International assessment of the quality of clinical practice guidelines in oncology using the Appraisal of Guidelines and Research and Evaluation Instrument

Comparative global analysis of stroke rehabilitation recommendations across income levels

OBJECTIVE

Successful implementation of stroke rehabilitation guidelines demands high-quality practice standards tailored to targeted sociodemographic contexts. The primary objective is to determine the quality differences in post-stroke rehabilitation practice guidelines (PGs), when comparing high-income countries (HIC) and low or middle-income countries (LMIC).

STUDY DESIGN AND SETTING

We conducted a scoping review of PGs in English or Spanish, published between 2012 and 2021, and providing recommendations on post-stroke rehabilitation. We used Search engines, databases, guideline libraries, gray literature, and references from previous reviews on post-stroke rehabilitation as sources of evidence. Quality assessment of PGs was performed using 6P's, ELSE, IOM, and AGREE II instruments. We evaluated each item using a scale between 0 to 3, based on the confidence of adherence to the standard. For AGREE II, we followed the instruction manual for scoring. At least two reviewers were independently involved in every step of the process. A cloud-based spreadsheet was used to chart data. We compared the results of PGs originating from HIC with those from LMIC.

RESULTS

The inclusion criteria were met by 35 documents, which were subjected to evaluation. The study included 21 documents from HIC and 14 from middle-income countries (MIC). No manuscripts from low-income countries were available for inclusion in the study. The quality of PGs from MIC was found to be lower, in terms of methodological rigor and adherence to international recommendations for guidelines development. PGs from both groups of countries failed to include all target audiences and stakeholders (according to the 6P's criteria) and integration of ethical, legal, social, and economic considerations.

CONCLUSION

There are gaps in the quality and availability of stroke rehabilitation guidelines worldwide, especially in LMIC. Designing and providing financial support for the implementation of high-quality guidelines will contribute to more effective implementation strategies in stroke rehabilitation programs and lead to improved patient outcomes.

Treatment confidence and patient participation in multidisciplinary tumor conferences: A structural equation modeling approach

OBJECTIVE

Multidisciplinary tumor conference (MTC) is a key instrument in multidisciplinary cancer care. In recent years, if and how patient participation in MTC can contribute to a more patient-centered care have been scientifically discussed. This study aimed to identify determinants of treatment confidence in the context of patient participation in MTC. Therefore, the association among health literacy-sensitive communication, trust in health-care providers (HCP), and treatment confidence is examined.

METHODS

This study used data from the multicenter, observational study "PINTU" on patient participation in MTC. Data were collected from November 2018 to February 2020. Validated scales for treatment confidence, health literacy-sensitive communication, and trust in providers were included in the structural equation modeling (SEM) analysis.

RESULTS

A total of 95 patients participated in MTC. The sample compromised n = 80 completed datasets. The SEM fit measures indicated good fit of the proposed model. The analysis showed a positive association between health literacy-sensitive communication and treatment confidence when adding the mediating effect of trust in providers.

CONCLUSION

Patient-centered communication during MTC in combination with a trustful relationship between participating patients and health-care providers is positively associated with treatment confidence. The results indicated the relevance of a trustful doctor-patient communication and relationship. Trainings for physicians targeting patient-centered communication could be a promising approach to strengthen patient participation.

Reassessing and Extending the European Standards of Care for Newborn Health: How to Keep Reference Standards in Line with Current Evidence

The European Standards of Care for Newborn Health (ESCNH) were launched in 2018. After three years, the first standards were reassessed and revised to align with current evidence. Moreover, new standards regarding emerging topics were developed. The aim of this paper is to outline the approach adopted for reassessing, revising and developing new standards for the ESCNH. We established a systematic approach to reassess the ESCNH including a public and an expert consultation. The public consultation was open to all stakeholders for feedback whereas the expert consultation followed a targeted consultation method. For developing new standards, a similar process to the original development was implemented. Overall, 20 standards were reassessed and six standards were developed. For the revision process, 23 experts were involved in the targeted consultation method and 253 questionnaires were completed via the open consultation. We demonstrated a systematic approach to update and extend reference standards, which can be applied by other developers of standards. Thereby, we highlighted that including a public and an expert consultation is crucial to improve quality and to ensure that all stakeholder perspectives are integrated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A scoping review and critical evaluation of the methodological quality of clinical practice guidelines on nutrition in the preconception

Introduction

Clinical practice guidelines (CPGs) contain recommendations for specific clinical circumstances, including maternal malnutrition. This study aimed to identify the CPGs that provide recommendations for preventing, diagnosing, and treating women's malnutrition. Additionally, we sought to assess the methodological quality using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

Methods

An online search for CPGs was performed, looking for those that contained lifestyle and nutritional recommendations to prevent, diagnose and treat malnutrition in women during the preconception period using PubMed and different websites. The reviewers utilized the AGREE II instrument to appraise the quality of the CPGs. We defined high-quality guidelines with a final score of > 70%.

Results

The titles and abstracts from 30 guidelines were screened for inclusion, of which 20 guidelines were fully reviewed for quality assessment. The overall quality assessment of CPGs was 73%, and only 55% reached a high-quality classification. The domains in the guidelines classified as high-quality had the highest scores in "Scope and Purpose" and "Clarity of Presentation" with a median of 98.5 and 93%, respectively.

Discussion

Further assessment is needed to improve the quality of the guidelines, which is an opportunity to strengthen them, especially in the domains with the lowest scores.

Children's Oncology Group 2023 blueprint: Nursing discipline

In contrast to other Children's Oncology Group (COG) committees, the COG nursing discipline is unique in that it provides the infrastructure necessary for nurses to support COG clinical trials and implements a research agenda aimed at scientific discovery. This hybrid focus of the discipline reflects the varied roles and expertise within pediatric oncology clinical trials nursing that encompass clinical care, leadership, and research. Nurses are broadly represented across COG disease, domain, and administrative committees, and are assigned to all clinically focused protocols. Equally important is the provision of clinical trials-specific education and training for nurses caring for patients on COG trials. Nurses involved in the discipline's evidence-based practice initiative have published a wide array of systematic reviews on topics of clinical importance to the discipline. Nurses also develop and lead research studies within COG, including stand-alone studies and aims embedded in disease/ treatment trials. Additionally, the nursing discipline is charged with responsibility for developing patient/family educational resources within COG. Looking to the future, the nursing discipline will continue to support COG clinical trials through a multifaceted approach, with a particular focus on patient-reported outcomes and health equity/disparities, and development of interventions to better understand and address illness-related distress in children with cancer.

Clinical Practice Guidelines in an Era of Accountability, Saudi Arabia: A Call for Action

INTRODUCTION

Clinical Practice Guidelines (CPGs) development and implementation in the Kingdom of Saudi Arabia are suboptimal. The Kingdom's Vision 2030 envisages a transformational change to achieve an effective, integrated, value-based ecosystem focused on patient health.

OBJECTIVES

This study aimed to develop a CPG appraisal tool that will support the realization of the Kingdom's Vision 2030 through the development of high-quality and highly implementable CPGs. To maximize its impact, all vital healthcare paradigms, such as systems thinking, value-based healthcare, and information technology, will robustly be incorporated in the tool.

