Assessment of the quality of recommendations from 161 clinical practice guidelines using the Appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX) instrument shows there is room for improvement

Recommendations for Mobilization and Manipulation Treatment and Screening for Vascular Complications in Clinical Practice Guidelines for Neck Pain: A Systematic Review

OBJECTIVE

This systematic review aimed to determine the methodological quality of international clinical practice guidelines (CPGs) and the clinical credibility and implementability of recommendations regarding manipulation or mobilization treatment recommendations proposed in CPGs for the management of people with neck pain. A secondary aim of this review was to provide an overview of recommendations for manipulation or mobilization in patients with neck pain. Manipulation or mobilization treatment of patients with neck pain is under debate for its potential risk of serious adverse events. Serious adverse events are rare, but it is the clinicians' responsibility to thoroughly screen patients at risk of vascular complications. A third aim of this review was to describe the extent to which the included guidelines inform clinical practice about screening for the risk of complications due to vascular pathology in the cervical spine.

METHODS

A systematic review of 13 electronic databases and 4 repositories was performed for potentially relevant guidelines published between January 1, 2000 and September 22, 2022. Two reviewers independently appraised eligible guidelines using Appraisal of Guidelines for Research and Evaluation II (AGREE II) and Appraisal of Guidelines for Research and Evaluation: Recommendation EXcellence (AGREE-REX) criteria. A best evidence synthesis was performed, and screening of risk factors was assessed.

RESULTS

A total of 19 CPGs were included, of which 5 were of high quality. All high-quality guidelines recommend the use of manipulation or mobilization, with or without exercise. Eight (42%) guidelines described the screening of risk factors for adverse events. Two (11%) guidelines met the a priori defined criteria for screening and scored present and complete.

CONCLUSION

International CPGs consistently recommend the use of manipulations and mobilizations in the treatment of neck pain. There is a notable absence of recommendations regarding the identification of patients at risk for vascular complications.

IMPACT

The findings of this study allow guideline developers to improve the quality of future neck pain guidelines and consider including vascular screening tools. Furthermore, it proposes recommendations to physical therapists interested in applying manipulations and mobilizations in the treatment of patients with neck pain.

LAY SUMMARY

International clinical practice guidelines consistently recommend the use of manipulations and mobilizations in the treatment of neck pain. There is a notable absence of recommendations regarding identifying patients at risk for vascular complications.

How Can We Make Information on Equity in Clinical Guidelines More Usable for Clinicians? A Case Study Methodology of General Practitioners

BACKGROUND

Clinical practice guidelines (CPGs) are moving toward greater consideration of population-level differences, like health inequities, when creating management recommendations. CPGs have the potential to reduce or perpetuate health inequities. The intrinsic design factors of electronic interfaces that contain CPGs are known barriers to guideline use. There is little existing guidance on supporting the uptake of equity-specific recommendations within CPGs by end users.

OBJECTIVE

To investigate (1) How do General Practitioners (GPs) use Therapeutic Guidelines to adapt their clinical management for disadvantaged populations and do they support equity recommendations in this CPG? (2) How could Therapeutic Guidelines embed health equity information into their guidelines?

METHODS

The Therapeutic Guidelines was used as a case study as it is the most frequently used CPG in Australian healthcare settings. We employed descriptive qualitative methods, focused on semistructured interviews with 17 eligible GPs. Interviews were structured around four case studies that initially explored the management of a patient from the general population, with their details then changed so they belonged to a disadvantaged population. We used a 'think aloud' interview technique to explore the clinician's application of CPGs.

RESULTS

Three themes were developed relating to: (1) GPs agree that health equity information needs to be intentionally included in guidelines and should focus on disadvantaged subgroups to support their clinical decision-making, (2) GPs want CPGs to include equity information which is relevant to the purpose and use of each guideline, acknowledging that other clinical aids could provide additional information when needed, (3) GPs want clearer signposting of information within guidelines to help navigation of key sections, highlighting the utility of symbols, colours and dropdown functions.

CONCLUSION

This research extends existing literature by showing that including equity information tailored to the articulated purpose of each CPG, as perceived by end users, may maximise uptake. Our outlined strategies could be used by CPG developers to make equity-focused management recommendations more accessible. This may increase the implementation of equity-focused recommendations by clinicians, supporting current primary care strategies in achieving more equitable outcomes.

Anesthesia Trauma Guidelines: A Systematic Review of Global Accessibility and Quality

This systematic review describes the available clinical practice guidelines (CPGs) for the anesthetic management of trauma and appraises the accessibility and quality of these resources. This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted across 8 databases (MEDLINE, Embase, Web of Science, CABI Digital Library, Global Index Medicus, SciELO, Google Scholar, and National Institute for Health and Care Excellence) for guidelines from 2010 to 2023. Two independent reviewers assessed guideline eligibility and extracted data, which were audited by a third reviewer. Data regarding author demographics, accessibility, clinical topics, and quality were collected. The quality of guidelines was evaluated according to the National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) Instrument. A total of 2426 articles were identified, of which 165 met eligibility criteria and were included. Guidelines were developed by 122 professional societies and authors from 51 countries. By region, Europe contributed with the most authors (61%), while Africa had the fewest (4%). Most CPGs were developed by authors from high-income countries (HIC) and only 12% had a first or last author from low- and middle-income countries (LMIC). The United States was the country with the most guideline authors. While 70% were open access, the average cost for paid access was US$36.61. Among the 8 languages identified, English was the most common. The most common topics were blood and fluid management, shock, and airway management. The overall quality of included guidelines was considered moderately high, with an average NEATS score of 3.13 of 5. Quality scores were lowest for involvement of patient perspectives, plans for updating, and presence of a methodologist. On logistic regression analysis, the involvement of a methodological expert was the only predictor of having a high-quality NEATS score, with no association observed with open accessibility, English language, society endorsement, first author from a HIC, or a multidisciplinary group composition. Though many countries and societies have contributed to the development of anesthesia CPGs for trauma, there has been a disproportionate lack of representation from LMICs, where the burden of trauma mortality is highest. In this study, we identify barriers to accessibility and areas for improving future guideline quality. We recommend ongoing efforts to incorporate perspectives from diverse settings and to increase the availability of high-quality, open-access guidelines to improve worldwide health outcomes in trauma.

Why do we need guidelines and why do they fail us?

Guidelines are powerful tools that support evidence-based care in a patient population that is increasingly complex and in systems that are rapidly evolving. When high quality guidelines are implemented well, they can improve patient outcomes, decrease clinician workload and even reduce disparities in care. Guidelines, however, are only as good as the evidence used to create them and are their effectiveness relies on the quality and completeness of their implementation. Guidelines have a lifespan and require redevelopment and reimplementation to achieve their greatest value.

