Quality assessment of clinical practice guidelines on the treatment of hepatocellular carcinoma or metastatic liver cancer. PLoS One. 2014;9:e103939. [PMID: 25105961 PMCID: PMC4126673 DOI: 10.1371/journal.pone.0103939]

Clinical practice guidelines and consensus statements for antenatal oral healthcare: An assessment of their methodological quality and content of recommendations

OBJECTIVES

To review the content of recommendations within antenatal oral healthcare guidance documents and appraise the quality of their methodology to inform areas of development, clinical practice, and research focus.

METHOD

A systematic search of five electronic databases, Google search engine, and databases from relevant professional and guideline development groups published in English, developed countries, and between 2010 and 2020 was undertaken to identify guidance documents related to antenatal oral healthcare. Quality of documents was appraised using the Appraisal of Guidelines Research and Evaluation II tool, and a 3-step quality cut-off value was used. Inductive thematic analysis was employed to categories discreet recommendations into themes.

RESULTS

Six guidelines and one consensus statement were analysed. Two documents developed within Australia scored ≥60% across five of the six domains of the quality appraisal tool and were recommended for use. Four documents (developed in the United States and Canada) were recommended for use with modifications, whilst one document (developed in Europe) was not recommended. A total of 98 discreet recommendations were identified and demonstrated considerable unanimity but differed in scope and level of information. The main content and number of recommendations were inductively categorised within the following clinical practice points: risk factor assessments (n = 2), screening and assessment (n = 10), pre-pregnancy care (referral, n = 1), antenatal care (health education and advice, n = 14; management of nausea and vomiting, n = 7; referral, n = 2), postnatal care (health education and advice, n = 1; anticipatory guidance, n = 6), documentation (n = 4), coordinated care (n = 4), capacity building (n = 6), and community engagement (n = 1).

CONCLUSION

The methodological rigour of included guidance documents revealed areas of strengths and limitations and posit areas for improvement. Further research could centre on adapting antenatal oral healthcare guidelines and consensus statements to local contexts. More high-quality studies examining interventions within antenatal oral healthcare are needed to support the development of recommendations.

Selecting the first line treatment in non-metastatic hepatocellular carcinoma - comparing clinical practice guidelines

Primary malignancy of the liver or hepatocellular carcinoma (HCC) is unique in its presentation, disease process, and management. Unlike breast or colon cancer, the staging of HCC depends on performance status and baseline liver function along with pathological characteristics. Apart from traditional options like surgery and systemic therapy, effective management can be achieved in selected cases with liver transplant and locoregional therapy (LRT) like transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and ablation. Liver study societies and cancer groups across the globe proposed guidelines to aid the treating physicians in choosing first-line treatment for liver cancer. It is tough to compare these guidelines as they differ not only in treatment recommendations but also in risk assessment (and staging). The approach to the same patient may be different in the country he or she is managed. In clinical practice, decisions are usually taken on the consensus of multidisciplinary tumor boards and do not necessarily adhere to any guidelines. In the early (and very early) stage HCC, curative options like surgery, transplant, and ablation are recommended. In intermediate stage HCC, LRT (TACE and TARE) is preferred in the first line and systemic therapy for treatment failure or residual disease. Systemic therapy, including the atezolizumab/bevacizumab combination and tyrosine kinase inhibitors (TKI) like sorafenib and lenvatinib, is used for advanced stages. Supportive care is advised for terminal stage HCC.

Indications of external radiotherapy for hepatocellular carcinoma from updated clinical guidelines: Diverse global viewpoints

The etiology and disease patterns of hepatocellular carcinoma (HCC) significantly vary among regions. Modern standard treatments commonly require multidisciplinary approaches, including applications of up-to date medicine and advanced procedures, and necessitate the support of socioeconomic systems. For these reasons, a number of clinical guidelines for HCC from different associations and regions have been presented. External beam radiation therapy was contraindicated for HCC until a few decades ago, but with the development of new technologies, its application has rapidly increased as selective irradiation for tumorous lesions became possible. Most of the guidelines had been opposed or indifferent to radiotherapy in the past, but several guidelines have introduced indications and recommendations for radiotherapy in their updated versions. This review will discuss the characteristics of important guidelines and their contents regarding radiotherapy and will also provide guidance to physicians who are considering applications of locoregional modalities that include radiotherapy.

An appraisal of emergency medicine clinical practice guidelines: Do we agree?

BACKGROUND

Clinical practice guidelines (CPGs) have been published by the American College of Emergency Physicians (ACEP) since 1990 to advance evidence-based emergency care. ACEP clinical policies have drawn anecdotal criticism for bias, yet the overall quality of these guidelines has not previously been quantified. We sought to examine ACEP clinical policies using a recognised, validated appraisal instrument: Appraisal of Guidelines for Research & Evaluation (AGREE II).