METHODS

The Saudi Health Council through its National Center of Evidence-Based Medicine (NCEBM) embarked on a program to develop this appraisal tool. A taskforce of experts was selected based on their experience in evidence-based practice and training. The task force, through a methodology of extensive literature review, deliberation, outside experts' feedback, and Delphi and consensus voting, developed a prototype appraisal tool that was named the Holistic Appraisal Tool for CPGs (HAT-CPG).

RESULTS

The HAT-CPG was developed comprising three sections: an initial basic information section, an internal validity section, and an external validity section with a total of 13 section items and 73 reporting elements.

CONCLUSION

It is envisaged that the Holistic Appraisal Tool will support CPG developers and users in Saudi Arabia in realizing the objectives for which it was developed.

Adoption of IWGDF guidance on prevention and management of foot problems in diabetes for local use in Iran by ADAPTE methodology: a step toward best practice

Purpose

Adoption of international working group on the diabetic foot (IWGDF) guidance on prevention and management of foot problems in patients with diabetes was the study aim.

Methods

The ADAPTE process consisted of three main phases of set-up, adoption, and finalization with overall 24 steps was used. In set- up phase, organizing committee by a multidisciplinary approach was established. In adoption phase, comprehensive search in databases and guideline resources was done. According to the inclusion criteria, the 2015IWGDF guidance was selected for adoption process. Quality, currency, content and consistency of the guidance were assessed. Also, consensus on different level of agreement for each recommendation were reported. On finalization phase, the adopted version was reviewed by the guidance developer and the final guidance for local use in Iran was disseminated.

Results

The 2015 IWGDF guidance with 77 recommendations was adopted after screening of 1760 documents retrieved from Jan. 2006 to Nov. 2016. An organizing committee was established according to a multidisciplinary approach including 73 members with endocrinology, orthopedic & vascular surgery, dermatology, infectious diseases, physical medicine and rehabilitation specialties, general practitioners and nurses. This guidance obtained a good quality in all six domains of AGREE II instrument (Score ≥ 80%), good currency, content, and consistency. Also, during the third round of Delphi, the consensus on the agreement level of each recommendation were greater than 80% and 77 recommendations of the original guidance were kept in the adopted version.

Conclusion

The 2015 IWGDF guidance with 77 recommendations adopted for local use in different health care settings of Iran.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01121-0.

AGREE II for TCM: Tailored to evaluate methodological quality of TCM clinical practice guidelines

Background: The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument has been widely used in the methodological quality assessment of clinical practice guidelines (CPG). Chinese medicine CPGs have unique characteristics which distinguish them from those of Western medicine, e.g. syndrome differentiation, on which treatments are based. As such, certain domains and items in AGREE II are unsuitable for assessing TCM CPGs. Therefore, it is necessary to adjust and supplement the description and rating section of some items of the AGREE Ⅱinstrument. Purpose: To adjust and expand AGREE II according to characteristics of TCM clinical practice guidelines. Methods: A research working group was established, consisting of a core working group and an expert consensus group, before a systematic literature search performed to screen for TCM guidelines. Two researchers evaluated the quality of the included guidelines using AGREE Ⅱ and later proposed adjustments to some items of AGREE Ⅱ and supplementary comments, which were applicable to TCM CPGs, and drafted an initial version of AGREE Ⅱ for TCM. Suggestions from literature on development and evaluation of TCM CPGs were solicited and integrated into the revised version, which 16 experts were then invited to advise on. When the experts reached a consensus, their comments to the draft were adopted by the core group into the final version. Results: After evaluating the included TCM guidelines, the two researchers offered adjustments and supplementary comments for AGREE Ⅱ Items 1, 7, 10, 11, 12, 15, and 18, and drafted an initial version of AGREE Ⅱ for TCM. Combining suggestions from the literature on development and quality evaluation of TCM clinical guidelines, the core working group modified AGREE Ⅱ items 2, 4, 5, 8, 9, 13, 20, and 21, then proposed the revised version of AGREE Ⅱ for TCM, on which was advised by a group of experts, before consensus on improvements was reached. The results of the first round of expert surveys showed strong agreement, and experts' opinions were adopted into the final version of AGREE Ⅱ for TCM. Conclusion: Based on the characteristics of the TCM CPGs, we adjustment and expansion were made to create AGREE II for TCM. This version is suitable for the assessment of methodological quality of TCM CPGs, capable of providing content support for the standardization of procedures and methods of formulating TCM CPGs.

A quality assessment of clinical practice guidelines with recommendations for family involvement in the care of individuals diagnosed with schizophrenia, bipolar mood disorder, and major depressive disorder: Critical appraisal utilizing AGREE II

INTRODUCTION

Evidence suggests that family-center collaborative care is useful for individuals identified with chronic mental illness. Clinical practice guidelines offer specific recommendations primarily based on to be had studies and are beneficial in informing evidence-based practice and guiding destiny studies.

OBJECTIVE

Identify current scientific practice guidelines including family-center collaborative care suggestions for individuals with Bipolar Mood Disorder, Schizophrenia, and Major Depressive Disorder and analyze the selection of guidelines for their methodological quality.

METHODS

A systematic search was conducted on seven electronic databases (G-I-N), (NICE), (MOH), (SIGN), (WHO), (NIH) and (APA) and additional sources. Three referees independently reviewed articles and selected guidelines for inclusion criteria. Subsequently, 18 trained appraisers independently assessed all 15 guidelines using AGREE II.

RESULTS

The mean scores for domains and overall quality were computed. For the overall assessment of the guidelines, 60% reached the quality threshold with domain scores of 60%. The overall average quality rating for these guidelines was 58/29%.

CONCLUSION

The applicability of the guidelines needs to be improved in order to improve their relevance and clinical utilization. As individuals with chronic mental illnesses progress through their disease course, families and health care providers play a crucial role in helping them. The analysis of research knowledge on effective rehabilitation techniques, including the involvement of families in treatment, can be enhanced by using well-developed and appropriate methods.

Critical appraisal of clinical practice guidelines for the management of COVID-19: protocol for a systematic review

BACKGROUND

In December 2019, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 was identified as the cause of an acute respiratory disease, coronavirus disease 2019 (COVID-19). Given the lack of validated treatments, there is an urgent need for a high-quality management of COVID-19. Clinical practice guidelines (CPGs) are one tool that healthcare providers may use to enhance patient care. As such, it is necessary that they have access to high-quality evidence-based CPGs upon which they may base decisions regarding the management and use of therapeutic interventions (TI) for COVID-19. The purpose of the proposed study is to assess the quality of CPGs that make management or TI recommendations for COVID-19 using the AGREE II instrument.

METHODS

The proposed systematic review will identify CPGs for TI use and/or the management of COVID-19. The MEDLINE, EMBASE, CINAHL, and Web of Science databases, as well as the Guidelines International Network, National Institute for Health and Clinical Excellence, Scottish Intercollegiate Guidelines Network, and the World Health Organization websites, will be searched from December 2019 onwards. The primary outcome of this study is the assessed quality of the CPGs. The quality of eligible CPGs will be assessed using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument. Descriptive statistics will be used to quantify the quality of the CPGs. The secondary outcomes of this study are the types of management and/or TI recommendations made. Inconsistent and duplicate TI and/or management recommendations made between CPGs will be compared across guidelines. To summarize and explain the findings related to the included CPGs, a narrative synthesis will also be provided.