Nonpharmacological Spine Pain Management in Clinical Practice Guidelines: A Systematic Review Using AGREE II and AGREE-REX Tools

OBJECTIVE: To summarize the content and critically appraise the quality and applicability of recent clinical practice guidelines (CPGs) for nonpharmacological, nonsurgical management of spine pain. DESIGN: Systematic review of CPGs. LITERATURE SEARCH: Six databases and seven guideline clearinghouses. STUDY SELECTION CRITERIA: Included de novo CPGs for nonpharmacological, nonsurgical management of spine pain designed for any primary health care providers, published in English, Arabic, French, or traditional Chinese within the past 12 years. DATA SYNTHESIS: Five reviewers independently appraised the guidelines using AGREE II and AGREE-REX. Interrater agreements were calculated for each domain and the total score of these tools using the intraclass correlation coefficient (2, 1) with absolute agreement. RESULTS: We included 30 CPGs, primarily (90%) developed in Western countries, which contained 404 recommendations. High-quality CPGs consistently recommended exercise therapy and multimodal care, encompassing a combination of exercises, mobilization/manipulation, education, alternative medicine, and cognitive-behavioral treatments. Generally, CPGs did not recommend assistive (eg, corsets and orthosis) devices or electro/thermotherapies (eg, therapeutic ultrasound and transcutaneous electrical nerve stimulation). Approximately half of the CPGs demonstrated good methodological quality according to AGREE II, whereas the rest were of poor quality. On the AGREE-REX assessment, one third of the recommendations were of excellent quality. CONCLUSION: Although recent guidelines frequently recommended exercise therapy and multimodal care for the management of spine pain, their recommendations often overlooked demographics and comorbidities. Despite methodological improvements, most CPGs lacked simple clinical applicability and considerations of knowledge users' values. J Orthop Sports Phys Ther 2025;55(1):1-14. Epub 4 November 2024. doi:10.2519/jospt.2024.12729.

Clinical Practice Guidelines on Palliative Sedation Around the World: A Systematic Review

Objective: The principal aim of this study was to identify, systematically and transparently, clinical practice guidelines (CPGs) on palliative sedation from around the world. Methods: A systematic search was performed using 5 databases, grey literature search tools, citation tracking, and contact with palliative care experts across the world. Current CPGs accredited by an international, national, or regional authority, published in English, German, French, or Italian, were subjected to content analysis. Results: In total, 35 CPGs from 14 countries and 1 international CPG were included in the analysis. The CPGs had diverse formal characteristics. Their thematic scope was difficult to analyze and compare because of differences in the terms and definitions of palliative sedation in those texts. We identified 3 main situations: (1) CPGs with a fully explicit thematic scope; (2) CPGs with a partially explicit thematic scope; and (3) CPGs without an explicit thematic scope. Several CPGs explicitly stated what forms of sedation were excluded from the text. However, this presentation was often confusing. Conclusion: Our review provides several pieces of information that could guide international reflections in this field, and be used to develop or update CPGs at all levels. Efforts should be made to clarify the thematic scope of each CPG on palliative sedation, in order to generate an understanding of the forms of this therapy addressed in the text.

Clinical practice guidelines for the treatment of squamous cell carcinoma of the head and neck: an assessment based on the AGREE II, AGREE-REX tools and the RIGHT checklist

Objective

The aim of this study was to obtain several published clinical practice guidelines (CPGs) for Head and neck squamous cell carcinoma (HNSCC) and critically assess and compare their quality by using three guideline quality evaluation tools, namely, AGREE II, AGREE-REX, and RIGHT, to support the development of future CPGs for HNSCC.

Methods

Clinical practice guidelines related to the diagnosis and treatment of HNSCC were screened through a comprehensive systematic literature search. Data were extracted from the guidelines which met the inclusion criteria, and two experienced head and neck oncology surgeons were trained to act as independent reviewers. The quality of the retrieved guidelines that met the inclusion and exclusion criteria was evaluated by using the AGREE II, AGREE-REX, and RIGHT tools. Then, the quality of the guidelines that met the criteria was assessed. Finally, conclusions and recommendations were drawn based on the scoring results.

Results

A total of eight guidelines met the inclusion criteria. Four guidelines(written by ASCO, NCCN, CCO and KCE) scored > 60% in five or more AGREE II quality domains, two guidelines(written by ASCO and KCE) scored > 60% in all AGREE-REX quality domains, and two guidelines(written by ASCO and KCE) scored > 60% in all quality domains on the RIGHT checklist and were considered "recommendable".

Conclusions

The authors recommend consulting the American Society of Clinical Oncology guidelines for HNSCC and suggest that future guideline development groups refer to the guideline evaluation framework for guideline writing to enhance the applicability and effectiveness of clinical practice guidelines.

Methodological Quality of Pulmonary Arterial Hypertension Treatment Evidence-Based Guidelines: A Systematic Review Using the AGREE II and AGREE REX Tools

PURPOSE

Pulmonary arterial hypertension (PAH) is a progressive disease with a poor prognosis, and its management should be grounded in well-developed clinical practice guidelines (CPG). Thus, we critically assess the methodological quality of the available CPG for pharmacological treatments for PAH.

METHODS

A systematic review (CRD42023387168) was performed in PubMed, Cochrane, Embase, and Tripdatabase (Jan-2023). Eligible records were appraised by four reviewers using the Appraisal of Guidelines, Research, and Evaluation Collaboration tool (AGREE II) and the complementary tool for assessing recommendations' quality and certainty, AGREE REX. Descriptive statistics were used to summarize the data.

RESULTS

Overall, 31 guidelines, mainly authored by professional societies (90%), targeting only physicians as primary users (84%), were identified. Guidelines presented a moderate overall quality (scores of 63% and 51% in AGREE II and AGREE REX, respectively), with a few domains showing slight improvements over the years. AGREE II "Scope and Purpose" (94%) and "Presentation Clarity" (99%) domains obtained the highest scores. The items related to "Stakeholder involvement," "Editorial independence," and "Clinical applicability" (AGREE REX) were fairly reported. Conversely, CPG lacks rigor in development (32% score, AGREE II), scarcely discusses the role of stakeholders, and provides deficient data on the implementation of recommendations (scores of 35% and 46% in AGREE II and AGREE REX, respectively). No differences in the quality of guidelines published by different developers or countries were observed (p > 0.05).

CONCLUSION

Methodological weaknesses are common among guidelines addressing PAH treatment, especially regarding scientific rigor, stakeholders' values and preferences, and facilitators and barriers to implementability. Particular attention should be given to developing future guidelines.

