Appraisal of WHO guidelines in maternal health using the AGREE II assessment tool

Socioeconomic and ethnic disparities in preterm births in an English maternity setting: a population-based study of 1.3 million births

BACKGROUND

Preterm birth is a major cause of infant mortality and morbidity and accounts for 7-8% of births in the UK. It is more common in women from socially deprived areas and from minority ethnic groups, but the reasons for this disparity are poorly understood. To inform interventions to improve child survival and their quality of life, this study examined the socioeconomic and ethnic inequalities in preterm births (< 37 weeks of gestation at birth) within Health Trusts in England.

METHODS

This study investigated socioeconomic and ethnic inequalities in preterm birth rates across the National Health Service (NHS) in England. The NHS in England can be split into different units known as Trusts. We visualised between-Trust differences in preterm birth rates. Health Trusts were classified into five groups based on their standard deviation (SD) variation from the average national preterm birth rate. We used modified Poisson regression to compute risk ratios (RR) and 95% confidence intervals (95% CI) with generalised estimating equations.

RESULTS

The preterm birth rate ranged from 6.8/100 births for women living in the least deprived areas to 8.8/100 births for those living in the most deprived areas. Similarly, the preterm birth rate ranged from 7.8/100 births for white women, up to 8.6/100 births for black women. Some Health Trusts had lower than average preterm birth rates in white women whilst concurrently having higher than average preterm birth rates in black and Asian women. The risk of preterm birth was higher for women living in the most deprived areas and ethnicity (Asian).

CONCLUSIONS

There was evidence of variation in rates of preterm birth by ethnic group, with some Trusts reporting below average rates in white ethnic groups whilst concurrently reporting well above average rates for women from Asian or black ethnic groups. The risk of preterm birth varied substantially at the intersectionality of maternal ethnicity and the level of socioeconomic deprivation of their residency. In the absence of other explanations, these findings suggest that even within the same Health Trust, maternity care may vary depending on the women's ethnicity and/or whether she lives in an area of high socioeconomic deprivation. Thus, social factors are likely key determinants of inequality in preterm birth rather than provision of maternity care alone.

COVID-19 therapies for inpatients: a review and quality assessment of clinical guidelines

Owing to condensed development processes, expanding evidence and differences in healthcare system characteristics, many COVID-19 guidelines differ in their quality and treatment recommendations, which has consequences for clinical practice. This review aimed to identify COVID-19 treatment guidelines, assess their quality and summarise their recommendations. Guidelines were identified for five therapies most commonly used among inpatients with COVID-19 (remdesivir, dexamethasone, tocilizumab, baricitinib and casirivimab/imdevimab) from 11 countries. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Full details of recommendations and supporting evidence were analysed for high-quality guidelines, defined as those scoring ≥50% in Domain 3 (Rigour of Development) of AGREE-II. Overall, guidelines differed substantially in their quality and, even among high-quality guidelines using the same evidence, recommendations regarding specific therapeutics varied. Potential reasons for this heterogeneity, including the availability and consistency of clinical data, visibility of trial end-points and context-specific factors, are discussed.

Consumer engagement in health care policy, research and services: A systematic review and meta-analysis of methods and effects

To assess the effects of consumer engagement in health care policy, research and services. We updated a review published in 2006 and 2009 and revised the previous search strategies for key databases (The Cochrane Central Register of Controlled Trials; MEDLINE; EMBASE; PsycINFO; CINAHL; Web of Science) up to February 2020. Selection criteria included randomised controlled trials assessing consumer engagement in developing health care policy, research, or health services. The International Association for Public Participation, Spectrum of Public Participation was used to identify, describe, compare and analyse consumer engagement. Outcome measures were effects on people; effects on the policy/research/health care services; or process outcomes. We included 23 randomised controlled trials with a moderate or high risk of bias, involving 136,265 participants. Most consumer engagement strategies adopted a consultative approach during the development phase of interventions, targeted to health services. Based on four large cluster-randomised controlled trials, there is evidence that consumer engagement in the development and delivery of health services to enhance the care of pregnant women results in a reduction in neonatal, but not maternal, mortality. From other trials, there is evidence that involving consumers in developing patient information material results in material that is more relevant, readable and understandable for patients, and can improve knowledge. Mixed effects are reported of consumer-engagement on the development and/or implementation of health professional training. There is some evidence that using consumer interviewers instead of staff in satisfaction surveys can have a small influence on the results. There is some evidence that consumers may have a role in identifying a broader range of health care priorities that are complementary to those from professionals. There is some evidence that consumer engagement in monitoring and evaluating health services may impact perceptions of patient safety or quality of life. There is growing evidence from randomised controlled trials of the effects of consumer engagement on the relevance and positive outcomes of health policy, research and services. Health care consumers, providers, researchers and funders should continue to employ evidence-informed consumer engagement in their jurisdictions, with embedded evaluation.

Systematic review registration: PROSPERO CRD42018102595.

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

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

Quality of biosafety guidelines for dental clinical practice in world in early COVID-19 pandemic: A systematic review

OBJECTIVES

To conduct a systematic review of coronavirus disease 2019 (COVID-19)-related biosafety guidelines for dental clinical practice in the early stage of the pandemic, focusing on quality assessment.

METHODS

Electronic (via PubMed, Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature database, Brazilian Library in Dentistry, and Cochrane Library) and gray literature searches were performed for documents published up to May 12, 2020. Guidelines updated until April 17, 2021 were identified. Documents were included as guidelines if they (1) consisted of a set of statements, directions, or principles presenting current or future rules or policy; (2) were developed by government agencies, institutions, organizations, or expert panels; and (3) were related to the general conduct of healthcare activities rather a particular condition. Two researchers, using the Appraisal of Guidelines for Research & Evaluation II, independently extracted the recommendations and evaluated the quality of the guidelines.

RESULTS

Twenty-seven documents from 19 countries were included in the review. These documents presented 122 recommendations related to (1) professional biosafety; (2) patients’/companions’ safety; (3) the organization and biosafety of the physical dental facility environment; and (4) the work process in dental care. Overall, the scientific quality of the guidelines was considered low. Some recommendations presented in these guidelines would require further research to establish their effectiveness.

CONCLUSIONS

We found a wide variety of biosafety guidelines for dental practice regarding COVID-19 in the early months of the pandemic, but their quality was low. Biosafety recommendations should be frequently updated.

Lessons for and from the COVID-19 pandemic response - An appraisal of guidance for the public health management of Invasive Meningococcal Disease

BACKGROUND

COVID-19 has focussed public attention on the management of communicable disease like never before. Surveillance, contact tracing, and case management are recognised as key components of outbreak prevention. Development of guidance for COVID-19 has drawn from existing management of other communicable diseases, including Invasive Meningococcal Disease (IMD). IMD is a rare but severe outcome of Neisseria meningitidis infection that can be prevented through vaccination. Cases still occur sporadically, requiring ongoing surveillance and consistent management. To this end, national and international public health agencies have developed and published guidance for identification and management of IMD cases.

AIM

To assess national and international guidelines for the public health management of IMD, with a focus on the recommendations for identification and management of "close contacts" to IMD cases.

METHODS

Guidelines from six national and international public health agencies were assessed using a modified version of the Appraisal of Guidelines, Research and Evaluation (AGREE II) Instrument in four key domains: stakeholder involvement, developmental rigour, clarity, and applicability. A direct comparison of terminology and recommendations for identification and management of close contacts to IMD cases was also conducted.