DISCUSSION

The results of this study will be of utmost importance to enhancing clinical decision-making among healthcare providers caring for patients with COVID-19. Moreover, the results of this study will be relevant to guideline developers in the creation of CPGs or improvement of existing ones, researchers who want to identify gaps in knowledge, and policy-makers looking to encourage and endorse the adoption of CPGs into clinical practice. The results of this review will be published in a peer-reviewed journal and presented at conferences.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register for Systematic Reviews (PROSPERO)- CRD42020219944.

AGREE II appraisals of clinical practice guidelines in rehabilitation showed poor reporting and moderate variability in quality ratings when users apply different cuff-offs: a methodological study

OBJECTIVES

To analyze the reporting characteristics of Appraisal of Guidelines Research and Evaluation (AGREE) II appraisals in rehabilitation and explore how much quality ratings of Clinical Practice Guidelines (CPGs) vary applying different cut-offs.

STUDY DESIGN AND SETTING

We conducted a methodological study re-analyzing data of an overview of AGREE II CPG appraisals in rehabilitation. Reporting characteristics of appraisals and methods used for quality rating were abstracted. We applied the most frequent cut-offs retrieved on all CPG sample to explore changes in quality ratings (i.e., high/low).

RESULTS

We included 40 appraisals (n = 544 CPGs).The AGREE II overall assessment 1 (overall CPG quality) was reported in 26 appraisals (65%) and the overall assessment 2 (recommendation for use) in 17 (42.5%). Twenty-five appraisals (62.5%) reported the use of cut-offs based on domains and/or overall assessments. Application of the most reported cut-offs led to variability in quality ratings in 26% of the CPGs, of which 92% CPGs shifted their rating from low to high-quality and 8% shifted from high to low-quality.

CONCLUSION

Rehabilitation stakeholders should take care to select the highest quality CPG in view of the poor reporting of AGREE II overall assessment 1 and 2 and moderate variability of quality ratings.

Methodological quality of guidelines for the management of opioid use disorder: A systematic review

WHAT IS KNOWN AND OBJECTIVE

Opioid Use Disorder (OUD) has a high mortality rate and affects millions of people worldwide. Many organizations and societies develop Clinical Practice Guidelines (CPGs) to serve as a framework for healthcare providers to decide and support best practice to manage and treat OUD. However, not all CPGs sufficiently address all the important aspects of optimal care for managing OUD. This study aims to review current CPGs for management of OUD, evaluate their methodological quality and summarize their recommendations.

METHODS

We conducted this systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Various databases were searched for CPGs and Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument was used to assess the methodological quality. We also summarized the treatments plans of CPGs across continuum of care (diagnosis and assessment, treatment initiation, pharmacotherapy and psychosocial).

RESULTS

This review included 28 CPGs of varying qualities. CPGs from high-income countries and international organizations rated high for their methodological quality. Most CPGs scored high for the scope and purpose domain and scored low for applicability domain. Recommendations for the continuum of care for OUD varied across CPGs. Buprenorphine was recommended in most of the CPGs, followed by methadone. Recommendations for psychosocial interventions also varied, with cognitive behaviour therapies and counselling or education being the common recommendations in many CPGs WHAT IS NEW AND CONCLUSION: We found most CPGs have scope and purpose and clarity of presentation. However, the methodological rigour and applicability scored low. CPGs need to frame health questions in a comprehensible manner and provide an update as evidence grows. It is important for CPG developers to consider methodological quality as a factor when developing CPG recommendations.

The Quality of Six Clinical Practice Guidelines in Health and Social Sciences: Are We on the Right Track?

Interest in the development and promotion of clinical practice guidelines (CPGs) continues to grow in many professions. However, the potential benefits associated with CPGs are dependent upon their quality. A number of studies have shown that the quality of CPGs varies greatly. Furthermore, the quality of many of the CPGs used in health and social sciences has yet to be examined. In light of this, the aim of this study was to examine the quality of CPGs that focus on intervention and care management in mental health in Quebec. A search of Quebec regulatory bodies websites was conducted and six CPGs were included in this study. The CPGs were assessed by four trained raters using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Items scores and domains scores were considered to determine the quality of the six CPGs. Results show that many of the CPGs did not achieve minimum ratings for numerous quality checks. Notably, none of the CPGs were designed using a rigorous methodology, they lacked transparency throughout the development process and insufficient consideration was given to the applicability of the recommendations they included. Because these shortcomings may hinder the efficacy and utilization of CPGs, suggestions to improve the development of CPGs and to improve their quality are discussed.

[Assessment of Brazilian clinical guidelines in oncology: gaps in drafting, applicability, and editorial independence]

The expansion in the variety of clinical guidelines in oncology is perceptible worldwide, highlighting the need to guarantee the quality of these documents. The study thus aimed to assess the quality of Brazilian national guidelines for treatments of breast, prostate, and colon and rectal cancers. We selected 12 Brazilian guidelines published by four different drafting groups (Ministry of Health, Supplementary Health System, and medical societies and associations), and the AGREE II instrument was applied. In all these guidelines, we identified important weaknesses in more than one Domain, especially low values for "applicability" and "editorial independence". The patterns observed per Domains are more related to the drafting group than the respective clinical conditions. Lower scores in "drafting rigor" and "editorial independence" were obtained by nongovernmental drafting groups, including absence of information or lack of its transparency. Although the "clarity of presentation" in the Ministry of Health guidelines was relatively lower, all the guidelines presented major limitations in "applicability". Consequently, in the overall assessment, none of the guidelines was recommended without modifications, and four were not recommended at all. Finally, it is necessary to upgrade the guidelines according to the underlying evidence ("methodological rigor") and to present the recommended practices in a comprehensible and applicable way ("applicability"), and to mitigate conflicting interests in order to offer cancer patients the best available care in Brazil.

Assessing the quality of seven clinical practice guidelines from four professional regulatory bodies in Quebec: What's the verdict?

RATIONALE, AIMS, AND OBJECTIVES

Clinical practice guidelines (CPGs) have become a common feature in the health and social care fields, as they promote evidence-based practice and aim to improve quality of care and patient outcome. However, the benefits of the recommendations reported in CPGs are only as good as the quality of the CPGs themselves. Indeed, rigorous development and strategies for reporting are significant precursors to successful implementation of the recommendations that are proposed. Unfortunately, research has demonstrated that there is much variability in their level of quality. Furthermore, the quality of many CPGs has yet to be examined. The aim of the present study was to assess the quality of seven CPGs from four Quebec professional regulatory bodies pertaining to clinical evaluations in the fields of medicine, psychoeducation, psychotherapy, and social work.

METHODS

The seven Quebec CPGs were assessed by four trained appraisers using the Appraisal of Guidelines for Research and Evaluation II guideline evaluation tool.

RESULTS

Results suggest that while some quality criteria were met, most were not, denoting that these CPGs are of sub-optimal quality.

CONCLUSION

Our findings highlight that there is still a lot to be done in order to improve the rigour and transparency with which scientific evidence is assessed and applied when developing CPGs. Impacts regarding the implementation of these CPGs are discussed in light of their use in clinical practice.