Long-term care for community-dwelling older adults: A systematic review of clinical practice guidelines and consensus statements

This review identified clinical practice guidelines (CPGs) and consensus statements (CSs) that include recommendations on long-term care for community-dwelling older adults. Additionally, it assessed their quality using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool to determine high-quality guidelines and synthesis recommendations from high-quality guidelines and evaluate the quality of these guidelines using the AGREE-Recommendation Excellence (AGREE-REX) tool. A systematic search was performed (November 2023) in MEDLINE, PubMed, Guidelines International Network (GIN), National Institute for Health and Care Excellence (NICE), New Zealand Guidelines Group (NZGG), Registered Nurses' Association of Ontario (RNAO), National Guideline Clearinghouse (NGC), and Scottish Intercollegiate Guidelines Network (SIGN). Two reviewers independently selected and assessed the articles using AGREE II. A meeting was held to appraise the quality of the guidelines (AGREE II mean score >70 %) using AGREE-REX. The analysis included 14 CPGs and 2 CSs. Of these, 7 CPGs reached the standard of >70 %, the 'Scope and purpose' domain obtained the highest score with 85.43 (± 17.87), and the 'Applicability' domain scored lowest with 46.93 (± 26.74). Regarding the score of AGREE-REX, the seven CPGs were considered as 'moderate', with the 'Clinical Applicability' domain having the highest score of 61.29 % (±10.80) and the 'Values and Preferences' domain having the lowest score of 38.14 % (±9.26). Four themes were synthesised from the seven high-quality CPGs: planning and delivering person-centred home care, cognitive impairment, and screening for impaired vision and falls. The quality of CPGs and CSs on long-term care for community-dwelling older adults has room for improvement, and higher-quality guidelines are required to meet the long-term care needs of community-dwelling older adults.

Do the clinical practice guidelines for paediatric dentistry meet the quality standards? A meta-research and quality appraisal using the AGREE II tool

BACKGROUND

Clinical practice guidelines (CPGs) enhance health care and aid clinicians' decisions.

AIM

To evaluate the quality of clinical guidelines in paediatric dentistry using the AGREE II tool.

DESIGN

PubMed, EMBASE, Scopus, LIVIVO, Lilacs, international guidelines websites, scientific societies, and gray literature were searched until September 2021. We included paediatric dental clinical guidelines and excluded drafts or guidelines for patients with special needs. Two independent reviewers performed quality assessment using the APPRAISAL OF GUIDELINES FOR RESEARCH & EVALUATION II (AGREE II) instrument. We calculated the mean overall domain scores (95% confidence interval) for each guideline. We used regression analysis to correlate the score of overall assessment and the six domains of AGREE II with guideline characteristics.

RESULTS

Forty-four guidelines were included in this study. Highest mean score was for Domain 4 (Clarity of Presentation; 58%, 95% CI: 50.8-64.9), whereas the lowest was for Domain 5 (Applicability; 16%, 95% CI: 10.8-21.4). The reporting quality was improved in Domains 1-5 with reporting checklists (p < .001), whereas that of Domain 6 was improved by decreasing years since publication (p = .047).

CONCLUSION

Paediatric dental guidelines do not comply with the methodological quality standard, especially in Domain 5 (Applicability). The AGREE reporting checklist should be implemented with a system to evaluate the certainty of evidence for future guidelines.

Moving toward the Development and Effective Implementation of High-Quality Guidelines in Pediatric Surgery: A Review of the Literature

Applying evidence-based guidelines can enhance the quality of patient care. While robust guideline development methodology ensures credibility and validity, methodological variations can impact guideline quality. Besides methodological rigor, effective implementation is crucial for achieving improved health outcomes. This review provides an overview of recent literature pertaining to the development and implementation of guidelines in pediatric surgery. Literature was reviewed to provide an overview of sound guideline development methodologies and approaches to promote effective guideline implementation. Challenges specific to pediatric surgery were highlighted. A search was performed to identify published guidelines relevant to pediatric surgery from 2018 to June 2023, and their quality was collectively appraised using the AGREE II instrument. High-quality guideline development can be promoted by using methodologically sound tools such as the Guidelines 2.0 checklist, the GRADE system, and the AGREE II instrument. While implementation can be promoted during guideline development and post-publication, its effectiveness may be influenced by various factors. Challenges pertinent to pediatric surgery, such as limited evidence and difficulties with outcome selection and heterogeneity, may impact guideline quality and effective implementation. Fifteen guidelines were identified and collectively appraised as suboptimal, with a mean overall AGREE II score of 58%, with applicability being the lowest scoring domain. There are identified challenges and barriers to the development and effective implementation of high-quality guidelines in pediatric surgery. It is valuable to prioritize the identification of adapted, innovative methodological strategies and the use of implementation science to understand and achieve effective guideline implementation.

Assessing the methodological strengths and limitations of the Spanish Society of Medical Oncology (SEOM) guidelines: a critical appraisal using AGREE II and AGREE-REX tool

BACKGROUND

The Spanish Society of Medical Oncology (SEOM) has provided open-access guidelines for cancer since 2014. However, no independent assessment of their quality has been conducted to date. This study aimed to critically evaluate the quality of SEOM guidelines on cancer treatment.

METHODS

Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE-REX tool was used to evaluate the qualities of the guidelines.

RESULTS

We assessed 33 guidelines, with 84.8% rated as "high quality". The highest median standardized scores (96.3) were observed in the domain "clarity of presentation", whereas "applicability" was distinctively low (31.4), with only one guideline scoring above 60%. SEOM guidelines did not include the views and preferences of the target population, nor did specify updating methods.

CONCLUSIONS

Although developed with acceptable methodological rigor, SEOM guidelines could be improved in the future, particularly in terms of clinical applicability and patient perspectives.

Advancing guideline quality through country-wide and regional quality assessment of CPGs using AGREE: a scoping review

BACKGROUND AND OBJECTIVE

Clinical practice guidelines (CPGs) are evaluated for quality with the Appraisal of Guidelines for Research and Evaluation (AGREE) tool, and this is increasingly done for different countries and regional groupings. This scoping review aimed to describe, map, and compare these geographical synthesis studies, that assessed CPG quality using the AGREE tool. This allowed a global interpretation of the current landscape of these country-wide or regional synthesis studies, and a closer look at its methodology and results.

STUDY DESIGN AND METHODS

A scoping review was conducted searching databases Medline, Embase, Epistemonikos, and grey literature on 5 October 2021 for synthesis studies using the later versions of AGREE (AGREE II, AGREE-REX and AGREE GRS) to evaluate country-wide or regional CPG quality. Country-wide or regional synthesis studies were the units of analysis, and simple descriptive statistics was used to conduct the analysis. AGREE scores were analysed across subgroups into one of the seven Sustainable Development Goal regions, to allow for meaningful interpretation.