RESULTS

Guidelines from Europe and the United Kingdom rated most highly using the AGREE II Instrument, both presenting a clear, critical assessment of the strength of the available evidence, and the risks, costs, and benefits behind recommendations for management of close contacts. Direct comparison of guidelines identified inconsistencies in the language defining close contacts to IMD cases.

CONCLUSION

Discrepancies between guidelines could be due to limited evidence concerning mechanisms behind disease transmission, along with the lack of a consistent process for development and review of guideline recommendations. COVID-19 management has demonstrated that international collaboration for development of public health guidance is possible, a practice that should be extended to management of other communicable diseases.

Integrating approaches for quality guideline development in LactaMap, an online lactation care support system

Background

Health professionals caring for women and infants experiencing difficulty with breastfeeding have reported deficiencies in evidence-based lactation knowledge. LactaMap is an online lactation care support system with more than 100 clinical practice guidelines to support breastfeeding care. Clinical practice guidelines support medical decision-making by summarising scientific evidence into systematically developed statements for specific clinical circumstances. Both common-sense and theory-based approaches have been used for guideline development and debate continues regarding which is superior. LactaMap clinical practice guidelines were created over the course of 5 years using a common-sense approach that was refined inductively. The aim of this study was to incorporate a theory-based framework approach into the methodology for ongoing update and review of LactaMap clinical practice guidelines.

Methods

The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was chosen as the framework-based approach to appraise LactaMap guideline quality. The study was conducted in two phases. The first phase appraised all 103 original LactaMap guidelines. The second phase appraised a subset of 15 updated LactaMap guidelines using improved methodology guided by phase 1, as well as 15 corresponding original (un-updated) guidelines.

Results

Mean Domain scores for 103 LactaMap original guidelines were above 75% in 3 of the 6 AGREE II quality Domains and no mean Domain score rated poorly. Update of guideline methodology was guided by phase 1 appraisals. Improved documentation of methods relating to questions in the Rigour of Development Domain resulted in improvement in mean Domain score from 39 to 72%.

Conclusions

This study showed that a theory-based approach to guideline development methodology can be readily integrated with a common-sense approach. Factors identified by AGREE II theory-based framework provided practical guidance for changes in methodology that were integrated prior to LactaMap website publication. Demonstration of high quality in LactaMap clinical practice guideline methodology ensures clinicians and the public can have trust that the content founded on them is robust, scientific and of highest possible quality.

Assessment of the quality, content and perceived utility of local maternity guidelines in hospitals in England implementing the saving babies' lives care bundle to reduce stillbirth

Introduction

The UK Department of Health have targeted a reduction in stillbirth by 50% by 2025; to achieve this, the first version of the Saving Babies’ Lives Care Bundle (SBLCB) was developed by NHS England in 2016 to improve four key areas of antenatal and intrapartum care. Clinical practice guidelines are a key means by which quality improvement initiatives are disseminated to front-line staff.

Methods

Seventy-five clinical practice guidelines covering the four areas of antenatal and intrapartum care in the first version of SBLCB were obtained from 19 maternity providers. The content and quality of guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Maternity health professionals in participating organisations were invited to participate in an anonymous survey to determine perceptions toward and experiences of the use of clinical practice guidelines using a series of Likert scales.

Results

Unit guidelines showed considerable variation in quality with median scores of 50%–58%. Only 4 (5.6%) guidelines were recommended for use in clinical practice without modifications, 54 (75.0%) were recommended for use subject to modifications and 12 (16.7%) were not recommended for use. The lowest scoring domains were ‘rigour of development’, ‘stakeholder involvement’ and ‘applicability’. A significant minority of unit guidelines omitted recommendations from national guidelines. The majority of staff believed that clinical practice guidelines standardised and improved the quality of care but over 30% had insufficient time to use them and 24% stated they were unable to implement recommendations.

Conclusion

To successfully implement initiatives such as the SBLCB change is needed to local clinical practice guidelines to reduce variation in quality and to ensure they are consistent with national recommendations. In addition, to improve clinical practice, adequate time and resources need to be in place to deliver and evaluate care recommended in the SBLCB.

Preschool wheezing and asthma in children: A systematic review of guidelines and quality appraisal with the AGREE II instrument

BACKGROUND

Asthma-like symptoms in preschool children, such as wheezing and dyspnea, are common time- and resource-consuming diagnostic and management challenges. Quality of wheezing and asthma recommendations varies. The purpose of this study, carried out by the European Academy of Allergy and Clinical Immunology (EAACI) Task Force for Preschool Wheeze, was to systematically review and assess the quality of guidelines for diagnosis and treatment of preschool wheezing and/or asthma.

METHODS

The Cochrane Library, MEDLINE, and EMBASE were searched until June 2018. The methodological rigor, quality, and transparency of relevant guidelines were assessed with the use of the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.

RESULTS

We identified 26 guidelines. The quality scores for each domain varied. Of all domains, clarity and presentation had the highest mean score, whereas applicability and stakeholder involvement had the lowest. The scores (median) for individual domains were as follows: score and purpose 86%; stakeholder involvement 49%; rigor of development 54%; clarity of presentation 85%; applicability 51%; and editorial independence 63%.

CONCLUSION

Although several guidelines on asthma management in children are available, however, their quality varies. Additionally, there is a considerable gap in reliable recommendations on the management and treatment of non-asthmatic preschool wheeze.

The quality assessment of intraabdominal infection guidelines/consensuses in 2 decades - which are better and any changes?

BACKGROUND AND AIM

Intraabdominal infection (IAI) is a common and important disease worldwide. An increasing number of related guidelines/consensuses have been published in recent years, the quality evaluation for these guidelines/consensuses is necessary to identify lower-quality documents and explore the quality distribution in different time range and areas in this field.

METHODS

The Appraisal of Guidelines for Research & Evaluation Instrument tool was adopted to assess the quality of IAI guidelines/consensuses by 3 researchers independently. Intraclass correlation coefficients (ICCs) among the researchers were retrieved to reflect reliability. The quality differences of these guidelines/consensuses issued before and after May 2009, both international and non-international, were compared by a Mann-Whitney U test.

RESULTS

Fourteen IAI guidelines/consensuses published in English were obtained following a literature search. The ICCs among the researchers were all above 0.75, indicating satisfactory reliability. This outcome showed that the overall quality of these guidelines/consensuses was mediocre and considered acceptable in all items. A few guidelines/consensuses were better in their scientific and methodological characteristics than the others. Moreover, there were no significant differences in the scores between the guidelines/consensuses issued before and after May 2009 or between international vs regional guidelines/consensuses.

CONCLUSIONS

Overall, the quality of the IAI guidelines/consensuses was generally acceptable and applicable, with a few deficiencies. Therefore, continuous improvement is essential. The guideline assessment tools should be applied in guideline/consensus development both widely and strictly to improve the methodological quality.