Updates to and quality of clinical practice guidelines for high-priority diseases in Japan

PURPOSE

To examine the update status of clinical practice guidelines (CPGs) for 24 main diseases in Japan, and to clarify the quality of and issues pertaining to the most recent versions of CPGs for each disease.

DATA SOURCES

CPGs were searched in two Japanese guideline databases.

STUDY SELECTION

All relevant Japanese CPGs published between January 1999 and July 2016 were selected.

DATA EXTRACTION

The developer and issue date were extracted for all target CPGs. The most recent CPGs were assessed using the Appraisal of Guidelines for Research and Evaluation-II (AGREE II) instrument.

RESULTS OF DATA SYNTHESIS

Among 106 target CPGs, 24 most recent CPGs were subjected to assessment using the AGREE II instrument. CPGs for 11 diseases (46%) had a mean time interval for update of ≥5 years. Among the 24 CPGs subjected to AGREE II assessment, median domain scores were 74% for "Domain 1: Scope and Purpose," 43% for "Domain 2: Stakeholder Involvement," 46% for "Domain 3: Rigor of Development," 69% for "Domain 4: Clarity of Presentation," 24% for "Domain 5: Applicability" and 27% for "Domain 6: Editorial Independence."

CONCLUSIONS

The systematic assessment of CPGs for 24 major diseases in Japan revealed a trend for a delay in timing of update for many CPGs. Moreover, the 24 most recent CPGs had low domain scores for domains 2, 3, 5 and 6. In the future, concrete measures will need to be considered in order to improve the quality of CPGs.

Enhancing capacity for clinical practice guidelines in South Africa

INTRODUCTION

Use of good quality, evidence-informed and up-to-date clinical practice guidelines (CPGs) has the potential to impact health outcomes. This paper describes the development, implementation and evaluation of a dedicated CPG training course to address the training needs of CPG stakeholders in South Africa.

METHODS

We first reviewed the content and teaching strategies of existing CPG courses. This review consisted of a systematic review of teaching and learning strategies for guideline teams and a document review of existing courses offered by international guideline groups, universities and professional groups. We then strengthened an existing CPG course and evaluated it.

RESULTS

We found no studies on teaching and learning strategies for guideline teams. We identified six CPG courses being offered as full courses (part of a postgraduate degree program) by universities or as independent training for continuing professional education by professional groups. Contents focused on new guideline development. One course included alternative methods of guideline approaches such as contextualization and adaptation. The format varied from face-to-face sessions, to online sessions, group exercises and discussions, seminar format and project based activities. The revised CPG four-month long course that we implemented was designed to be pragmatic, reflective and contextually relevant. It used local guideline examples, authentic tasks, and an online forum for discussions and resources. It covered de novo CPG development, alternative methods of development (adopting, contextualising, adapting), and implementing CPGs. Course evaluation identified strengths and areas for improvement.

CONCLUSION

Dedicated capacity development has potential to positively influence CPG development and implementation.

Development and Validation of a Tool to Assess the Quality of Clinical Practice Guideline Recommendations

IMPORTANCE

Clinical practice guidelines (CPGs) may lack rigor and suitability to the setting in which they are to be applied. Methods to yield clinical practice guideline recommendations that are credible and implementable remain to be determined.

OBJECTIVE

To describe the development of AGREE-REX (Appraisal of Guidelines Research and Evaluation-Recommendations Excellence), a tool designed to evaluate the quality of clinical practice guideline recommendations.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study of 322 international stakeholders representing CPG developers, users, and researchers was conducted between December 2015 and March 2019. Advertisements to participate were distributed through professional organizations as well as through the AGREE Enterprise social media accounts and their registered users.

EXPOSURES

Between 2015 and 2017, participants appraised 1 of 161 CPGs using the Draft AGREE-REX tool and completed the AGREE-REX Usability Survey.

MAIN OUTCOMES AND MEASURES

Usability and measurement properties of the tool were assessed with 7-point scales (1 indicating strong disagreement and 7 indicating strong agreement). Internal consistency of items was assessed with the Cronbach α, and the Spearman-Brown reliability adjustment was used to calculate reliability for 2 to 5 raters.

RESULTS

A total of 322 participants (202 female participants [62.7%]; 83 aged 40-49 years [25.8%]) rated the survey items (on a 7-point scale). All 11 items were rated as easy to understand (with a mean [SD] ranging from 5.2 [1.38] for the alignment of values item to 6.3 [0.87] for the evidence item) and easy to apply (with a mean [SD] ranging from 4.8 [1.49] for the alignment of values item to 6.1 [1.07] for the evidence item). Participants provided favorable feedback on the tool's instructions, which were considered clear (mean [SD], 5.8 [1.06]), helpful (mean [SD], 5.9 [1.00]), and complete (mean [SD], 5.8 [1.11]). Participants considered the tool easy to use (mean [SD], 5.4 [1.32]) and thought that it added value to the guideline enterprise (mean [SD], 5.9 [1.13]). Internal consistency of the items was high (Cronbach α = 0.94). Positive correlations were found between the overall AGREE-REX score and the implementability score (r = 0.81) and the clinical credibility score (r = 0.76).

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that the AGREE-REX tool can be useful in evaluating CPG recommendations, differentiating among them, and identifying those that are clinically credible and implementable for practicing health professionals and decision makers who use recommendations to inform clinical policy.

Impact and use of reviews and 'overviews of reviews' to inform clinical practice guideline recommendations: protocol for a methods study

INTRODUCTION

Guidelines are systematically developed recommendations to assist practitioner and patient decisions about treatments for clinical conditions. High quality and comprehensive systematic reviews and 'overviews of systematic reviews' (overviews) represent the best available evidence. Many guideline developers, such as the WHO and the Australian National Health and Medical Research Council, recommend the use of these research syntheses to underpin guideline recommendations. We aim to evaluate the impact and use of systematic reviews with and without pairwise meta-analysis or network meta-analyses (NMAs) and overviews in clinical practice guideline (CPG) recommendations.

METHODS AND ANALYSIS

CPGs will be retrieved from Turning Research Into Practice and Epistemonikos (2017-2018). The retrieved citations will be sorted randomly and then screened sequentially by two independent reviewers until 50 CPGs have been identified. We will include CPGs that provide at least two explicit recommendations for the management of any clinical condition. We will assess whether reviews or overviews were cited in a recommendation as part of the development process for guidelines. Data extraction will be done independently by two authors and compared. We will assess the risk of bias by examining how each guideline developed clinical recommendations. We will calculate the number and frequency of citations of reviews with or without pairwise meta-analysis, reviews with NMAs and overviews, and whether they were systematically or non-systematically developed. Results will be described, tabulated and categorised based on review type (reviews or overviews). CPGs reporting the use of the Grading of Recommendations, Assessment, Development and Evaluation approach will be compared with those using a different system, and pharmacological versus non-pharmacological CPGs will be compared.

ETHICS AND DISSEMINATION

No ethics approval is required. We will present at the Cochrane Colloquium and the Guidelines International Network conference.

Assessing the Quality of Existing Clinical Practice Guidelines for Chemotherapy Drug Extravasation by Appraisal of Guidelines for Research and Evaluation II

Background:

Extravasation is a potentially hazardous event that may occur during chemotherapy. The aim of this study is to assess the quality of existing Clinical Practice Guidelines (CPGs) for chemotherapy drug extravasation by Appraisal of Guidelines for Research and Evaluation II (AGREE II).