RESULTS

Fifty-seven studies fulfilled our eligibility criteria, which had included a total of 2918 CPGs. Regions of the Global North, and Eastern and South-Eastern Asia were most represented. Studies were consistent in reporting and presenting their AGREE domain and overall results, but only 18% (n = 10) reported development methods, and 19% (n = 11) reported use of Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Overall scores for domains Rigor of development and Editorial independence were low, notably in middle-income countries. Editorial Independence scores, especially, were low across all regions with a maximum domain score of 46%. There were no studies from low-income countries.

CONCLUSION

There is an increasing tendency to appraise country-wide and regionally grouped CPGs, using quality appraisal tools. The AGREE tool, evaluated in this scoping review, was used well and consistently across studies. Findings of low report rates of development of CPGs and of use of GRADE is concerning, as is low domain scores globally for Editorial Independence. Transparent reporting of funding and competing interests, as well as highlighting evidence-to-decision processes, should assist in further improving CPG quality as clinicians are in dire need of high-quality guidelines.

Adapting a Clinical Practice Guideline for Management of Patients with Knee and Hip Osteoarthritis by Hong Kong Physiotherapists

Knee and hip osteoarthritis are common disabling conditions globally. Although numerous international clinical practice guidelines exist to guide physiotherapy management, not all recommendations issued from these guidelines can be translated to other contexts without considering the cultural acceptability and clinical implementability of targeted countries. Because the ADAPTE framework provides a robust methodology to adapt guidelines to the local context, this study used its methodology to adapt high-quality guideline recommendations to promote optimal physiotherapy care for knee and hip osteoarthritis in Hong Kong. The ADAPTE framework was used and modified to complete the adaptation process. International clinical practice guidelines were identified from eight guideline clearinghouses and six electronic databases. Two independent reviewers critically appraised the eligible guidelines using the AGREE II tool. We extracted and tabulated recommendations from high-quality guidelines. A voting-based consensus among interdisciplinary experts was conducted to decide on suitable recommendations for the Hong Kong context and whether there was a need to modify them. Pertinent recommendations were then translated into the traditional Chinese language. Our team members suggested modifying four tools and adding one to explore the patient's feedback on the recommendations, to the ADAPTE framework. The adaptation was performed on three high-quality guidelines. We adapted 28 and 20 recommendations for treating knee and hip osteoarthritis, respectively. We recommend a multimodal treatment for managing knee and hip osteoarthritis. Land- and aquatic-based exercises, patient education, and self-management were strongly recommended for patients with knee osteoarthritis. Land- and aquatic-based exercises were strongly recommended for patients with hip osteoarthritis. This is the first adaptation study in Hong Kong. It provides guidance to local physiotherapists on managing patients with knee and hip osteoarthritis. Future studies should test the effectiveness of implementing this adapted guideline to improve local physiotherapy care in Hong Kong.

The Appraisal of Clinical Practice Guidelines for Breast Cancer-Related Lymphedema

Background: Approaches to screening, assessment, and treatment of breast cancer-related lymphedema (BCRL) vary widely. We evaluated overall quality of clinical practice guidelines (CPGs) for managing BCRL using the Appraisal of Guidelines for REsearch and Evaluation II (AGREE II) tool, and relevance of consensus recommendations for the Canadian health context. Methods and Results: We searched electronic databases, gray literature, national lymphedema frameworks, and expert opinions, to identify lymphedema CPGs, printed/published from January 2013 to October 2021. Using AGREE II, six health care professionals reviewed CPGs for consensus. Domain-specific AGREE II quality consensus scores were required (≥70% for Rigor of Development; ≥ 60% for Stakeholder Involvement and Editorial Independence; and ≥50% for Clarity of Presentation, Applicability, Scope, and Purpose). Results and overall recommendations from the CPGs were summarized and synthesized. Nine CPGs met inclusion criteria for review. Wide variability of evidence-based recommendations, and limited clinical considerations were found. Scope and Purpose, and Clarity of Presentation were adequate in six of nine CPGs; Stakeholder Involvement in seven of nine CPGs; and Editorial Independence in three of nine CPGs. Across all CPGs, Applicability was minimally reported. Only the Queensland Health CPG met quality consensus scores for Rigor and Development; however, the focus was limited to compression therapy. Conclusions: No CPG reviewed could be adopted for the Canadian health context. The proposed Canadian BCRL CPG will focus on stakeholder engagement, methodology, and implementation/evaluation. Using AGREE II allowed for assessment of quality of methods used to develop identified CPGs from other countries before consideration of adoption in a Canadian Context.

The long-term risk of cardiovascular disease among women with a history of hypertensive disorders of pregnancy: a systematic review of clinical practice guidelines

BACKGROUND

The lifelong risks of cardiovascular disease following preeclampsia and gestational hypertension are well-established. However, it is unclear whether this evidence has been translated into clinical practice guidelines. Thus, this review aimed to assess the quality and content of Australian clinical practice guidelines regarding the risk of cardiovascular disease following gestational hypertension and preeclampsia.

METHODS

We conducted a systematic search of MEDLINE (Ovid), EMBASE (Ovid), and CINAHL databases, as well as hospital, obstetric society, and medical college websites. Publications were included if: they were a clinical practice guideline; were published in the previous ten years; and included recommendations for the management of future cardiovascular disease risk following hypertensive disorders of pregnancy. Quality assessment was performed using Appraisal of Guidelines for Research and Evaluation Instrument Version Two (AGREE-II) and AGREE Recommendations Excellence Instrument (AGREE-REX).

RESULTS

Eighteen guidelines were identified, and of these, less than half (n = 8) included recommendations for managing future cardiovascular risk following hypertensive disorders of pregnancy. Across these eight, four main counselling recommendations were found regarding (1) risk of future cardiovascular disease; (2) risk factor screening; (3) lifestyle interventions; and (4) prenatal counselling for future pregnancies. The quality and content of these recommendations varied significantly, and the majority of guidelines (87.5%) were assessed as low to moderate quality.

CONCLUSIONS

There are limited Australian clinical practice guidelines providing appropriate advice regarding future risk of cardiovascular disease following hypertensive disorders of pregnancy. The quality and content of these guidelines varied significantly. These findings highlight the need for improved translation from evidence-based research to enhance clinical care and guidance.

Clinical practice guidelines for frailty vary in quality but guide primary health care: a systematic review

OBJECTIVES

To appraise the methodological quality, clinical applicability, and reporting quality of clinical practice guidelines (CPGs) for frailty in primary care and identify research gaps using evidence mapping.

STUDY DESIGN AND SETTING

We conducted a systematic literature search in PubMed, Web of Science, Embase, CINAHL, guideline databases, and frailty or geriatric society websites. Appraisal of Guidelines Research and Evaluation II, AGREE-Recommendations Excellence, and Reporting Items for Practice Guidelines in Healthcare checklist were used to evaluate overall quality for frailty CPGs as "high", "medium", or "low" quality. We used bubble plots to show recommendations in CPGs.