Appraisal of physical health guidelines for severe mental illness

Objectives The aim of this study was to identify current physical health guidelines for severe mental illness (SMI) and appraise them using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument. Methods Relevant research databases and grey literature were systematically searched to identify physical health guidelines for people with SMI. The grey literature was explored by web searches and targeted searches of the English websites of relevant peak bodies and government health agencies from Organisation for Economic Co-operation and Development countries. Included guidelines were independently appraised by two authors (NF and JH) using the AGREE II Instrument. Results Of the 5352 records screened, 33 were assessed for eligibility. Fifteen practice guidelines met the inclusion criteria. The median domain scores as rated by the AGREE II Instrument ranged from 17% to 69%. The World Health Organization guideline, which demonstrated a broad range of clinical recommendations and sound methodological rigour, was rated the best. Conclusions Most guidelines scored poorly when rated by the AGREE II Instrument. However, these guidelines may still be useful in assisting evidence-based clinical practice. The methodological rigour of future guidelines can be improved by ensuring the AGREE II domains are addressed during the development phase. What is known about the topic? Compared with the general population, people with SMI experience greater chronic disease morbidity and mortality. There is limited evidence from randomised controlled trials to guide physical health care monitoring for people with SMI. Current guidelines and practice are largely based on expert consensus, clinical experience and good intentions. What does this paper add? Using the AGREE II Instrument, this paper appraises the current physical health guidelines for people with SMI. The attributes of the guidelines examined included the evidence base, clarity of presentation, applicability in the real world, the involvement of stakeholders and conflicts of interest of various parties involved in guideline development. What are the implications for practitioners? This review highlights the scarcity of high-quality and evidence-based guidelines for clinicians and researchers to address the physical health of people with SMI.

Clinical practice guidelines for the management of community-acquired pneumonia: A critical appraisal using the AGREE II instrument

OBJECTIVE

The aim of this study was to appraise the methodological quality of published clinical practice guidelines (CPGs) of community-acquired pneumonia (CAP) using AGREE II instrument for further enhancing the CAP CPG development.

METHODS

We performed a systematic review of published CPGs on CAP from January 2007 to May 2019. All reviewers independently assessed each CPG using the AGREE II instrument. A standardised score was calculated for each of the six domains.

RESULTS

Our search strategy identified 4125 citations but just 18 met our inclusion criteria. Agreement among reviewers was very good: 0.98. The domains that scored better were: "scope and purpose" and "clarity and presentation". Those that scored worse were "editorial independence", and "applicability". According to the AGREE II evaluation for each Guideline, the NICE, IDSA, BTS, SWAB, Korea, Consensur II, Colombian and Peruvian CPGs were the only recommended with no further modifications. In addition, ERS and SEPAR CPGs were recommended with modifications, with lower scores regarding the editorial independence and applicability.

CONCLUSION

In conclusion, published CPGs for CAP management vary in quality with a need to improve the methodological and applicability rigour. This could be achieved following the standards for guidelines development and a better emphasis on how to apply CPGs recommendations in clinical practice.

Management of rectal cancer in Canada: an evidence-based comparison of clinical practice guidelines

Background

Rectal cancer requires a multidisciplinary and multimodality treatment approach. Clinical practice guidelines (CPGs) provide a framework for delivering consistent, evidence-based health care. We compared provincial/territorial CPGs across Canada to identify areas of variability and evaluate their quality.

Methods

We retrieved CPGs from Canadian organizations responsible for cancer care oversight and evaluated their quality and developmental methodology using the AGREE-II instrument. Recommendations for diagnostic and staging investigations, treatment by stage, and post-treatment surveillance of stage I–III rectal cancers were abstracted and compared.

Results

We identified 7 sets of CPGs for analysis, varying in content, presentation, quality, and year last updated. Differences were noted in locoregional staging: 4 recommended magnetic resonance imaging over endorectal ultrasonography, 2 recommended either modality, and 3 specified scenarios for one over the other. Recommendations also varied for use of staging computed tomography of the chest versus chest radiography and for surgical management and indications for transanal excision. Recommendations for neoadjuvant therapy in stage II/III disease also differed: 3 guidelines recommended long-course chemoradiation over short-course radiation therapy alone, while 3 others recommended short-course radiation in specific clinical scenarios. Adjuvant chemotherapy for stage II/III disease was uniformly recommended, with variable protocols. The use of proctosigmoidoscopy and interval/duration of endoscopic post-treatment surveillance varied among guidelines.

Conclusion

Canadian CPGs vary in their recommendations for staging, treatment, and surveillance of rectal cancer. Some of these differences reflect areas with limited definitive evidence. Consistent guidelines with uniform implementation across provinces/territories may lead to more equitable care to patients.

Migrant Healthcare Guidelines: A Systematic Quality Assessment

Significant international and cross-border migration has led to a growing availability of migrant healthcare guidelines (MHGs), which we systematically reviewed for quality. PubMed, MEDLINE, CINHAL, PsychINFO and guideline developer/guideline databases were searched for MHGs published 2006-2016. Three independent reviewers assessed eligible MHGs using the Appraisal of Guidelines, Research and Evaluation II instrument (AGREE II). MHGs were identified as high quality if they had a score of ≥ 60% in at least three of the six domains, including "rigour of development", and overall quality was assessed on a seven-point Likert scale. We included 32 MHGs. Overall agreement between reviewers was very good. Mean scores for each AGREE II domain were as follows: 85 ± 19.0% for "scope and purpose"; 51 ± 30.5% for "stakeholder involvement"; 34 ± 31.9% for "rigour of development"; 86 ± 7.3% for "clarity of presentation"; 40 ± 23.6% for "applicability"; and 27 ± 38.5% for "editorial independence". Nine and six MHGs were deemed "recommended" or "recommended with modifications", respectively, and 17 were "not recommended". Our review of MHGs has highlighted critical deficiencies in rigour of development, applicability, editorial independence and stakeholder involvement that point to the need for improvements in future MHGs.

The quality of guidelines for diabetic foot ulcers: A critical appraisal using the AGREE II instrument

This study aims to evaluate the quality of clinical practice guidelines(CPGs) for patients with diabetic foot worldwide. A search of guidelines websites, databases and academic institutions websites was performed from January 1^st, 2010, until June 30^th, 2018. Four assessors independently rated the quality of each CPG using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Twelve CPGs satisfied the inclusion criteria. The median scores for the 6 AGREE II domains (scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence) were 92.5%, 72.5%, 71.5%, 89%, 47%, and 77%, respectively. The overall quality of the CPGs was good since the majority of the CPGs reached an overall guideline quality between 5 and 7 points. Different CPGs had widely varying scores in the same area, ranging from 25 to 94 points.

Are paediatric clinical practice guidelines trustworthy?

AIM

To assess the methodological and reporting quality of paediatric clinical practice guidelines (CPGs) in National Guideline Clearinghouse (NGC) using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument and Reporting Items for Practice Guidelines in Healthcare (RIGHT) standard.

METHODS

We identified all published CPGs through the NGC, and search records were screened in duplicate for inclusion. Two researchers evaluated the methodological and reporting quality of paediatric CPGs using the AGREE II instrument and RIGHT standard. STATA version 12.0 and SPSS version 22.0 software were used to analyse the related data.

RESULTS

A total of 50 paediatric CPGs were included. The scores for all six domains by AGREE II instrument were presented as follows: scope and purpose (85.6 ± 9.59), stakeholder involvement (69.15 ± 19.32), rigour of development (73.19 ± 17.18), clarity of presentation (78.51 ± 14.36), applicability (54.61 ± 22.63) and editorial independence (68.42 ± 13.06). In the seven domains of the RIGHT standard, the reporting rate of the recommendation domain was the lowest (52.86%).The highest reporting rate was the other information domain, which was 68%.There was a high correlation between reporting the completeness of CPGs using the AGREE II instrument and RIGHT standard (r = 0.77, P < 0.001).