Materials and Methods:

Valid electronic databases and CPGs from 2007 to August 2018 were searched by keywords of CPGs, extravasation, chemotherapy, and cancer. CPGs were evaluated independently by five experts through AGREE II tool, and the consensus among evaluators was calculated by ICC (Intra-class Correlation Coefficient).

Results:

Five of the 111 CPGs matched the inclusion criteria. The methodological quality of CPGs in domains of “scope and purpose,“ “stakeholder involvement,“ “clarity of presentation,“ and “applicability“ were good, in the domain of “rigor of development,“ was acceptable, and in “editorial independence“ domain, it needed more attention of developers of CPGs. The range of assessors' consensus was within a range of moderate to very good (0.55--0.93).

Conclusions:

The methodological quality of existing CPGs of chemotherapy drugs extravasation assessed by AGREE II tool is appropriate. Four CPGs had high level while one had moderate level of quality. Therefore, their use is recommended in the clinic to reduce the risk of chemotherapy extravasation to the entire treatment team and the nurses working in the oncology departments.

Quality assessment of clinical practice guidelines used in oral and maxillofacial surgery

An assessment of the quality of oral and maxillofacial surgery clinical practice guidelines is lacking. The aim of this investigation was to assess the quality of guidelines using the RIGHT (Reporting Items for practice Guidelines in HealThcare) checklist. The primary outcome was to assess the score (quality) of guidelines based on the RIGHT checklist and to identify predictors (region, type, single or multi-centre, and speciality/non-speciality) influencing the quality score. In this review, following a search of electronic databases and national society websites, a total of 25 guidelines were independently assessed by two assessors against the 22-item RIGHT checklist. Inter-assessor reliability was assessed. Deficiencies in the reporting of items relating to limitations, funding, declaration and management of interests, healthcare questions, and quality assurance were evident. The median overall score for the guidelines was 28 (range 14-66). Guidelines produced by multiple centres (β=57.15, 95% confidence interval -26.62 to 87.68, P= 0.001, multivariate analysis) and non-speciality societies (β=20, 95% confidence interval -0.03 to 40.03, P=0.05, univariate analysis) tended to have higher quality scores. Overall, the quality of clinical practice guidelines used in oral and maxillofacial surgery was deemed suboptimal. If clinical practice guidelines are to be used in making treatment decisions for patients, clinicians should be aware of their possible limitations.

An exploratory quality assessment of orthodontic clinical guidelines using the AGREE II instrument

Objectives

Clinical guidelines act as a means of assisting clinicians in improving the quality of healthcare provided. We aim to assess the quality of currently available international orthodontic guidelines.

Materials and methods

A cross-sectional systematic assessment of orthodontic clinical guidelines was undertaken. A Medline search using the keywords 'guideline', 'orthodontics', and 'dent', and search of specific dental and orthodontic organization websites for orthodontic-related clinical guidelines. Relevant guidelines published between 1999 and 2012 in English were identified. Draft guidelines and endorsements were excluded. The quality of each guideline was evaluated by a single calibrated assessor using the AGREE II instrument. Variation in the quality of guidelines produced by different organizations was also assessed.

Results

Seventeen guidelines were included in this study. Overall, the reporting of scope and purpose (84.31, 95% CI: 70.91-97.72) and clarity of presentation (75.49, 95% CI: 61.68-89.3) domains of the AGREE II instrument were deemed of high quality. Lower scores were obtained for the following domains: rigour of development (52.08, 95% CI: 37.59-66.57), editorial independence (47.06, 95% CI: 20.6-73.51), stakeholder agreement (46.41, 95% CI: 29.66-63.15), and applicability (27.45, 95% CI: 8.26-46.64). There was a noted difference in the individual domain scores of orthodontic guidelines produced by the different organizations.

Conclusions

In relation to the AGREE II instrument, the quality of orthodontic guidelines for use in clinical practice are deemed sub-optimal. Variation in the quality of guidelines produced different organizations is evident.

A critical appraisal of the quality of head and neck cancer imaging guidelines using the AGREE II tool: A EuroAIM initiative

Background

Diagnostic imaging guidelines are increasingly embraced in oncologic imaging in order to improve examinations appropriateness and technical quality. The usefulness of guidelines employment in clinical practice is dramatically related to the quality of the guidelines themselves. However, an extreme variability in guidelines’ quality may occur. Following a European Network for the Assessment of Imaging in Medicine (EuroAIM) initiative, the aim of this study was to assess the quality of the available guidelines regarding head and neck cancer (HNC) imaging.

Methods

A literature search was conducted to identify imaging guidelines focused on HNC. Selected guidelines were evaluated by four independent appraisers using the Appraisal of Guidelines for Research & Evaluation version 2.0 (AGREE II) tool, which comprises 23 key items, rated on a 7‐point scale (1—strongly disagree to 7—strongly agree) and organized within six domains. For each domain, the intraclass correlation coefficient (ICC) was used to assess the agreement among appraisers’ scores.

Results

After literature search, three guidelines were selected and evaluated. One guideline scored “average” as overall quality, while the remaining two scored a “low” overall quality. The highest result (total score = 75.0% ± 19.3%) was obtained in domain 4 (Clarity of presentation) while the lowest (total score = 27.1% ± 4.2%) in domain 6 (Editorial independence). ICC analysis showed a very good agreement (range: 0.932‐0.961) among the four appraisers.

Conclusions

Our results showed a heterogeneous quality of existing guidelines in HNC imaging. Issues raised from this appraisal should be considered when developing future guidelines on HNC imaging.

Appraising of the Clinical Practice Guidelines Quality in the Non-Pharmacological Management of Chemotherapy-Induced Febrile Neutropenia; A Review

Background:

Febrile neutropenia is a common and serious chemotherapy side effect, is associated with increased mortality, morbidity, and treatment expenditures. Several CPGs (Clinical practice guidelines) have been released for managing chemotherapy-induced febrile neutropenia. The aim of this study is Appraisal of the clinical practice Guidelines quality in the management of chemotherapy-induced febrile neutropenia.

Methods:

A review study with a systematic search of the present CPGs for the management of chemotherapy-induced febrile neutropenia. After screening the CPGs based on eligibility criteria, three CPGs were selected and 5 independent reviewers appraised them for methodological quality by using the AGREE II Instrument.

Results:

Three CPGs were included; all of them were evidence-based guidelines. The clarity of presentation domain scored the highest and the applicability domain has the lowest score among all domains of AGREE instrument and the rest of domains scored as descending respectively; Scope and purpose, stakeholder involvement, editorial independence, rigor of development. In general, the intra-class correlation coefficient (ICC) scores of all domains were very good according to the Landis and Koch’s scale, except the Applicability domain scored as substantial.

Conclusions:

This study showed the quality of appraised CPGs. Three domains of these CPGs based on the AGREE instrument scored less than other domains and were in relatively unfavorable status: applicability, rigor of development, editorial independence. Given the importance of these domains in guideline implementation, it is necessary to take actions for reducing these defects.