RESULTS

Twelve CPGs were identified. According to the overall quality evaluation, five CPGs were considered as high quality, six as medium quality, and one as low quality. The recommendations in CPGs were generally consistent and mainly focused on frailty prevention, identification, multidisciplinary, nonpharmacological, and other treatments. However, evidence was lacking in some areas, such as effective prevention strategies and implementation of recommendations.

CONCLUSION

The frailty CPGs vary in quality but have consistent recommendations that can guide clinical practice in primary care. This could point the way for future research to address existing gaps and facilitate the development of trustworthy CPGs for frailty.

A systematic review and critical appraisal of guidelines and their recommendations for sedation interruptions in adult mechanically ventilated patients

OBJECTIVE

The objectives of the review were to (i) assess the methodological quality of all accessible and published guidelines and care bundles that offer a recommendation related to sedation interruptions, using the AGREE-II instrument, to (ii) determine what is the recommended best practice for sedation interruptions from the available guidelines, and then to have (iii) a closer inspection of the overall credibility and applicability of the recommendations using the AGREE-REX instrument. This review will benefit the outcomes of critically ill patients and the multidisciplinary team responsible for the care of mechanically ventilated adults with continuous medication infusions by providing a synthesis of the recommended action(s), actor(s), contextual information, target(s), and timing related to sedation interruptions from current best practice.

REVIEW METHOD USED

We conducted a systematic review.

DATA SOURCES

We applied a peer-reviewed search strategy to four electronic databases from 2010 to November 2021-MEDLINE, CINAHL, Embase, and The Cochrane Database of Systematic Reviews-and included grey literature.

REVIEW METHOD

Findings are reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses checklist. We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II and AGREE Recommendation Excellence tools.

RESULTS

We identified 11 clinical practice guidelines and care bundles comprising 15 recommendations related to sedation interruption. There are three key findings: (i) deficiencies exist with the methodological quality of included guidelines, (ii) sedation interruption is recommended practice for the care of adult mechanically ventilated patients, and (iii) the current evidence is of low quality, which impacts overall credibility and applicability of the recommendations.

CONCLUSIONS

Sedation interruptions are currently best practice for adult mechanically ventilated patients; however, the available guidelines and recommendations have several deficiencies. Future research is needed to further understand the role of the nurse and other actors to enact this practice.

Clinical practice guidelines for the antenatal management of dichorionic diamniotic twin pregnancies: a systematic review

OBJECTIVE

This review aimed to identify guidelines with recommendations applicable to the antenatal management of dichorionic diamniotic twin pregnancies within high-income countries, appraise their methodological quality, and discuss the similarities and variability across guidelines.

METHOD

A systematic literature review of electronic databases was performed. Manual searches of guideline repositories and websites of professional organisations were performed to identify additional guidelines. The protocol for this systematic review was registered on PROSPERO (CRD42021248586, 25 June 2021). AGREE II and AGREE-REX tools were applied to assess the quality of eligible guidelines. A narrative and thematic synthesis described and compared the guidelines and their recommendations.

RESULTS

Twenty-four guidelines were included, from which 483 recommendations were identified across 4 international organisations and 12 countries. Guidelines addressed eight themes and recommendations were classified accordingly: chorionicity and dating (103 recommendations), fetal growth (105 recommendations), termination of pregnancy (12 recommendations), fetal death (13 recommendations), fetal anomalies (65 recommendations), antenatal care (65 recommendations), preterm labour (56 recommendations) and birth (54 recommendations). Guidelines showed significant variability in recommendations, with conflicting recommendations regarding non-invasive preterm testing, definitions surrounding selective fetal growth restriction, screening for preterm labour and the timing of birth. Guidelines lacked a focus on standard antenatal management of DCDA twins, management of discordant fetal anomaly and single fetal demise.

CONCLUSIONS

Specific guidance for dichorionic diamniotic twins is overall indistinct and access to guidance regarding the antenatal management of these pregnancies is currently difficult. Management of discordant fetal anomaly or single fetal demise needs greater consideration.

Health equity considerations in guideline development: a rapid scoping review

BACKGROUND

Systematic guidance for considering health equity in guidelines is lacking. This scoping review aims to synthesize current best practices for integrating health equity into guideline development and the benefits or drawbacks of these practices.

METHODS

We searched Ovid MEDLINE ALL and Embase Classic+Embase on the Ovid platform, CINAHL on EBSCO, and Web of Science (Core Collection) from 2010 to 2022. We searched grey literature from 2015 to 2022, using the Canadian Agency for Drugs and Technologies in Health Grey Matters checklist and searches of potentially relevant websites. Articles were screened independently by 1 reviewer. Proposed best practices, advantages and disadvantages, and tools were extracted independently by 1 reviewer and qualitatively synthesized based on the relevant steps of a comprehensive checklist covering the stages of guideline development.

RESULTS

We included 26 articles that proposed best practices for incorporating health equity within the guideline development process. These practices were organized under different stages of the development process, including guideline planning, evidence review, guideline development and dissemination. Included studies provided best practices from guideline producers, articles discussing health equity in current guidelines, articles addressing strategies to increase equity in the guideline implementation process, and literature reviews of promising health equity practices.

INTERPRETATION

Our scoping review identified best practices to incorporate health equity considerations at each phase of guideline development. Identified practices may be used to inform equity-promoting strategies with the guideline development process; however, guideline producers should carefully consider the advantages and disadvantages of best practices when integrating health equity.

Quality and credibility of clinical practice guidelines recommendations for the management of neonatal hypoglycemia. A protocol for a systematic review and recommendations' synthesis

INTRODUCTION

Hypoglycemia is one of the most frequent metabolic conditions in neonates. Clinical practice guidelines (CPGs) influence clinical practice as high-quality CPGs facilitate the use of evidence in practice. This proposed study aims to systematically identify and appraise CPGs and CPG recommendations (CPGRs) for treating neonatal hypoglycemia (NH).

METHODS AND ANALYSIS

We will conduct searches in MEDLINE, EMBASE, CINAHL, Cochrane Library, LILACS (Latin American & Caribbean Health Sciences Literature), and Epistemonikos. Authors will search CPGs-specific databases and grey literature. Two reviewers will independently perform the titles and abstract screening, full-text review, and data extraction. Two appraisers will assess the quality of the CPGs and their recommendations using AGREE II (Appraisal of Guidelines Research and Evaluation) and AGREE-REX (Appraisal of Guidelines Research and Evaluation-Recommendations Excellence) instruments. Scores of ≥ 60% in the rigour of development domain will be considered for defining high-quality with AGREE II tool. CPGRs with scores >60% in the three domains will be used to determine high quality with the AGREE REX tool. We will perform a synthesis of the CPGRs to identify the consistency among the CPGRs and the methodological quality of primary studies that support them.