CONCLUSIONS

The paediatric CPGs from NGC have good quality. There was a high correlation in the completeness of reporting for paediatric CPGs using the AGREE II instrument and RIGHT standard. It could be concluded that the CPGs of good methodological quality have good reporting quality. Maybe the researcher should effectively combine the AGREE II instrument and RIGHT standard in the development process of CPGs.

Quality and utilization of the Finnish clinical practice guideline in schizophrenia: evaluation using AGREE II and the vignette approach

PURPOSE

This study aims to evaluate the quality of the Finnish clinical practice guideline related to schizophrenia care and how it can be utilized in psychiatric services.

PARTICIPANTS AND METHODS

The data were collected from one psychiatric ward and seven psychiatric outpatient units situated in two cities in Southern Finland. A total of 49 professionals working in these sites participated in this study. A descriptive study design was adopted. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument with six domains including 23 items was used to assess the quality of the guideline, whereas a vignette was implemented to describe how staff would use the guideline in hypothetical cases in daily practice. The analysis of AGREE II was based on rating each of the 23 items on a seven-point scale and calculating a quality score for the six domains. To describe the utilization of the guideline, eight key recommendations of the guideline were deductively rated out of the respondents' answers.

RESULTS

The results showed that the "scope and purpose" of the guideline were well described, but "applicability" was insufficient. The overall quality of the guideline was high (73%). Almost one fifth of the respondents were in agreement with key recommendations.

CONCLUSION

The overall quality of Guideline for Schizophrenia was good, but its "applicability" and utilization should be improved.

Evaluation of Noninvasive Prenatal Testing (NIPT) guidelines using the AGREE II instrument

Objective: The rapid increase of cell-free fetal DNA analysis for Down syndrome screening requires evidence-based clinical practice guidelines for noninvasive prenatal testing (NIPT). Several studies show that the quality of many guidelines is low and there are still many health areas where this quality is not systematically evaluated. Given the absence of research, in the NIPT field, we used an internationally validated tool to evaluate a set of three NIPT practice guidelines and to look at dimensions that can be improved.Methods: Four appraisers, experts in prenatal screening, evaluated three main NIPT guidelines published in the last 2 years using the AGREE II (Appraisal of Guidelines for Research and Evaluation II), a tool specifically designed for guideline quality appraisal.Results: Guidelines scored higher in domains related with scope, purpose, and clarity of presentation, and lower in stakeholder involvement and rigor of development. Intradomain items evaluation showed asymmetries between guidelines. The UK-NSC was the guideline with the best scores.Discussion: Several areas of NIPT guidelines, such as stakeholders involvement, selection of supporting evidence, external reviews, updating processes, and competing interests disclosure, can be improved. Appraisers recommend modifications to all NIPT guidelines that can lead to substantial improvements in their methodological quality and subsequently make a contribution to prenatal screening improvement.

An evaluation of the objective quality and perceived usefulness of maternity clinical practice guidelines at a tertiary maternity unit

BACKGROUND

Compliance with maternity clinical practice guidelines developed by National Women's Health has been found to be low at audit.

OBJECTIVE

To explore the reasons for poor compliance with maternity guidelines by evaluating the quality of a sample of National Women's Health guidelines using a validated instrument and assessing local guideline users' perceptions of and attitudes toward guidelines.

DESIGN

Five independent reviewers evaluated the quality of 10 purposively selected guidelines for adherence to the Appraisal of Guidelines Research & Evaluation (AGREE) II instrument standards. A self-administered questionnaire for staff was undertaken regarding views of and barriers to guideline use.

RESULTS

None of the guidelines attained a score over 50% for the following domains: stakeholder involvement, rigour of development, applicability, editorial independence. The highest scoring domain was clarity of presentation (mean 69%). All guidelines scored the minimum possible for editorial independence. Survey respondents had positive attitudes toward guidelines, believed that their use could improve quality of care within the service, and felt that encouragement from senior staff members and peers would encourage their use. Accessibility was the most commonly cited of many barriers identified.

CONCLUSION

The National Women's Health guidelines evaluated in this study cannot be considered to be high quality, and could be improved by reporting on methodology of the development process. Although poor guideline development may contribute to failure of the local maternity guidelines, it appears that accessibility is a major barrier to their use and implementation.

Systematic review of current guideline appraisals performed with the Appraisal of Guidelines for Research & Evaluation II instrument-a third of AGREE II users apply a cut-off for guideline quality

OBJECTIVES

To investigate whether Appraisal of Guidelines for Research & Evaluation (AGREE) II users apply a cut-off based on standardized domain scores or overall guideline quality to distinguish between high- and low-quality guidelines, as well as to investigate which criteria they use to generate this cut-off and which type of cut-off they apply.

STUDY DESIGN AND SETTING

We conducted a systematic search in MEDLINE, EMBASE, DARE, and the HTA-database for German- and English-language studies appraising guidelines with AGREE II. Information on cut-offs was extracted and analyzed descriptively.

RESULTS

We identified 118 relevant publications. Thirty-nine (33%) used a cut-off, of which 24 (62%) used a 2-step and 13 (33%) used a 3-step approach. The cut-off for high quality lay between 50% and 70% (2-step) and 60% and 83% (3-step) of the highest possible rating. Twenty-four (62%) publications applied a cut-off based on standardized domain scores and 7 (18%) based on overall guideline quality. Eleven (28%) applied cut-offs to derive the recommendation for guideline use.

CONCLUSION

A third of AGREE II users apply a cut-off to distinguish between high- and low-quality guidelines, often without clearly describing how the cut-off is generated. Many users might welcome a clear distinction between high- and low-quality guidelines; specifying a cut-off for this purpose might be useful.

Guideline appraisal with AGREE II: online survey of the potential influence of AGREE II items on overall assessment of guideline quality and recommendation for use

BACKGROUND

The AGREE II instrument is the most commonly used guideline appraisal tool. It includes 23 appraisal criteria (items) organized within six domains. AGREE II also includes two overall assessments (overall guideline quality, recommendation for use). Our aim was to investigate how strongly the 23 AGREE II items influence the two overall assessments.

METHODS

An online survey of authors of publications on guideline appraisals with AGREE II and guideline users from a German scientific network was conducted between 10th February 2015 and 30th March 2015. Participants were asked to rate the influence of the AGREE II items on a Likert scale (0 = no influence to 5 = very strong influence). The frequencies of responses and their dispersion were presented descriptively.

RESULTS

Fifty-eight of the 376 persons contacted (15.4%) participated in the survey and the data of the 51 respondents with prior knowledge of AGREE II were analysed. Items 7-12 of Domain 3 (rigour of development) and both items of Domain 6 (editorial independence) had the strongest influence on the two overall assessments. In addition, Items 15-17 (clarity of presentation) had a strong influence on the recommendation for use. Great variations were shown for the other items. The main limitation of the survey is the low response rate.

CONCLUSIONS

In guideline appraisals using AGREE II, items representing rigour of guideline development and editorial independence seem to have the strongest influence on the two overall assessments. In order to ensure a transparent approach to reaching the overall assessments, we suggest the inclusion of a recommendation in the AGREE II user manual on how to consider item and domain scores. For instance, the manual could include an a-priori weighting of those items and domains that should have the strongest influence on the two overall assessments. The relevance of these assessments within AGREE II could thereby be further specified.