The quality of guidelines in non-pharmacological prevention and management of chemotherapy-induced neuropathy: A review

Chemotherapy-induced peripheral neuropathy is a common adverse effect occurring in patients undergoing neurotoxic chemotherapy. However, there is no FDA-approved treatment option for it. Given the importance of clinical practice guidelines in this area, this study aimed to determine the methodological quality of extant CIPN guidelines. The study was done as part of the adaptation process of CIPN related CPGs at Isfahan University of Medical Sciences, Iran. A systematic search of published CPGs about chemotherapy-induced CIPN in which the AGREE II instrument was applied for appraising CPGs of CIPN was performed. In general, amongst all of the AGREE II Instrument’s domains in the evaluated CPGs, the clarity of presentation and stakeholder involvement domains took favorable scores; and other domains obtained unfavorable and relatively favorable scores. The quality of cancer therapy-induced neuropathy CPGs needs to be improved and designing high-quality CPGs must be considered.

Clinical practice guidelines for fertility preservation in young women undergoing gonadotoxic treatment: an overview and critical appraisal of methodological quality and content

RESEARCH QUESTION

What is the methodological quality and content of internationally available clinical practice guidelines (CPGs) on fertility preservation (FP) care in adult women?

DESIGN

Internationally available CPGs on FP care in adult women were identified after conducting an extensive literature search and consulting (inter)national key experts. The methodological quality of the CPGs was appraised by an (inter)national panel of experts using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. The content of the best CPGs, scoring ≥60% for the domain 'Rigour of development' of the AGREE II instrument, was extracted and categorized according to their topic.

RESULTS

Thirty of the 1808 documents found were included. After consulting (inter)national key experts, 30 CPGs were included, six of which scored ≥60% for their 'Rigour of development'. The number of FP-related topics discussed by these six CPGs ranged from 4 to 12. The number of recommendations provided by the CPGs on these topics varied. The number of topics to which ≥5 recommendations were dedicated ranged from 0 to 4 between CPGs.

CONCLUSION

CPGs on the subject of FP care are available, but there is room for improvement in quality and content. Although written for use in daily practice, the CPGs can also be used to develop quality indicators to monitor the quality of current FP care or to evaluate future improvement initiatives.

Are clinical guidelines designed according to guidelines? Cross-sectional assessment of quality and transparency of clinical guidelines in urology

PURPOSE

Guidelines and recommendations become increasingly important in clinical urologic practice. This study aims to inform clinicians using guidelines on how to evaluate the quality of the methodology and transparency of these documents.

METHODS

The guidelines on management of castration-resistant prostate cancer of the American Urology Association, European Association of Urology, National Comprehensive Cancer Network, National Institute for Health and Care Excellence, European Society of Medical Oncology were reviewed using the AGREE-II tool (Appraisal of Guidelines for Research and Evaluation). We reported and compared the domain scores for the domains 1 scope and purpose, 2 stakeholder involvement, 3 rigor of development, 4 clarity of presentation, 5 applicability, and 6 editorial independence (100% indicates highest-best quality score).

RESULTS

The domains evaluated highest and with lowest variability were 'editorial independence' (92% {88-95%}) and 'clarity of presentation' (83% {72-90%}), while the domains with the lowest scores and most variability were 'stakeholder involvement' (56% {36-79%}) and 'applicability' (40% {30-63%}). Length and extent of detail of guidelines vary considerably, each with its own strengths and limitations and adapted to target users. Standard external review using AGREE criteria may be preferable. A formal search strategy was not performed. Findings may be outdated by guidelines' updates.

CONCLUSIONS

Clinicians using practice guidelines need to be aware of the different domains of methodology and transparency used to assess the quality of guidelines contents and recommendations. Urologists increasingly use guidelines for support in evidence-based recommendations in clinical practice. It is very important to know how to assess these documents. This study applies standard criteria to compare the design and background of different available guidelines on prostate cancer no longer responding to hormonal treatment.

Overtesting and undertesting in primary care: a systematic review and meta-analysis

BACKGROUND

Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste.

OBJECTIVE

To identify overuse and underuse of diagnostic tests in primary care.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND ELIGIBILITY CRITERIA

We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care.

RESULTS

We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively.

CONCLUSIONS

There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy.

PROSPERO REGISTRATION NUMBER

CRD42016048832.

CoCanCPG. Coordination of Cancer Clinical Practice in Europe

All European countries are facing common challenges for delivering appropriate, evidence-based care to patients with cancer. Despite tangible improvements in diagnosis and treatment, marked differences in cancer survival exist throughout Europe. The reliable translation of new research evidence into consistent patient-oriented strategies is a key endeavour to overcome inequalities in healthcare. Clinical-practice guidelines are important tools for improving quality of care by informing professionals and patients about the most appropriate clinical practice. Guideline programmes in different countries use similar strategies to achieve similar goals. This results in unnecessary duplication of effort and inefficient use of resources. While different initiatives at the international level have attempted to improve the quality of guidelines, less investment has been made to overcome existing fragmentation and duplication of effort in cancer guideline development and research. To provide added value to existing initiatives and foster equitable access to evidence-based cancer care in Europe, CoCanCPG will establish cooperation between cancer guideline programmes. CoCanCPG is an ERA-Net coordinated by the French National Cancer Institute with 17 partners from 11 countries. The CoCanCPG partners will achieve their goal through an ambitious, step-wise approach with a long-term perspective, involving: 1. implementing a common framework for sharing knowledge and skills; 2. developing shared activities for guideline development; 3. assembling a critical mass for pertinent research into guideline methods; 4. implementing an appropriate framework for cooperation. Successful development of joint activities involves learning how to adopt common quality standards and how to share responsibilities, while taking into account the cultural and organisational diversity of the participating organisations. Languages barriers and different organisational settings add a level of complexity to setting up transnational collaboration. Through its activities, CoCanCPG will make an important contribution towards better access to evidence-based cancer practices and thus contribute to reducing inequalities and improving care for patients with cancer across Europe.

Evidence-based recommendations on care for breast cancer survivors for primary care providers: a review of evidence-based breast cancer guidelines

OBJECTIVE

To review evidence-based (EB) recommendations on survivorship care for primary care providers (PCPs) in EB breast cancer guidelines.

DESIGN AND SETTING

Guidelines were collected via experts and via literature database, guideline database and cancer agency websites searches.

METHOD

EB guidelines in any language published between 2012 and 2017 were collected. EB recommendations on survivorship care relevant for PCPs were extracted and grouped into three categories (recurrence detection, long-term effects and recurrence prevention). The content of the recommendations was analysed and summarised in the number and type of clinical topics addressed. The Appraisal of Guidelines for Research and Evaluation II instrument was used to evaluate the methodological quality of the guidelines.

RESULTS

Six guidelines, of which two were of acceptable methodological quality, were included. One was specifically made for general practitioners. Fifteen clinical topics were identified. Guidelines differed in the clinical topics addressed and for some identical topics in the content of the recommendations. Many recommendations were based on low-quality evidence. Recurrence detection received most attention, physical examination and mammography were often highlighted. Potential complications largely varied in number and type. Intimacy concerns, vaginal dryness, dyspareunia, fatigue, menopausal symptoms, peripheral neuropathy and lymphedema were reported in more than one guideline. Recurrence prevention was mentioned in four guidelines; all recommended physical activity.