ETHICS AND DISSEMINATION

The results will help us to identify the methodological and quality gaps in the existing CPGs for the treatment of NH. Our findings will be submitted to peer-review journals and presented at academic conferences. Based on the study design, approval from the institutional ethics board is not required for this project.

TRIAL REGISTRATIONS

Systematic Review Registration Number (PROSPERO): CRD 42021239921.

Quality appraisal of clinical nutrition practice guidelines for critically ill adult patients: a systematic review using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX)

Nutritional therapy should follow evidence-based practice, thus several societies regarding nutrition and critical care have developed specific Clinical Practice Guidelines (CPG). However, to be regarded as trustworthy, the quality of the CPG for critically ill patients and its recommendations need to be high. This systematic review aimed to appraise the methodology and recommendations of nutrition CPG for critically ill patients. We performed a systematic review (protocol number CRD42020184199) with literature search conducted on PubMed, Embase, Cochrane Library and other four specific databases of guidelines up to October 2021. Two reviewers, independently, assessed titles and abstracts and potentially eligible full-text reports to determine eligibility and subsequently four reviewers appraised the guidelines quality using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX). Ten CPG for nutrition in critically ill patients were identified. Only Academy of Nutrition and Dietetics and European Society of Intensive Care Medicine had a total acceptable quality and were recommended for daily practice according AGREE-II. None of the CPG recommendations had an overall quality score above 70 %, thus being classified as moderate quality according AGREE-REX. The methodological evaluation of the critically ill adult patient CPG revealed significant discrepancies and showed a need for improvement in its development and/or reporting. In addition, recommendations about nutrition care process presented a moderate quality.

What information can we gain from the quality appraisal of guidelines with physical activity recommendations for cancer patients?A systematic review using the AGREE II and AGREE-REX tools

PURPOSE

There has been growing amount of evidence supporting the benefits of physical activity (PA) on oncological patients' cancer-related health outcomes. Although guidelines on cancer rehabilitation are widely available, the varying quality and practical applicability limited the clinical application of PA recommendations. To assist the future development of guidelines, in this systematic review, we evaluated the quality and applicability of current cancer rehabilitation guidelines with PA recommendations and synthesized PA recommendations for the oncological population.

METHODS

A systematic search was conducted in PubMed, CINAHL, PEDro, EMBASE, and guideline repositories to identify guidelines with PA recommendations for cancer patients from 1 May 2016 to 1 June 2022. The quality of included guidelines was appraised using the tools "Appraisal of Guidelines for Research and Evaluation II" (AGREE II) and AGREE-REX (Recommendation Excellence). PA recommendations were synthesized from the guidelines.

RESULTS

Sixteen guidelines were extracted. The AGREE II domain "clarity of presentation" obtained the highest score, while "applicability" received the lowest, ranging from 33.33% to 98.58%. The AGREE-REX domains "values and preferences" and "implementability" generally scored lower and ranged from 45.83% to 74.17% and 55% to 88.33%, respectively. Eight high-quality guidelines were identified, and the included PA recommendations were extracted.

CONCLUSION

There were some disparities in the quality of the included guidelines. Methodological weaknesses were commonly observed in domains "applicability," "values and preferences," and "implementability"; particular attention should be given to these domains when developing future guidelines. Furthermore, this analysis indicated that more rigorous, high-quality studies are needed to generate evidence for supporting PA recommendations and provide guidance on research gaps in the field of cancer rehabilitation.

ePOCT+ and the medAL-suite: Development of an electronic clinical decision support algorithm and digital platform for pediatric outpatients in low- and middle-income countries

Electronic clinical decision support algorithms (CDSAs) have been developed to address high childhood mortality and inappropriate antibiotic prescription by helping clinicians adhere to guidelines. Previously identified challenges of CDSAs include their limited scope, usability, and outdated clinical content. To address these challenges we developed ePOCT+, a CDSA for the care of pediatric outpatients in low- and middle-income settings, and the medical algorithm suite (medAL-suite), a software for the creation and execution of CDSAs. Following the principles of digital development, we aim to describe the process and lessons learnt from the development of ePOCT+ and the medAL-suite. In particular, this work outlines the systematic integrative development process in the design and implementation of these tools required to meet the needs of clinicians to improve uptake and quality of care. We considered the feasibility, acceptability and reliability of clinical signs and symptoms, as well as the diagnostic and prognostic performance of predictors. To assure clinical validity, and appropriateness for the country of implementation the algorithm underwent numerous reviews by clinical experts and health authorities from the implementing countries. The digitalization process involved the creation of medAL-creator, a digital platform which allows clinicians without IT programming skills to easily create the algorithms, and medAL-reader the mobile health (mHealth) application used by clinicians during the consultation. Extensive feasibility tests were done with feedback from end-users of multiple countries to improve the clinical algorithm and medAL-reader software. We hope that the development framework used for developing ePOCT+ will help support the development of other CDSAs, and that the open-source medAL-suite will enable others to easily and independently implement them. Further clinical validation studies are underway in Tanzania, Rwanda, Kenya, Senegal, and India.

Quality assessment of clinical practice guidelines for neonatal sepsis using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument: A systematic review of neonatal guidelines

Background and objective

Neonatal sepsis (NS) continues to be a critical healthcare priority for the coming decades worldwide. The aim of this study was to critically appraise the quality of recent clinical practice guidelines (CPGs) for neonatal sepsis and to summarize and compare their recommendations.

Methods

This study involves a systematic review of CPGs. We identified clinical questions and eligibility criteria and searched and screened for CPGs using bibliographic and CPG databases and professional societies. Each included CPG was assessed by four independent appraisers using the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument. We summarized the recommendations in a comparison practical table. The systematic review was drafted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Its protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42021258732).

Results

Our search retrieved 4,432 citations; of which five CPGs were eligible and appraised: American Academy of Pediatrics (AAP 2018) (35 and 34 weeks); Canadian Pediatric Society (CPS 2017); National Institute for Health and Care Excellence (NICE 2021); and Queensland Maternity and Neonatal Services (QH 2020). Among these, the overall assessment of two evidence-based CPGs scored > 70% (NICE and QH), which was consistent with their higher scores in the six domains of the AGREE II instrument. In domain 3 (rigor of development), NICE and QH scored 99 and 60%, respectively. In domain 5 (applicability), they scored 96 and 74%, respectively, and in domain 6 (editorial independence), they scored 90 and 71%, respectively.

Conclusion

The methodological quality of the NICE CPG was superior followed by the QH CPG with relevant recommendations for use in practice.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021258732, PROSPERO (CRD42021258732).