Review and appraisal of guidelines for the management of asthma during pregnancy

BACKGROUND

Asthma affects 12.7% of pregnancies in Australia. Poorly controlled asthma is associated with increased maternal and infant morbidity and mortality. Optimal antenatal management of asthma during pregnancy has the potential to reduce complications relating to asthma. Evidence-based clinical practice guidelines help to translate health research findings into practice and when implemented can improve health outcomes. National and International guidelines currently provide recommendations for optimal asthma care in pregnancy.

AIM

To appraise the existing asthma in pregnancy guidelines with respect to their evidence for recommendations, consistency of recommendations and appropriateness for clinical practice.

METHOD

The Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to appraise four English language asthma in pregnancy guidelines, published or updated between 2007 and 2016. The recommendations, range and level of evidence was analysed.

RESULTS

Two of the four guidelines scored highly in most domains of the appraisal. Many of the recommendations made in the appraised guidelines were consistent. Due to the lack of randomised controlled trials involving pregnant women with asthma, most recommendations were evidenced by consensus and expert opinion rather than high quality meta-analysis, systematic reviews of randomised controlled trials.

CONCLUSION

The recommended antenatal asthma management was generally consistent among the guidelines but lacked clarity in some areas which then leave them open to interpretation. More randomised controlled trials involving pregnant women with asthma are required to fortify the recommendations made and asthma management guidelines should be included in Australian Antenatal Care Guidelines as they currently are not.

A critical review of recent clinical practice guidelines for pediatric urinary tract infection

INTRODUCTION

Concerns regarding the quality, credibility, and applicability of recently published pediatric urinary tract infection (UTI) clinical practice guidelines have been raised due to the inconsistencies of recommendations between them. We aimed to determine the quality of the recent clinical practice guidelines on pediatric UTI by using the Appraisal of Guidelines Research and Evaluation (AGREE II) instrument, and summarize the standard of care in diagnosis and management of pediatric UTI from the top three clinical practice guidelines.

METHODS

A systematic literature search was performed on medical literature electronic databases and international guideline repository websites. English language-based clinical practice guidelines from 2007-2016 endorsed by any international society or government organization providing recommendations for the management of pediatric UTI were considered. Eligible clinical practice guidelines were independently appraised by six reviewers using the AGREE II tool. Clinical practice guidelines were assessed for standardized domains and summarized for overall quality. Inter-rater reliability was assessed using inter-class coefficient (ICC).

RESULTS

Thirteen clinical practice guidelines were critically reviewed. The Spanish clinical practice guidelines, American Academy of Pediatrics, and National Institute for Health and Clinical Excellence clinical practice guidelines consistently scored high on all AGREE domains (total averaged domain scores 90, 88, and 88, respectively). Among the six reviewers, there was a high degree of inter-rater reliability (average measure ICC 0.938; p<0.0001). There is reasonable consensus among the top three clinical practice guidelines in their major recommendations.

CONCLUSIONS

The clinical practice guidelines from Spain, American Academy of Pediatrics, and National Institute for Health and Clinical Excellence, with their major recommendations being similar, have scored highly on the AGREE II indicators of quality for the clinical practice guidelines development process.

An appraisal of practice guidelines for smoking cessation in people with severe mental illness

OBJECTIVE

To review the quality of current smoking cessation guidelines that include recommendations for people with severe mental illness.

METHODS

A systematic search of scientific databases, central government health authority websites, psychiatry peak bodies, guideline clearing houses and Google was undertaken for relevant smoking cessation guidelines. Three reviewers independently assessed guideline quality using the AGREE II (Appraisal of Guidelines for REsearch and Evaluation II) instrument. Two reviewers extracted recommendations specific to smokers with severe mental illness.

RESULTS

Thirteen guidelines met the inclusion criteria. Seven guidelines scored ⩾60% in at least four domains. Median scores for 'Editorial independence', 'Rigour of development', 'Stakeholder Involvement' and 'Applicability' were less than 60%. The highest median scores were for 'Scope and purpose' (87%, 69-96%) and 'Clarity of presentation' (87%, 56-98%). 'Editorial independence' (33.3%, 0-86%) and 'Rigour of development' (54%, 11-92%) had the lowest median domain scores. The guidelines varied greatly in their recommendations but the majority recommended nicotine replacement therapy, bupropion or varenicline as first-line pharmacotherapy, along with behavioural support.

CONCLUSION

Many guidelines did not adequately report their methods or the competing interests of the authors. Future guidelines development may benefit from more specifically addressing AGREE II criteria and the needs of smokers with severe mental illness.

A critical appraisal of guidelines used for management of severe acute malnutrition in South Africa's referral system

Background

Focusing on healthcare referral processes for children with severe acute malnutrition (SAM) in South Africa, this paper discusses the comprehensiveness of documents (global and national) that guide the country’s SAM healthcare. This research is relevant because South African studies on SAM mostly examine the implementation of WHO guidelines in hospitals, making their technical relevance to the country’s lower level and referral healthcare system under-explored.

Methods

To add to both literature and methods for studying SAM healthcare, we critically appraised four child healthcare guidelines (global and national) and conducted complementary expert interviews (n = 5). Combining both methods enabled us to examine the comprehensiveness of the documents as related to guiding SAM healthcare within the country’s referral system as well as the credibility (rigour and stakeholder representation) of the guideline documents’ development process.

Results

None of the guidelines appraised covered all steps of SAM referrals; however, each addressed certain steps thoroughly, apart from transit care. Our study also revealed that national documents were mostly modelled after WHO guidelines but were not explicitly adapted to local context. Furthermore, we found most guidelines’ formulation processes to be unclear and stakeholder involvement in the process to be minimal.

Conclusion

In adapting guidelines for management of SAM in South Africa, it is important that local context applicability is taken into consideration. In doing this, wider stakeholder involvement is essential; this is important because factors that affect SAM management go beyond in-hospital care. Community, civil society, medical and administrative involvement during guideline formulation processes will enhance acceptability and adherence to the guidelines.

A review of the quality of current diabetes clinical practice guidelines

OBJECTIVE

To obtain an evaluation of current type 2 diabetes mellitus (T2DM) clinical practice guidelines.

METHODS

Relevant guidelines were identified through a systematic search of MEDLINE/PubMed. Pan American Health Organization (PAHO) country offices were also contacted to obtain national diabetes guidelines in use but not published/available online. Overall, 770 records were identified on MEDLINE/PubMed for citations published from 2008 to 2013. After an initial screening of these records, 146 were found to be guidelines related to diabetes. Inclusion and exclusion criteria were used to further refine the search and obtain a feasible number of guidelines for appraisal. Guideline evaluation was conducted by health professionals using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, which was developed to address the issue of variability in guideline quality and assesses the methodological rigor and transparency in which a guideline is developed. A total of 17 guidelines were selected and evaluated.

RESULTS

Ten guidelines scored ≥ 70% and seven guidelines scored ≥ 80%. The range was 21%-100%. The mean scores for Latin America and the Caribbean (LAC) country guidelines (n = 6) were compared to the mean scores for non-LAC country guidelines (n = 11). International guidelines consistently scored notably higher in all domains and overall quality than LAC guidelines.

CONCLUSIONS

Based on this study's findings, it is clear that T2DM clinical practice guideline development requires further improvements, particularly with regard to the involvement of stakeholders and editorial independence. This issue is most apparent for LAC country guidelines, as their quality requires major improvement in almost all aspects of the AGREE II criteria. Continued efforts should be made to generate and update high-quality guidelines to improve the management of increasingly prevalent noncommunicable diseases, such as T2DM.