CONCLUSION

The number of EB recommendations in guidelines is limited. Moreover, recommendations differ between guidelines and most are based on low-quality evidence. More high-quality research is needed to develop and adapt guidelines to support PCPs in providing optimal breast cancer survivorship care.

Evaluation of clinical practice guidelines using the AGREE instrument: comparison between data obtained from AGREE I and AGREE II

Objective

The Appraisal of Guidelines for Research and Evaluation (AGREE) is a representative, quantitative evaluation tool for evidence-based clinical practice guidelines (CPGs). Recently, AGREE was revised (AGREE II). The continuity of evaluation data obtained from the original version (AGREE I) has not yet been demonstrated. The present study investigated the relationship between data obtained from AGREE I and AGREE II to evaluate the continuity between the two measurement tools.

Results

An evaluation team consisting of three trained librarians evaluated 68 CPGs issued in 2011–2012 in Japan using AGREE I and AGREE II. The correlation coefficients for the six domains were: (1) scope and purpose 0.758; (2) stakeholder involvement 0.708; (3) rigor of development 0.982; (4) clarity of presentation 0.702; (5) applicability 0.919; and (6) editorial independence 0.971. The item “Overall Guideline Assessment” was newly introduced in AGREE II. This global item had a correlation coefficient of 0.628 using the six AGREE I domains, and 0.685 using the 23 items. Our results suggest that data obtained from AGREE I can be transferred to AGREE II, and the “Overall Guideline Assessment” data can be determined with high reliability using a standardized score of the 23 items.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-3041-7) contains supplementary material, which is available to authorized users.

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.

International variations in clinical practice guidelines for palliative sedation: a systematic review

OBJECTIVES

Palliative sedation is a highly debated medical practice, particularly regarding its proper use in end-of-life care. Worldwide, guidelines are used to standardise care and regulate this practice. In this review, we identify and compare national/regional clinical practice guidelines on palliative sedation against the European Association for Palliative Care (EAPC) palliative sedation Framework and assess the developmental quality of these guidelines using the Appraisal Guideline Research and Evaluation (AGREE II) instrument.

METHODS

Using the PRISMA criteria, we searched multiple databases (PubMed, CancerLit, CINAHL, Cochrane Library, NHS Evidence and Google Scholar) for relevant guidelines, and selected those written in English, Dutch and Italian; published between January 2000 and March 2016.

RESULTS

Of 264 hits, 13 guidelines-Belgium, Canada (3), Ireland, Italy, Japan, the Netherlands, Norway, Spain, Europe, and USA (2) were selected. 8 contained at least 9/10 recommendations published in the EAPC Framework; 9 recommended 'pre-emptive discussion of the potential role of sedation in end-of-life care'; 9 recommended 'nutrition/hydration while performing sedation' and 8 acknowledged the need to 'care for the medical team'. There were striking differences in terminologies used and in life expectancy preceding the practice. Selected guidelines were conceptually similar, comparing closely to the EAPC Framework recommendations, albeit with notable variations.

CONCLUSIONS

Based on AGREE II, 3 guidelines achieved top scores and could therefore be recommended for use in this context. Also, domains 'scope and purpose' and 'editorial independence' ranked highest and lowest, respectively-underscoring the importance of good reportage at the developmental stage.

[Factors influencing the quality of clinical practice guidelines in ovarian cancer]

OBJECTIVE

To identify the characteristics of the published clinical practice guidelines for the management of epithelial ovarian cancer that suggest a good methodological quality.

MATERIAL AND METHODS

A literature review was performed on 25 clinical practice guidelines for epithelial ovarian cancer that were identified in different databases (MEDLINE, Guidelines International Network, National Guidelines Clearing house) published between 2007 and 2014. The quality of the guidelines was evaluated using the Appraisal of Guidelines Research and Evaluation II tool. Descriptive and bivariate analyses were performed to assess the association between the quality of the guidelines and of some of their features and their developers.

RESULTS

Just under half (48%) of the guidelines were rated as low quality. Scientific societies or independent centres and private funding, or under-reporting the source of funding, were statistically associated with lower quality of clinical practice guidelines (P<.01). The guidelines developed by National Program Guidelines had a median of consistently higher scores in all domains of the Appraisal of Guidelines Research and Evaluation II, with significant differences in the definition of scope and objectives, the participation of stakeholders, the methodological rigour of development, and applicability to the context.

CONCLUSIONS

Features such as the nature of the developer and funding of the guidelines are predictors of quality that should be taken into account prior to the use of the recommendations of a document.

Appraisal of clinical practice guidelines for management of paediatric type 2 diabetes mellitus using the AGREE II instrument: a systematic review protocol

BACKGROUND

The prevalence of type 2 diabetes mellitus (T2DM) in children and adolescents is increasing. This has spurred the development and publication of clinical practice guidelines (CPGs) for the management of paediatric T2DM. Given the long-term complications of T2DM, optimal management is important to prevent or delay these complications. However, the quality of published CPGs has not yet been empirically evaluated. Our objective is to systematically appraise all published CPGs for the management of T2DM in children and adolescents.

METHODS

We will identify all published CPGs that address T2DM in children and adolescents through MEDLINE, Embase, CINAHL, Trip, and the National Guideline Clearinghouse and will screen diabetes and paediatric societies and associations' websites. Search records will be screened in duplicate for inclusion. Grey literature will be covered by systematically searching publications of all relevant diabetes societies and associations and other health organizations for CPGs that meet our inclusion criteria. CPGs deemed eligible for inclusion will be retrieved. Quality assessment will be conducted using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool by a team of four appraisers. Scaled scores of the AGREE II will be used to gauge the overall quality of CPGs.

DISCUSSION

The results of this review will be disseminated through presentations at local, national, and international conferences and publication in a peer-reviewed journal. The results of this review can help improve the reporting of future guidelines, inform decisions of policy-makers to endorse CPGs, and affect the choice of guideline use in clinical practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016034187.

Fertility preservation in children, adolescents, and young adults with cancer: Quality of clinical practice guidelines and variations in recommendations

BACKGROUND

Fertility preservation care for children, adolescents, and young adults (CAYAs) with cancer is not uniform among practitioners. To ensure high-quality care, evidence-based clinical practice guidelines (CPGs) are essential. The authors identified existing CPGs for fertility preservation in CAYAs with cancer, evaluated their quality, and explored differences in recommendations.

METHODS

A systematic search in PubMed (January 2000-October 2014); guideline databases; and Web sites of oncology, pediatric, and fertility organizations was performed. Two reviewers evaluated the quality of the identified CPGs using the Appraisal of Guidelines for Research and Evaluation II Instrument (AGREE II). From high-quality CPGs, the authors evaluated concordant and discordant areas among the recommendations.

RESULTS

A total of 25 CPGs regarding fertility preservation were identified. The average AGREE II domain scores (scale of 0%-100%) varied from 15% on applicability to 100% on clarity of presentation. The authors considered 8 CPGs (32%) to be of high quality, which was defined as scores ≥60% in any 4 domains. Large variations in the recommendations of the high-quality CPGs were observed, with 87.2% and 88.6%, respectively, of discordant guideline areas among the fertility preservation recommendations for female and male patients with cancer.