METHODS

Systematic assessment of current ACEP clinical policies was conducted using the AGREE II instrument, which contains 23 appraisal items (scored on a 1-7 scale) in six domains and two overall assessments. Each policy was independently appraised by five trained appraisers. Primary outcomes were AGREE II ratings for each item, domain and "Overall Assessment," and scores were reported as standardised percentages from all five appraisers. Secondary analyses examined associations between AGREE II ratings and policy publication date, strength of underlying evidence and strength of recommendations. Additional analysis examined relationships between domain and "Overall Assessment" ratings.

RESULTS

Twenty guidelines published from April 2007 to November 2017 were included. Of the six domains, "Scope and Purpose" scored highest (mean 90%) and "Applicability" scored lowest (mean 35%). The four remaining domains ("Stakeholder Involvement," "Rigor of Development," "Clarity of Presentation" and "Editorial Independence") had mean scores of 53%-78%. The mean "Overall Assessment" rating was 69% and was not associated with policy publication date, strength of underlying evidence or strength of recommendations. We found positive associations between "Overall Assessment" ratings and two domains: "Rigor of Development" (r = 0.70) and "Clarity of Presentation" (r = 0.70).

CONCLUSIONS

Based on validated AGREE II criteria, ACEP clinical policies can be most improved by addressing their application in practice. ACEP clinical policies' overall quality did not improve over the assessed time period and is not explained by the quality of underlying evidence.

Quality assessment of clinical practice guidelines for infectious diseases in China

AIM

We aimed to appraise the quality of Chinese Society of Infectious Diseases of China Medical Association clinical practice guidelines (CPGs) for infectious diseases in China.

METHODS

We performed the electronic search and hand search on the above-mentioned CPGs for infectious diseases published from January 1997 to October 2017. Each publication was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

Thirteen guidelines were identified and enrolled for the further evaluation. The median scores of the AGREE II domains across all 13 guidelines were as follows: scope and purpose 73.61% (36.11% to 84.72%), stakeholder involvement 12.50% (8.33% to 20.83%), rigor of development 19.27% (12.50% to 26.04%), clarity of presentation 86.11% (23.61% to 94.44%), applicability 33.33% (26.04% to 50.00%), and editorial independence 8.33% (4.17% to 16.67%). The clarity of presentation domain got the highest score among the six domains. Moreover, when compared the CPGs by the year of publication (2002 to 2006 vs. 2007 to 2017), the quality scores were higher in the CPGs published in the last 10 years than those published before, but with no significant difference.

CONCLUSIONS

The quality score of CPGs for infectious diseases in China from January 1997 to October 2017 was moderate, but had significant shortcomings, especially in the stakeholder involvement and editorial independence domains. However, the AGREE II instrument is useful and feasible for appraising the CPGs and should be applied to develop, implement, and promote the CPGs in China.

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.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2954-8) contains supplementary material, which is available to authorized users.

Evaluation of the current guidelines for resection of hepatocellular carcinoma using the Appraisal of Guidelines for Research and Evaluation II instrument

BACKGROUND & AIMS

Numerous guidelines for the management of hepatocellular carcinoma (HCC) have been developed. The Appraisal of Guidelines for Research & Evaluation (AGREE II) is the only validated instrument to assess the methodological quality of guidelines. We aim to appraise the methodological quality of existing guidelines for the resection of HCC using the AGREE II instrument.

METHODS

Cochrane, Medline, Google Scholar and Embase were searched using both PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria and free text. The assessment of the included clinical practice guidelines and consensuses were performed using the AGREE II instrument, version 2013. Guidelines with a score ⩾80% for the overall appraisal item were considered as applicable without modifications.

RESULTS

Literature searches identified 22 clinical practice guidelines. Five out of 22 guidelines passed the 70% mark on overall assessment, 11 out of 22 had shortcomings on indications, contraindications, side effects, key recommendations, technical aspects, transparency and health economics. Ten of 22 scored below the 50% mark showing that the guideline had low methodological and overall quality. Only 3/22 clinical practice guidelines were considered applicable without modifications.

CONCLUSIONS

The methodological quality of guidelines for the surgical management of HCC is generally poor. Future guideline development should be informed by the use of the AGREE II instrument. Guidelines based upon high quality evidence could improve stratification of patients and individualized treatment strategies. Lay summary: The methodology of clinical practice guidelines for resection for hepatocellular carcinoma (HCC) evaluated with the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument is generally poor. However, there are some clinical practice guidelines that are based upon higher quality evidence and can form the framework within which patients with HCC can be selected for surgical resection. Future guideline development should be informed by the use of the AGREE II instrument.

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.

Methodological Quality of Consensus Guidelines in Implant Dentistry

BACKGROUND

Consensus guidelines are useful to improve clinical decision making. Therefore, the methodological evaluation of these guidelines is of paramount importance. Low quality information may guide to inadequate or harmful clinical decisions.

OBJECTIVE

To evaluate the methodological quality of consensus guidelines published in implant dentistry using a validated methodological instrument.

METHODS

The six implant dentistry journals with impact factors were scrutinised for consensus guidelines related to implant dentistry. Two assessors independently selected consensus guidelines, and four assessors independently evaluated their methodological quality using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. Disagreements in the selection and evaluation of guidelines were resolved by consensus. First, the consensus guidelines were analysed alone. Then, systematic reviews conducted to support the guidelines were included in the analysis. Non-parametric statistics for dependent variables (Wilcoxon signed rank test) was used to compare both groups.