Quality assessment of clinical practice guidelines for eosinophilic esophagitis using the AGREE II instrument

BACKGROUND

High-quality evidence-based clinical practice guidelines can guide diagnosis and treatment to optimize outcomes. We aimed to systematically review the quality of international guidelines on eosinophilic esophagitis (EoE).

METHODS

MEDLINE and Scopus databases were searched for appropriate guidelines up to 2016. Two gastroenterologists and two methodologists independently evaluated the documents using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

RESULTS

Amongst the 25 records initially retrieved, four guidelines developed by recognized scientific organizations met inclusion criteria. AGREE II results varied widely across domains, but none achieved an overall assessment score of over 60%. Scope and purpose (61.82 ± 19.24%), clarity of presentation (57.13 ± 40.56%) and editorial independence (93.75 ± 1.69%) showed the highest mean rating, whereas stakeholder involvement (28.82 ± 11.19%), rigor of development (32.29 ± 12.02%) and applicability (21.62 ± 7.14%) did not reach quality thresholds. Intraclass correlation coefficients for agreement was excellent among appraisers (0.903), between gastroenterologists and methodologists (0.878) and for each individual guideline (0.838 to 0.955).

CONCLUSION

Clinical practice guidelines for EoE vary significantly in quality, are invariably limited and currently, none can be 'strongly recommended'.

Guideline appraisal with AGREE II: Systematic review of the current evidence on how users handle the 2 overall assessments

INTRODUCTION

The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument is the most commonly used guideline appraisal tool. It includes 23 appraisal criteria (items) organized within 6 domains and 2 overall assessments (1. overall guideline quality; 2. recommendation for use). The aim of this systematic review was twofold. Firstly, to investigate how often AGREE II users conduct the 2 overall assessments. Secondly, to investigate the influence of the 6 domain scores on each of the 2 overall assessments.

MATERIALS AND METHODS

A systematic bibliographic search was conducted for publications reporting guideline appraisals with AGREE II. The impact of the 6 domain scores on the overall assessment of guideline quality was examined using a multiple linear regression model. Their impact on the recommendation for use (possible answers: "yes", "yes, with modifications", "no") was examined using a multinomial regression model.

RESULTS

118 relevant publications including 1453 guidelines were identified. 77.1% of the publications reported results for at least one overall assessment, but only 32.2% reported results for both overall assessments. The results of the regression analyses showed a statistically significant influence of all domains on overall guideline quality, with Domain 3 (rigour of development) having the strongest influence. For the recommendation for use, the results showed a significant influence of Domains 3 to 5 ("yes" vs. "no") and Domains 3 and 5 ("yes, with modifications" vs. "no").

CONCLUSIONS

The 2 overall assessments of AGREE II are underreported by guideline assessors. Domains 3 and 5 have the strongest influence on the results of the 2 overall assessments, while the other domains have a varying influence. Within a normative approach, our findings could be used as guidance for weighting individual domains in AGREE II to make the overall assessments more objective. Alternatively, a stronger content analysis of the individual domains could clarify their importance in terms of guideline quality. Moreover, AGREE II should require users to transparently present how they conducted the assessments.

Quality of clinical practice guidelines in delirium: a systematic appraisal

OBJECTIVE

To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality.

DESIGN

Systematic literature search for formal guidelines (in English or French) with focus on delirium assessment and/or management in adults (≥18 years), guideline summary papers and evaluation studies.Full appraisal of delirium guidelines published between 2008 and 2013 and obtaining a 'Rigour of Development' domain screening score cut-off of >40% using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

DATA SOURCES

Multiple bibliographic databases, guideline organisation databases, complemented by a grey literature search.

RESULTS

3327 database citations and 83 grey literature links were identified. A total of 118 retrieved delirium guidelines and related documents underwent full-text screening. A final 21 delirium guidelines (with 10 being >5 years old), 12 guideline summary papers and 3 evaluation studies were included. For 11 delirium guidelines published between 2008 and 2013, the screening AGREE II 'Rigour' scores ranged from 3% to 91%, with seven meeting the cut-off score of >40%. Overall, the highest rating AGREE II domains were 'Scope and Purpose' (mean 80.1%, range 64-100%) and 'Clarity and Presentation' (mean 76.7%, range 38-97%). The lowest rating domains were 'Applicability' (mean 48.7%, range 8-81%) and 'Editorial Independence' (mean 53%, range 2-90%). The three highest rating guidelines in the 'Applicability' domain incorporated monitoring criteria or audit and costing templates, and/or implementation strategies.

CONCLUSIONS

Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice.

Appraising the methodological quality of the clinical practice guideline for diabetes mellitus using the AGREE II instrument: a methodological evaluation

OBJECTIVES

To evaluate the methodological quality of the Palestinian Clinical Practice Guideline for Diabetes Mellitus using the Translated Arabic Version of the AGREE II.

DESIGN

Methodological evaluation. A cross-cultural adaptation framework was followed to translate and develop a standardised Translated Arabic Version of the AGREE II.

SETTING

Palestinian Primary Healthcare Centres.

PARTICIPANTS

Sixteen appraisers independently evaluated the Clinical Practice Guideline for Diabetes Mellitus using the Translated Arabic Version of the AGREE II.

MAIN OUTCOME MEASURES

Methodological quality of diabetic guideline.

RESULTS

The Translated Arabic Version of the AGREE II showed an acceptable reliability and validity. Internal consistency ranged between 0.67 and 0.88 (Cronbach's α). Intra-class coefficient among appraisers ranged between 0.56 and 0.88. The quality of this guideline is low. Both domains 'Scope and Purpose' and 'Clarity of Presentation' had the highest quality scores (66.7% and 61.5%, respectively), whereas the scores for 'Applicability', 'Stakeholder Involvement', 'Rigour of Development' and 'Editorial Independence' were the lowest (27%, 35%, 36.5%, and 40%, respectively).

CONCLUSIONS

The findings suggest that the quality of this Clinical Practice Guideline is disappointingly low. To improve the quality of current and future guidelines, the AGREE II instrument is extremely recommended to be incorporated as a gold standard for developing, evaluating or updating the Palestinian Clinical Practice Guidelines. Future guidelines can be improved by setting specific strategies to overcome implementation barriers with respect to economic considerations, engaging of all relevant end-users and patients, ensuring a rigorous methodology for searching, selecting and synthesising the evidences and recommendations, and addressing potential conflict of interests within the development group.

Guidelines on vitamin D replacement in bariatric surgery: Identification and systematic appraisal

INTRODUCTION

Bariatric surgery is the most effective therapeutic option to reduce weight in morbidly obese individuals, but it results in a number of mineral and vitamin deficiencies. Clinical Practice Guidelines (CPGs) attempt to balance those benefits and harms to provide guidance to physicians and patients.

OBJECTIVES

We compare and evaluate the quality of the evidence and of the development process of current CPGs that provide recommendations on vitamin D replacement in patients undergoing bariatric surgery, using a validated tool.

METHODS

We searched 4 databases, with no time restriction, to identify relevant and current CPGs. Two reviewers assessed eligibility and abstracted data, in duplicate. They evaluated the quality of CPGs development process using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) tool that consists of 6 domains. A content expert verified those assessments.