CONCLUSIONS

Only approximately one-third of the identified CPGs were found to be of sufficient quality. Of these CPGs, the fertility preservation recommendations varied substantially, which can be a reflection of inadequate evidence for specific recommendations, thereby hindering the ability of providers to deliver high-quality care. CPGs including a transparent decision process for fertility preservation can help health care providers to deliver optimal and uniform care, thus improving the quality of life of CAYAs with cancer and cancer survivors. Cancer 2016;122:2216-23. © 2016 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.

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.

[Cancer pain management: Systematic review and critical appraisal of clinical practice guidelines]

OBJECTIVE

Although several clinical practice guidelines have been developed in the last decades, cancer pain management is still deficient. The purpose of this work was to carry out a comprehensive and systematic literature review of current clinical practice guidelines on cancer pain management, and critically appraise their methodology and content in order to evaluate their quality and validity to cope with this public health issue.

MATERIALS AND METHODS

A systematic review was performed in the main databases, using English, French and Spanish as languages, from 2008 to 2013. Reporting and methodological quality was rated with the Appraisal of Guidelines, Research and Evaluation II (AGREE-II) tool, including an inter-rater reliability analysis. Guideline recommendations were extracted and classified into several categories and levels of evidence, aiming to analyse guidelines variability and evidence-based content comprehensiveness.

RESULTS

Six guidelines were included. A wide variability was found in both reporting and methodological quality of guidelines, as well as in the content and the level of evidence of their recommendations. The Scottish Intercollegiate Guidelines Network guideline was the best rated using AGREE-II, while the Sociedad Española de Oncología Médica guideline was the worst rated. The Ministry of Health Malaysia guideline was the most comprehensive, and the Scottish Intercollegiate Guidelines Network guideline was the second one.

CONCLUSIONS

The current guidelines on cancer pain management have limited quality and content. We recommend Ministry of Health Malaysia and Scottish Intercollegiate Guidelines Network guidelines, whilst Sociedad Española de Oncología Médica guideline still needs to improve.

A systematic review and quality appraisal of international guidelines for early breast cancer systemic therapy: Are recommendations sensitive to different global resources?

The breast cancer incidence in low and middle income countries (LMCs) is increasing globally, and patient outcomes are generally worse in these nations compared to high income countries (HICs). This is partly due to resource constraints associated with implementing recommended breast cancer therapies. Clinical practice guideline (CPG) adherence can improve breast cancer outcomes, however, many CPGs are created in HICs, and include costly recommendations that may not be feasible in LMCs. In addition, the quality of CPGs can be variable. The aim of this study was to perform a systematic review of CPGs on early breast cancer systemic therapy with potential international impact, to evaluate their content, quality, and resource sensitivity. A MEDLINE and gray literature search was completed for English language CPGs published between 2005 and 2010, and then updated to July 2014. Extracted guidelines were evaluated using the AGREE 2 instrument. Guidelines were specifically analyzed for resource sensitivity. Most of the extracted CPGs had similar recommendations with regards to systemic therapy. However, only one, the Breast Health Global Initiative, made recommendations with consideration of different global resources. Overall, the CPGs were of variable quality, and most scored poorly in the quality domain evaluating implementation barriers such as resources. Published CPGs for early breast cancer are created in HICs, have similar recommendations, and are generally resource-insensitive. Given the visibility and influence of these CPGs on LMCs, efforts to create higher quality, resource-sensitive guidelines with less redundancy are needed.

Importance of meta-analysis and practical obstacles in oncological and epidemiological studies: statistics very close but also far!

Studies of epidemiological and prognostic factors are very important for oncology practice. There is a rapidly increasing amount of research and resultant knowledge in the scientific literature. This means that health professionals have major challenges in accessing relevant information and they increasingly require best available evidence to make their clinical decisions. Meta-analyses of prognostic and other epidemiological factors are very practical statistical approaches to define clinically important parameters. However, they also feature many obstacles in terms of data collection, standardization of results from multiple centers, bias, and commentary for intepretation. In this paper, the obstacles of meta-analysis are briefly reviewed, and potential problems with this statistical method are discussed.

Evaluation of Implementation, Adaptation and Use of the Recently Proposed Urea Cycle Disorders Guidelines

BACKGROUND

Implementation of guidelines and assessment of their adaptation is not an extensively investigated process in the field of rare diseases. However, whether targeted recipients are reached and willing and able to follow the recommendations has significant impact on the efficacy of guidelines. In 2012, a guideline for the management of urea cycle disorders (UCDs) has been published. We evaluate the efficacy of implementation, adaptation, and use of the UCD guidelines by applying different strategies.

METHODS

(i) Download statistics from online sources were recorded. (ii) Facilities relevant for the implementation of the guidelines were assessed in pediatric units in Germany and Austria. (iii) The guidelines were evaluated by targeted recipients using the AGREE instrument. (iv) A regional networking-based implementation process was evaluated.

RESULTS

(i) Download statistics revealed high access with an increase in downloads over time. (ii) In 18% of hospitals ammonia testing was not available 24/7, and emergency drugs were often not available. (iii) Recipient criticism expressed in the AGREE instrument focused on incomplete inclusion of patients' perspectives. (iv) The implementation process improved the availability of ammonia measurements and access to emergency medication, patient care processes, and cooperation between nonspecialists and specialists.

CONCLUSION

Interest in the UCD guidelines is high and sustained, but more precise targeting of the guidelines is advisable. Surprisingly, many hospitals do not possess all facilities necessary to apply the guidelines. Regional network and awareness campaigns result in the improvement of both facilities and knowledge.

Evaluation of the quality of guidelines for myasthenia gravis with the AGREE II instrument

Background

Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioners in making decisions about appropriate healthcare in specific clinical circumstances. The methodological quality of CPGs for myasthenia gravis (MG) are unclear.

Objective

To critically evaluate the methodological quality of CPGs for MG using AGREE II instrument.

Method

A systematical search strategy on PubMed, EMBASE, DynaMed, the National Guideline Clearinghouse (NGC) and the Chinese Biomedical Literature database (CBM) was performed on September 20th 2013. All guidelines related to MG were evaluated with AGREE II. The software used for analysis was SPSS 17.0.

Results

A total of 15 CPGs for MG met the inclusion criteria (12 CPGs in English, 3 CPGs in Chinese). The overall agreement among reviews was moderate or high (ICC >0.70). The mean scores (mean ± SD) for al six domains were presented as follows: scope and purpose (60.93% ±16.62%), stakeholder involvement (40.93% ±20.04%), rigor of development (37.22% ±30.46%), clarity of presentation (64.26% ±16.36%), applicability (28.19% ±20.56%) and editorial independence (27.78% ±28.28%). Compared with non-evidence-based CPGs, evidence-based CPGs had statistically significant higher quality scores for all AGREE II domains (P<0.05). All domain scores appear slightly higher for CPGs published after AGREE II instrument development and validation (P>0.05). The quality scores of CPGs developed by NGC/AAN were higher than the quality scores of CPGs developed by other organizations for all domains. The difference was statistically significant for all domains with the exception of clarity of presentation (P = 0.07).

Conclusions

The qualities of CPGs on MG were generally acceptable with several flaws. The AGREE II instrument should be adopted by guideline developers, particularly in China.