Quality and clinical applicability of recommendations for incontinence-associated dermatitis: A systematic review of guidelines and consensus statements

AIMS AND OBJECTIVES

The aim of this study was to assess methodological quality of all currently available guidelines and consensus statements for IAD using the Appraisal of Guidelines, Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence (AGREE-REX) instruments.

BACKGROUND

Globally, incontinence-associated dermatitis (IAD) is a significant health challenge. IAD is a complex healthcare problem that reduces quality of life of patients, increases healthcare costs and prolongs hospital stays. Several guidelines and consensus statements are available for IAD. However, the quality of these guidelines and consensus statements remains unclear.

DESIGN

A systematic review of guidelines and consensus statements.

METHODS

Our study was undertaken using PRISMA guidelines. We searched seven electronic databases. Guidelines and consensus statements had to be published in English, Chinese or German languages. Five independent reviewers assessed the methodological quality of guidelines and consensus statements using the AGREE II and AGREE-REX instruments. Mean with standard deviation (SD) and median with interquartile range (IQR) were calculated for descriptive analyses. We generated bubble plots to describe the assessment results of each domain of each guideline and consensus statement.

RESULTS

We included ten guidelines and consensus statements. The NICE guidelines, obtained the highest scores, fulfilled 86.11%-98.61% of criteria in AGREE II and 76.67%-91.11% for AGREE-REX. In the domains 'Stakeholder Involvement' (4.39 ± 1.64), 'Rigor of Development' (3.38 ± 1.86), 'Applicability' (3.62 ± 1.64), 'Editorial Independence' (3.91 ± 2.56) and 'Values and Preferences' (2.98 ± 1.41), the remaining guidelines and consensus statements showed deficiencies.

CONCLUSIONS

Altogether, this study demonstrated that the currently available guidelines and consensus statements for IAD have room for methodological improvement. NICE guidelines on faecal incontinence and urinary incontinence have better quality. Remaining guidelines and consensus statements showed substantial methodological weaknesses, especially the domains of 'Stakeholder Involvement', 'Rigor of Development', 'Applicability', 'Editorial independence' and 'Values and Preferences'. This study was registered on INPLASY. (Registration number: INPLASY202190078).

RELEVANCE TO CLINICAL PRACTICE

The currently available guidelines and consensus statements on IAD have room for methodological improvement.

Quality of clinical practice guidelines for gestational and congenital toxoplasmosis: A systematic review of the literature

OBJECTIVE

To evaluate the methodological quality and transparency of the clinical practice guidelines (CPGs) for the prevention, diagnosis, and treatment of gestational and congenital toxoplasmosis (CT).

METHODS

Systematic review of the literature on gestational and CT CPGs conducted in the MEDLINE, Embase, TripDatabase, Biblioteca Virtual en Salud databases and extensive manual searches in 19 CPG repositories. The characteristics of each of the guidelines were extracted using My AGREE PLUS on-line. Three reviewers assessed overall quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

RESULTS

The combined systematic review found 8651 citations. Of them 46 full texts were reviewed, and eight documents were finally included: four toxoplasmosis CPGs, three prenatal care CPGs that included recommendations on toxoplasmosis, and one pregnancy infection guideline that also included recommendations on toxoplasmosis. The AGREE II domains found to have the highest scores were 'clarity of presentation' (85%; [37%-100%]), followed by 'scope and purpose' (73%; [33%-98%]), and 'editorial independence' (51%; [3%-94%]); the domains with the lowest scores were 'rigour of development' (36%; [11%-79%]), 'stakeholder involvement' (34%; [24%-85%]), and 'applicability' (17%; [6%-83%]). The Colombian and Spanish-Agencia de Evaluación de Tecnologías Sanitarias de Andalucía (AETSA) CPGs had the highest global AGREE II scores. Absolute interrater agreement was good to excellent.

CONCLUSION

Substantial quality variation was found among CPGs, which provided recommendations in accordance with the context of the disease in the corresponding country or region. Only two of the CPGs appraised obtained a good score and are classified as 'recommended'.

Do clinical practice guidelines consider evidence about diagnostic test consequences on patient-relevant outcomes? A critical document analysis

RATIONALE, AIMS AND OBJECTIVES

Supporting evidence for diagnostic test recommendations in clinical practice guidelines (CPGs) should not only include diagnostic accuracy, but also downstream consequences of the test result on patient-relevant outcomes. The aim of this study is to assess the extent to which evidence-based CPGs about diagnostic tests cover all relevant test-treatment pathway components.

METHODS

We performed a systematic document analysis and quality assessment of publicly accessible CPGs about three common diagnostic tests: C-reactive protein, colonoscopy and fractional exhaled nitric oxide. Evaluation of the impact of the full test-treatment pathway (diagnostic accuracy, burden of the test, natural course of target condition, treatment effectiveness, and link between test result and administration of treatment) on patient relevant outcomes was considered best practice for developing medical test recommendations.

RESULTS

We retrieved 15 recommendations in 15 CPGs. The methodological quality of the CPGs varied from poor to excellent. Ten recommendations considered diagnostic accuracy. Four of these were funded on a systematic review and rating of the certainty in the evidence. None of the CPGs evaluated all steps of the test-treatment pathway. Burden of the test was considered in three CPGs, but without systematically reviewing the evidence. Natural course was considered in two CPGs, without a systematic review of the evidence. In three recommendations, treatment effectiveness was considered, supported with a systematic review and rating of the certainty in the evidence in one CPG. The link between test result and treatment administration was not considered in any CPG.

CONCLUSIONS

The included CPGs hardly seem to consider evidence about test consequences on patient-relevant outcomes. This might be explained by reporting issues and challenging methodology. Future research is needed to investigate how to facilitate guideline developers in explicit reliable consideration of all steps of a test-treatment pathway when developing diagnostic test recommendations.

European clinical practice guidelines on the use of chemotherapy for advanced oesophageal and gastric cancers: a critical review using the AGREE II and the AGREE-REX instruments

PURPOSE

To assess the methodological quality of all relevant and recent European clinical practice guidelines (CPGs) for advanced oesophageal and gastric cancers, and to synthesise their recommendations on the use of chemotherapy.

METHODS

We searched PubMed, EMBASE, guidelines repositories, and other sources from 2010 onwards. We appraised quality using AGREE-II and AGREE-REX.

RESULTS

11 CPGs were included (five high, five low, and one moderate quality). Most guidelines showed deficiencies in the domain "applicability", with only three scoring above 60%. Nine did not report having sought the views and preferences of the target population. The lowest scores for AGREE-REX were item Values and Preferences of Target Users (1.6; SD 1.3), and item Values and Preferences of Policy/Decision-Makers (1.8; SD 1.7). The domain Clinical Applicability got the highest score and the domain Implementability got the lowest.