RESULTS

We identified 3 eligible CPGs: (1) the Endocrine Society (ES) guidelines (2010); (2) the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and the American Society for Metabolic & Bariatric Surgery (ASMBS) guidelines (update 2013); and (3) the Interdisciplinary European (IE) guidelines on Metabolic and Bariatric Surgery (latest update 2014). The ES and the AACE/TOS/ASMBS guidelines recommended high doses of vitamin D, varying from 3000IU daily to 50,000IU 1-3 times weekly. Vitamin D doses were not mentioned in the IE guidelines. The recommendations were based on a low quality of evidence, if any, or limited to a single high quality trial, for some outcomes. In terms of quality, only the IE guidelines described their search methodology but none of the CPGs provided details on evidence selection and appraisal. None of the three CPGs rigorously assessed the preferences of the target population, resource implications, and the applicability of these guidelines. According to the AGREE II tool, we rated the ES guidelines as average in quality, and the other two as low in quality.

CONCLUSION

Current CPGs recommendations on vitamin D supplementation in bariatric surgery differ between societies. They do not fulfill criteria for optimal guideline development, in part possibly due to limited resources, and are based on expert opinion. Thus, the pressing need for high quality randomized trials to inform CPGs, to be developed based on recommended standards.

Nursing Practice Guidelines in China do Need Reform: A Critical Appraisal Using the AGREE II Instrument

BACKGROUND

An increasing number of nursing practice guidelines (NPGs) of varying methodological and reporting quality have been issued and published in international journals. Currently, the quality of NPGs in mainland China has not been explored.

OBJECTIVE

To assess the quality of NPGs in China mainland using the AGREE II (Advancing Guideline Development, Reporting and Evaluation in Health Care) instrument.

METHODS

The authors searched the electronic databases of Chinese Biomedical Literature Database, China National Knowledge Infrastructure, The VIP Database, Wan Fang Database, Chinese Master's Theses Full-Text Database, China Doctor Dissertation Full-Text Database, and China Proceedings of Conference Full-Text Database and the web of China Guideline Clearinghouse for NPGs in China published from the inception of databases to December, 2013. Four independent assessors rated the quality of each guideline using AGREE II. The authors classified NPGs into two types: evidence-based NPG (EB-NPG) and consensus-based NPG (CB-NPG), and compared their quality. The authors also considered whether the quality of NPGs changed over time.

RESULTS

Forty-two NPGs were appraised. Methodological rigor and reporting of NPGs were poor. Across all guidelines, the appraisers assigned the highest scores to the domain "scope and purpose," and the lowest scored to the domain of "editorial independence." EB-NPGs were significantly superior to the CB-NPGs in the domains of "stakeholder involvement," "rigor of development," and "editorial independence." There was no improvement over time for all domains.

LINKING EVIDENCE TO ACTION

This research found an absence of a systematic guideline development methodology and a tendency to rely on expert opinion in the process of developing NPGs. The readers should consider these flaws and limitations when using recommendations in those NPGs.

The 'Adapted ADAPTE': an approach to improve utilization of the ADAPTE guideline adaptation resource toolkit in the Alexandria Center for Evidence-Based Clinical Practice Guidelines

RATIONALE, AIMS AND OBJECTIVES

The ADAPTE methodology for adaptation of guidelines has been used by many organizations to develop high-quality clinical practice guidelines. Although it is a valid alternative for de novo development of guidelines, it might demand more time and resources in some institutions. The present study demonstrates the proposed 'adapted ADAPTE' methodology to support more clarity, simplicity and practicality. It also aims at avoiding duplication within the process and reducing the resources and time allocated to the CPG adaptation projects.

METHODS

Clinical guidelines' adaptation in the Center for Evidence-Based Clinical Practice Guidelines at the Alexandria Faculty of Medicine and University Hospitals involves two stages: (1) cross-sectional or retrospective study to reveal the current practice and prescribing patterns concerning the selected health topic; (2) the 'adapted ADAPTE' methodology for CPGs adaptation that was based on the original ADAPTE Process.

RESULTS

The 'adapted ADAPTE' included three modified tools, three new tools based on the original ADAPTE framework and alternatives for four ADAPTE steps to enhance utilization. The finalized adapted CPGs included nine high priority topics for paediatrics and two topics for emergency medicine.

CONCLUSIONS

The ADAPTE methodology for guideline adaptation can be customized or 'adapted' to the local health care setting and resources. This proposal facilitates supports and improves the utilization and update of the ADAPTE process by CPG programmes or activities in health care organizations. This is of particular importance in health care systems in developing countries with limited resources in the Eastern Mediterranean region like Egypt.

A critical review of recent clinical practice guidelines on the diagnosis and treatment of non-neurogenic male lower urinary tract symptoms

INTRODUCTION

We provide an overview of the quality of recent clinical clinical practice guidelines (CPGs) for non-neurogenic male lower urinary tract symptoms (LUTS) and summarize the recommendations for their diagnosis, assessment, and treatment.

METHODS

We systematically searched recent (2008-2013) CPGs for non-neurogenic male LUTS. Eligible CPGs were assessed and appraised using Appraisal of Guidelines, Research and Evaluation II (AGREE II) tool by a CPG-appraisal group. The appraisal scores for each guideline were summarized according to each domain and in total. A recommendation summary was made across the guidelines for diagnostics, conservative management, medical, minimally invasive therapy, and surgical management.

RESULTS

A total of 8 guidelines were considered. According to AGREE II appraisal of guidelines, the National Institute for Health and Clinical Excellence (NICE), American Urological Association (AUA) and European Association of Urology (EAU) consistently scored high on the guideline domains assessed. Recommendations on diagnostics, conservative management, medical, and surgical management were consistent among the top 3 guidelines. However, we noted a discrepancy in recommending minimally invasive therapy as an alternative management of moderate to severe or bothersome non-neurogenic male LUTS secondary to benign prostatic enlargement (BPE); the NICE guideline, in particular, does not recommend using minimally invasive therapy.

CONCLUSION

The quality of recent CPGs on non-neurogenic male LUTS was appraised and summarized. The guidelines from NICE, AUA and EAU were considered highly compliant to the AGREE II proposition for guideline formation and development.

Evaluation of the quality of guidelines for the management of reduced fetal movements in UK maternity units

Background

The development of evidence-based guidelines is a key step in ensuring that maternity care is of a universally high standard. To influence patient care national and international guidelines need to be interpreted and implemented locally. In 2011, the Royal College of Obstetricians and Gynaecologists published guidelines for the management of reduced fetal movements (RFM), which can be an important symptom of fetal compromise. Following dissemination it was anticipated that this guidance would be implemented in UK maternity units. This study aimed to assess the quality of local guidelines for the management of RFM in comparison to published national standards.

Methods

Cross-sectional survey of maternity unit guidelines for RFM. The guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool and scored by two independent investigators. Two national guidelines were used as standards to evaluate unit guidelines.

Results

Responses were received from 98 units (42%); 12 units had no guideline. National guidelines scored highly using the AGREE II tool but there was wide variation in the quality of individual maternity unit guidelines, which were frequently of low quality. No guidelines incorporated all the recommendations from the national guideline. Maternity unit guidelines performed well for clarity and presentation but had low scores for stakeholder involvement, rigour of development and applicability.

Conclusions

In contrast to national evidence based guidance the quality of maternity unit guidelines for RFM is variable and frequently of low quality. To increase quality, guidelines need to include up to date evidence and audit standards which could be taken directly from national evidence-based guidance. Barriers to local implementation and resource implications need to be taken into consideration. Training may also improve the implementation of the guideline. Research is needed to inform strategies to realize the benefits of clinical guidance in practice.

