenous AZM in children.

Developing a Thai national critical care allocation guideline during the COVID-19 pandemic: a rapid review and stakeholder consultation

BACKGROUND

At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic.

METHODS

The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage.

RESULTS

Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay.

CONCLUSIONS

The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.

The CSN COVID-19 Rapid Response Program

The coronavirus disease (COVID-19) pandemic has created unprecedented challenges in caring for individuals living with kidney disease. In response to a growing call for up-to-date information and evidence-informed advice, the Canadian Society of Nephrology has established a COVID-19 Rapid Response Team that will leverage existing evidence and national expertise to inform kidney care practices in the COVID-19 era. Given limited published evidence and compressed timelines, formal clinical practice guidelines are not feasible, and we have adopted rapid review methods to instead provide interim guidance across identified priority areas. In this article, we describe the methodological approach that was applied in developing a first iteration of guidance documents addressing clinical and operational aspects of care for patients treated with in-center hemodialysis, home dialysis, those with advanced chronic kidney disease, those with glomerulonephritis, and those with acute kidney injury. We further describe strategies for maintaining ongoing engagement with the renal community to elicit emerging needs and perspectives as the situation unfolds.

Developing trustworthy recommendations as part of an urgent response (1-2 weeks): a GRADE concept paper

OBJECTIVES

The aim of this study is to propose an approach for developing trustworthy recommendations as part of urgent responses (1-2 week) in the clinical, public health, and health systems fields.

STUDY DESIGN AND SETTING

We conducted a review of the literature, outlined a draft approach, refined the concept through iterative discussions, a workshop by the Grading of Recommendations Assessment, Development and Evaluation Rapid Guidelines project group, and obtained feedback from the larger Grading of Recommendations Assessment, Development and Evaluation working group.

RESULTS

A request for developing recommendations within 2 week is the usual trigger for an urgent response. Although the approach builds on the general principles of trustworthy guideline development, we highlight the following steps: (1) assess the level of urgency; (2) assess feasibility; (3) set up the organizational logistics; (4) specify the question(s); (5) collect the information needed; (6) assess the adequacy of identified information; (7) develop the recommendations using one of the 4 potential approaches: adopt existing recommendations, adapt existing recommendations, develop new recommendations using existing adequate systematic review, or develop new recommendations using expert panel input; and (8) consider an updating plan.

CONCLUSION

An urgent response for developing recommendations requires building a cohesive, skilled, and highly motivated multidisciplinary team with the necessary clinical, scientific, and methodological expertise; adapting to shifting needs; complying with the principles of transparency; and properly managing conflicts of interest.

Using GRADE in situations of emergencies and urgencies: certainty in evidence and recommendations matters during the COVID-19 pandemic, now more than ever and no matter what

OBJECTIVES

The public, policy makers, and science communities are subject to many false, uninformed, overly optimistic, premature, or simply ridiculous health claims. The coronavirus disease 2019 (COVID-19) pandemic and its context is a paramount example for such claims. In this article, we describe why expressing the certainty in evidence to support a decision is critical and why the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach matters now, perhaps more than ever and no matter what the specific topic is in relation to COVID-19. We finally also offer suggestions for how it can be used appropriately to support decision-making at global, national, and local level when emergency, urgent or rapid responses are needed.

STUDY DESIGN AND SETTING

This is an invited commentary to address the objectives above building on examples from the recent COVID-19 pandemic. This includes an iterative discussion of examples and development of guidance.

RESULTS

The GRADE approach is a transparent and structured method for assessing the certainty of evidence and when developing recommendations that requires little additional time. We describe why emergency, urgent, or rapid responses do not justify omitting this critical assessment of the evidence. In situations of emergencies and urgencies, such as the COVID-19 pandemic, GRADE can similarly be used to express and convey certainty in intervention effects, test accuracy, risk and prognostic factors, consequences of public health measures, and qualitative bodies of evidence.

CONCLUSIONS

Assessing and communicating the certainty of evidence during the COVID-19 pandemic is critical. Those offering evidence synthesis or making recommendations should use transparent ratings of the body of evidence supporting a claim regardless of time that is available or needed to provide this response.

Development of rapid guidelines: 3. GIN-McMaster Guideline Development Checklist extension for rapid recommendations

BACKGROUND

Practice guidelines require a substantial investment of resources and time, often taking between 1 and 3 years from conceptualisation to publication. However, urgent situations require the development of recommendations in a shorter timeframe. In this third and final article in the series exploring challenges and solutions in developing rapid guidelines (RGs), we propose guiding principles for the development of RGs.

METHODS

We utilised the Guideline International Network-McMaster Guideline Development Checklist (GDC) as a starting point for elements to consider during RG development. We built on those elements using the findings from a systematic review of guideline manuals, a survey of international organisations conducting RGs, and interviews of guideline developers within WHO. We reviewed initial findings and developed an intermediate list of elements, as well as narrative guidance. We then invited experts to validate the intermediate list, reviewing for placement, brevity and redundancy. We used this iterative process and group consensus to determine the final elements for RG development guidance.

RESULTS

Our work identified 21 principles within the topics of the Guideline International Network-McMaster GDC to guide the planning and development of RGs. Principles fell within 15 of the 18 checklist topics, highlighting strategies to streamline and expedite the guideline development process.

CONCLUSIONS

We defined principles to guide the development of RGs, while maintaining a standardised, rigorous and transparent process. These principles will serve as guidance for guideline developers responding to urgent situations such as public health urgencies. Integration of these principles within currently disseminated guideline development standards will facilitate the use of those tools in situations necessitating RG recommendations.