RESULTS

Of 258 initially retrieved articles, 27 consensus guidelines were selected. Median scores in four domains (applicability, rigour of development, stakeholder involvement, and editorial independence), expressed as percentages of maximum possible domain scores, were below 50% (median, 26%, 30.70%, 41.70%, and 41.70%, respectively). The consensus guidelines and consensus guidelines + systematic reviews data sets could be compared for 19 guidelines, and the results showed significant improvements in all domain scores (p < 0.05).

CONCLUSIONS

Methodological improvement of consensus guidelines published in major implant dentistry journals is needed. The findings of the present study may help researchers to better develop consensus guidelines in implant dentistry, which will improve the quality and trust of information needed to make proper clinical decisions.

Proposal of a new diagnostic algorithm for hepatocellular carcinoma based on the Japanese guidelines but adapted to the Western world for patients under surveillance for chronic liver disease

To date, despite many scientific evidences, the guidelines of the principal hepatological societies, such as the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, and the Asian Pacific Association for the Study of the Liver, do not recognize the diagnostic superiority of magnetic resonance imaging (MRI) over computed tomography in the diagnosis of hepatocellular carcinoma (HCC) and, for the most part, do not contemplate the use of hepatospecific contrast media, such as gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (EOB). The aim of this paper was to analyze the recent results of EOB-MRI in the study of chronic liver disease and the differences between the American Association for the Study of Liver Diseases and the Japan Society of Hepatology guidelines, of which the latter represents the most consolidated experience on EOB-MRI use for HCC diagnosis. Finally, a new diagnostic algorithm for HCC in patients under surveillance for chronic liver disease was formulated, which contemplates the use of EOB. This new diagnostic algorithm is based on the Japan Society of Hepatology algorithm but goes beyond it by adapting it to the Western world, taking into account both the difference between the two and the latest results concerning the diagnosis of HCC. This new diagnostic algorithm for HCC is proposed in order to provide useful diagnostic tools to all those Western countries where the use of EOB (more expensive than extracellular contrast media) is widespread but in which common strategies to manage the nodules that this new contrast agent allows identifying have not been available to date.

Systematic review of guidelines for management of intermediate hepatocellular carcinoma using the Appraisal of Guidelines Research and Evaluation II instrument

BACKGROUND

Hepatocellular carcinoma is the second leading cause of cancer-related mortality worldwide. Multiple guidelines have been developed to assist clinicians in its management. We aimed to explore methodological quality of these guidelines focusing on treatment of intermediate hepatocellular carcinoma by transarterial chemoembolization.

METHODS

A systematic search was performed for Clinical Practice Guidelines and Consensus statements for hepatocellular carcinoma management. Guideline quality was appraised using the Appraisal of Guidelines Research and Evaluation II instrument, which rates guideline development processes across 6 domains: 'Scope and purpose', 'Stakeholder involvement', 'Rigour of development', 'Clarity of presentation', 'Applicability' and 'Editorial independence'. Thematic analysis of guidelines was performed to map differences in recommendations.

RESULTS

Quality of 21 included guidelines varied widely, but was overall poor with only one guideline passing the 50% mark on all domains. Key recommendations as (contra)indications and technical aspects were inconsistent between guidelines. Aspects on side effects and health economics were mainly neglected.

CONCLUSIONS

Methodological quality of guidelines on transarterial chemoembolization in hepatocellular carcinoma management is poor. This results in important discrepancies between guideline recommendations, creating confusion in clinical practice. Incorporation of the Appraisal of Guidelines Research and Evaluation II instrument in guideline development may improve quality of future guidelines by increasing focus on methodological aspects.

miR-411 regulated ITCH expression and promoted cell proliferation in human hepatocellular carcinoma cells

Hepatocellular carcinoma (HCC) is one of the most common human malignancies and the third most common cause of cancer mortality in the world. In this study, we report that miR-411 expression is markedly upregulated in HCC cells and HCC tissues compared with normal control tissues and cells. Previous studies have shown that miR-411 plays a crucial role in a variety of biological processes in various human cancer cells. However, the specific function of miR-411 in HCC remains unclear. Ectopic expression of miR-411 promoted the proliferation and anchorage-independent growth of HCC cells, whereas inhibition of miR-411 reduced this effect. Bioinformatics analysis further revealed ITCH, a putative tumor suppressor as a potential target of miR-411. Data from luciferase reporter assays showed that miR-411 directly binds to the 3'-untranslated region (3'-UTR) of ITCH mRNA and repressed expression at both transcriptional and translational levels. In functional assays, miR-411 promoted HCC cell proliferation, which could be suppressed by miR-411-in. Taken together, our data provide convincing evidence that miR-411 functions as an onco-miRNA, which was associated with cell proliferation of HCC, and its oncogenic effect is mediated chiefly through direct suppression of ITCH expression.