Appraisal of guidelines developed by the World Health Organization

OBJECTIVE

To appraise the quality of guidelines developed by the World Health Organization (WHO) that were approved by its Guidelines Review Committee (GRC) and identify strengths and weaknesses in the guideline development process.

STUDY DESIGN

Cross-sectional.

METHODS

Three individuals independently assessed GRC-approved WHO guidelines using the Appraisal of Guidelines for Research and Evaluation II instrument (AGREE II). Scores were standardized across domains and overall quality was determined through consensus.

RESULTS

124 guidelines met inclusion criteria and were assessed. 58 guidelines were recommended for use, 58 were recommended with modifications and eight were not recommended. The highest scoring domains across guidelines were scope and purpose, and clarity of presentation. The recommended guidelines had higher rigor of development and applicability domain scores in comparison to other guidelines. 77% of the guidelines referenced an underlying evidence review and 49% used GRADE to assess the body of evidence or the strength of the recommendation. The domains in need of improvement included stakeholder engagement, editorial independence, and applicability. Guidelines not recommended for use were generally insufficient in their rigor of development.

CONCLUSIONS

WHO guidelines need further improvement, most importantly in the rigor of their development (i.e., use of evidence reviews). Other areas for improvement include increased stakeholder engagement, a more explicit process for recommendation formulation and disclosure of interests, discussion of the facilitators, barriers, resource implications, and criteria for monitoring the outcomes of guideline implementation. WHO guidelines can improve through increased transparency, adherence to the WHO Handbook for Guideline Development, and better oversight by the GRC.

Quality assessment of guidelines on thromboprophylaxis in orthopaedic surgery

We evaluated the quality of guidelines on thromboprophylaxis in orthopaedic surgery by examining how they adhere to validated methodological standards in their development. A structured review was performed for guidelines that were published between January 2005 and April 2013 in medical journals or on the Internet. A pre-defined computerised search was used in MEDLINE, Scopus and Google to identify the guidelines. The AGREE II assessment tool was used to evaluate the quality of the guidelines in the study. Seven international and national guidelines were identified. The overall methodological quality of the individual guidelines was good. 'Scope and Purpose' (median score 98% interquartile range (IQR)) 86% to 98%) and 'Clarity of Presentation' (median score 90%, IQR 90% to 95%) were the two domains that received the highest scores. 'Applicability' (median score 68%, IQR 45% to 75%) and 'Editorial Independence' (median score 71%, IQR 68% to 75%) had the lowest scores. These findings reveal that although the overall methodological quality of guidelines on thromboprophylaxis in orthopaedic surgery is good, domains within their development, such as 'Applicability' and 'Editorial Independence', need to be improved. Application of the AGREE II instrument by the authors of guidelines may improve the quality of future guidelines and provide increased focus on aspects of methodology used in their development that are not robust.

Pediatric clinical practice guidelines for acute procedural pain: a systematic review

BACKGROUND

Procedural pain assessment and management have been extensively studied through multiple research studies over the past decade. Results of this research have been included in numerous pediatric pain practice guidelines.

OBJECTIVE

To systematically review the quality of existing practice guidelines for acute procedural pain in children and provide recommendations for their use.

METHODS

A systematic search was conducted on Medline, Embase, CINAHL, PsycINFO, and Scopus from 2000 to July 2013. A gray literature search was also conducted through the Translating Research Into Practice database, Guidelines International Network database, and National Guideline Clearinghouse. Four reviewers rated relevant guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument. Screening of guidelines, assessment of methodological quality, and data abstraction were conducted by 2 pairs of raters. Disagreements in overall assessments were resolved through consensus.

RESULTS

Eighteen guidelines from 4930 retrieved abstracts were included in this study. Based on the AGREE II domains, the guidelines generally scored high in the scope and purpose and clarity of presentation areas. Information on the rigor of guideline development, applicability, and editorial independence were specified infrequently. Four of the 18 guidelines provided tools to help clinicians apply the recommendations in practice settings; 5 were recommended for use in clinical settings, and the remaining 13 were recommended for use with modification.

CONCLUSIONS

Despite the increasing availability of clinical practice guidelines for procedural pain in children, the majority are of average quality. More transparency and comprehensive reporting are needed for the guideline development process.

Independent appraiser assessment of the quality, methodological rigour and transparency of the development of the 2008 international consensus statement on concussion in sport

AIM

In recent years, considerable effort has been devoted to the development and revisions to an international consensus statement on concussion in sport (ICSCS). The aim of this study was to obtain expert views on the methodological rigour and transparency with which the 2008 ICSCS was developed, as a precursor to the development of the 2012 update.

METHODS

Delegates registered for the 2012 fourth International Conference on Concussion in Sport, selected local concussion researchers not involved in any prior international consensus meetings, and all authors of the 2008 ICSCS published paper were invited to assess the methodological rigour and transparency with which the 2008 ICSCS was developed. The online Appraisal of Guidelines for Research and Evaluation (AGREE) II assessment tool, with six quality domains, was used and domain scores were expressed as a percentage of the maximum possible score for that domain.

RESULTS

18 appraisers completed the online AGREE II assessment. Ten appraisers said they would recommend the 2008 ICSCS for use (without modification) and seven said they would recommend its use with some modification. The 'scope and purpose' and 'clarity of presentation' were rated highest, both scoring 78%. The lowest scoring domain was 'applicability' with a score of 55%.

CONCLUSIONS

The quality of the ICSCS is important because it is used to guide return-to-play decisions and the management of sport-related concussions. This appraisal of the 2008 ICSCS suggests that a greater focus is needed on the actual implementation of future ICSCS and the relationship between implementation and desired health outcomes.

Methodological rigour and transparency of clinical practice guidelines developed by neurology professional societies in Croatia

BACKGROUND

Clinical practice guidelines are systematically created documents that summarize knowledge and assist in delivering high-quality medicine by identifying evidence that supports best clinical care. They are produced not only by international professional groups but also by local professionals to address locally-relevant clinical practice. We evaluated the methodological rigour and transparency of guideline development in neurology formulated by professionals in a local medical community.

METHODS

We analyzed clinical guidelines in neurology publicly available at the web-site of the Physicians' Assembly in Croatia in 2012: 6 guidelines developed by Croatian authors and 1 adapted from the European Federation of Neurological Societies. The quality was assessed by 2 independent evaluators using the AGREE II instrument. We also conducted a search of the Cochrane Library to identify potential changes in recommendation from Cochrane systematic reviews included in guideline preparation.

RESULTS

The methodological quality of the guidelines greatly varied across different domains. "Scope and Purpose" and "Clarity of Presentation" domains received high scores (100% [95% confidence interval (CI) 98.5-100] and 97% [77.9-100], respectively), the lowest scores were in "Stakeholder Involvement" (19% [15.5-34.6]) and "Editorial Independence" (0% [0-19.2]). Conclusions of 3 guidelines based on Cochrane systematic reviews were confirmed in updated versions and one update provided new information on the effectiveness of another antidepressant. Two Cochrane reviews used in guidelines were withdrawn and split into new reviews and their findings are now considered to be out of date.

CONCLUSION

Neurological guidelines used in Croatia differ in structure and their methodological quality. We recommend to national societies and professional groups to develop a more systematic and rigorous approach to the development of the guidelines, timely inclusion of best evidences and an effort to involve target users and patients in the guideline development procedures.