CONCLUSIONS

An urgent area of research is how to develop credible and implementable recommendations on the clinical use of CT for advanced oesophageal and gastric cancer.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42021236753).

The quality and clinical applicability of recommendations in anxiety disorders guidelines: A systematic review of seventeen guidelines from seven countries

BACKGROUND

Anxiety disorders are the most common mental disorders, for which some countries and organizations have developed guidelines. It is necessary to understand the quality of these guidelines.

METHODS

The relevant guidelines were searched systematically by five reviewers using Appraisal of Guidelines for Research and Evaluation (AGREE) II and AGREE Recommendation Excellence (AGREE-REX) instruments. The scores in each domain were descriptively analyzed, and guidelines from different countries were compared.

RESULTS

Seventeen guidelines were included. The scores in the domains "rigor of development" and "applicability" were the lowest and ranged from 16% to 77% and 25% to 71%, respectively. The scores in the domains "implementability" and "values and preferences" were similar and ranged from 30% to 67% and 25% to 77%. In terms of the comparison among countries, the Canadian guidelines achieved the highest scores in many domains but only scored 43% in the domain of "values and preferences". The Indian guidelines scored less than 50% in many domains but achieved a high score of 83% in the domain "scope and purpose".

LIMITATIONS

Language restrictions may cause selection bias. Besides, insufficient reports may lead to deviation of assessment results.

CONCLUSIONS

There was no obvious advantage in guidelines from different countries. There was still a lot of room for improvement in some domains, especially "applicability", "implementability", "rigor of development" and "values and preferences".

Market viability: a neglected concept in implementation science

This debate paper asserts that implementation science needs to incorporate a key concept from entrepreneurship—market demand—and demonstrates how assessing an innovation’s potential market viability might advance the pace and success of innovation adoption and sustainment. We describe key concepts, language distinctions, and questions that entrepreneurs pose to implementation scientists—many of which implementation scientists appear ill-equipped to answer. The paper concludes with recommendations about how concepts from entrepreneurship, notably market viability assessment, can enhance the translation of research discoveries into real-world adoption, sustained use, and population health benefits. The paper further proposes activities that can advance implementation science’s capacity to draw from the field of entrepreneurship, along with the data foundations required to assess and cultivate market demand.

A protocol for a systematic review of clinical practice guidelines for the antenatal management of dichorionic diamniotic twin pregnancy

Overview: The protocol outlines the process designed to systematically review clinical practice guidelines (CPGs), addressing the antenatal management of dichorionic diamniotic (DCDA) twin pregnancies. Background: CPGs are statements that include recommendations intended to optimise patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. CPGs are typically created by scientific institutes, organisations and professional societies, and high-quality CPGs are fundamental to improve patient outcomes, standardise clinical practice and improve the quality of care. While CPGs are designed to improve the quality of care, to achieve this, the identification and appraisal of current international CPGs is required. Because twin pregnancies are identified as high-risk pregnancies, a systematic review of the CPGs in this field is a useful first step for establishing the required high level of care. Aim: The aim of the systematic review is to identify, appraise and examine published CPGs for the antenatal management of DCDA twin pregnancies, within high-income countries. Methods: We will identify published CPGs addressing any aspect of antenatal management of care in DCDA twin pregnancies, appraise the quality of the identified CPGs using the Appraisal of Guidelines for Research and Evaluation version 2 (AGREE II) the Appraisal of Guidelines Research and Evaluation - Recommendations excellence (AGREE-REX) instruments and examining the recommendations from the identified CPGs. Ultimately, this protocol aspires to clearly define the process for a reproducible systematic review of CPGs within a high-income country, addressing any aspect of antenatal management of DCDA twin pregnancies. PROSPERO registration: CRD42021248586 (24/06/2021).

The quality and clinical applicability of recommendations in pressure injury guidelines: A systematic review of clinical practice guidelines

BACKGROUND

Pressure injuries are one of the most frequently occurring, yet preventable hospital-acquired adverse events. Given there are many clinical practice guidelines available on the prevention and treatment of pressure injuries, it is useful to understand the quality of these guidelines and the clinical application of their recommendations.

OBJECTIVE

To critically evaluate the quality and applicability of the recommendations in pressure injury prevention and treatment clinical practice guidelines.

DESIGN

Systematic review, reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

We systematically searched the literature published from 2005 to 2020 using MEDLINE, EMBASE, CINAHL, the Cochrane Library, ProQuest and PubMed electronic databases, and nine guideline repositories.

REVIEW METHODS

We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE Recommendation Excellence (AGREE-REX) tools. Overall % mean scores across AGREE II and AGREE-REX domains were calculated for each guideline. Clinical practice guidelines were then ranked in tertiles based on "high", "moderate" or "low" quality. The review protocol was registered in the International Prospective Register of Systematic Reviews.

RESULTS

Initial combined database and repository searches yielded 3247 documents. Of these,73 full text documents were reviewed. The final analysis included 12 complete guidelines and 14 related documents. Overall AGREE II scores ranged from 32% to 96% while AGREE-REX scores were generally lower ranging from 10% to 75%. Combined % mean scores across AGREE II and AGREE-REX criteria suggest that four guidelines were ranked as "high" (range 69% to 85%) and are recommended without modification. These included; the 2019 International Guideline, the 2016 Canadian Guideline, the 2014 NICE Guideline, and the 2013 Belgian Guideline.

CONCLUSIONS

There is disparity in the quality of the included guidelines, however four high quality guidelines are available. These guidelines could ideally be implemented in daily practice and adapted to local policies.

Quality of 2019 American optometric association clinical practice guideline for diabetic eye care

PURPOSE

The 2019 American Optometric Association (AOA) clinical practice guideline intends to assist optometrists in providing evidence-based eye care for people with diabetes. This technical report evaluated the methodological and reporting quality of the guideline.

METHODS

Four independent reviewers appraised the 2014 and 2019 versions of the AOA's guideline using the AGREE II instrument. Average scaled scores across the six domains of the AGREE II and an overall independent score were calculated based on the formula provided.

RESULTS

The 2019 guideline scored high (range: 75-93%) in all domains except for the domain of applicability (34%). In the domain of rigour of development, significant improvements were noted in the 2019 guideline (median score: 7.0, interquartile range (IQR): 6.0-7.0) compared to the 2014 guideline (median: 5.0, IQR: 4.0-6.0) (p < 0.0001). The appraisal of the guideline also identified room for further improvements, especially in relation to implementing the guideline.

CONCLUSION

The overall and domain specific quality of the AOA 2019 guideline was high, however, improvement in its applicability domain is required. The findings of this study will aid uptake of the guideline and inform improvement efforts for other international optometric guidelines.