Quality of reporting and evidence in American Academy of Pediatrics guidelines

Clinical Practice Guideline Development in Pediatric Emergency Medicine Departments Across the United States: A Cross-sectional Study

OBJECTIVE

This cross-sectional study aimed to assess the process of clinical practice guideline (CPG) development in pediatric emergency medicine departments (PEDs) across the United States, with a focus on identifying areas for improvement to enhance the quality of CPGs.

METHODS

An electronic survey was distributed to PEDs with pediatric emergency medicine fellowship programs. Respondents were asked about their CPG development processes (ie, guideline committee composition, consideration of conflicts of interest, grading recommendations, guideline training opportunities) based on the Appraisal of Guidelines, Research, and Evaluation (AGREE II) tool as well as implementation and monitoring. Univariate analysis was used to assess associations between the number of AGREE II elements adhered to and annual patient volume.

RESULTS

Of the 84 PEDs surveyed, 44 (52.4%) responded, representing institutions from 28 states. Most PEDs (97.7%, n = 43) reported developing their own guidelines, citing the need to improve care quality and standardize patient care as primary reasons. Although most guideline committees included multidisciplinary team members (74.4%, n = 32), routine patient involvement in committees was rare (11.6%, n = 5), and barriers such as time and resource constraints hindered their inclusion. Formal training for committee members in guideline development was uncommon (18.6%, n = 8). There was an association between higher annual patient volume and the number of AGREE II elements adhered to (P = 0.03). Few PEDs considered potential conflicts of interest among committee members (13.6%, n = 6). Over half of surveyed PEDs (54.5%, n = 24) lacked a systematic approach to grading recommendations. Educational materials and workshops were the most common guideline implementation strategies.

CONCLUSIONS

Our findings highlight need for improvement in the CPG development process in PEDs. Including patients in committees, providing formal training for committee members, and adopting a rigorous approach to grading recommendations are crucial steps toward enhancing guideline quality. Emphasizing these improvements has the potential to improve the quality of CPGs for pediatric emergency care.

Quality appraisal of clinical guidelines for Helicobacter pylori infection and systematic analysis of the level of evidence for recommendations

OBJECTIVES

To systematically assess the quality of clinical practice guidelines (CPGs) for Helicobacter pylori (HP) infection and identify gaps that limit their development.

STUDY DESIGN AND SETTING

CPGs for HP infection were systematically collected from PubMed, Embase, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, and six online guideline repositories. Three researchers independently used the AGREE Ⅱ tool to evaluate the methodological quality of the eligible CPGs. In addition, the reporting and recommendation qualities were appraised by using the RIGHT and AGREE-REX tools, respectively. The distribution of the level of evidence and strength of recommendation among evidence-based CPGs was determined.

RESULTS

A total of 7,019 records were identified, and 24 CPGs met the eligibility criteria. Of the eligible CPGs, 19 were evidence-based and 5 were consensus-based. The mean overall rating score of AGREE II was 50.7% (SD = 17.2%). Among six domains, the highest mean score was for scope and purpose (74.4%, SD = 17.7%) and the lowest mean score was for applicability (24.3%, SD = 8.9). Only three of 24 CPGs were high-quality. The mean overall score of recommendation quality was 35.5% (SD = 12.2%), and the mean scores in each domain of AGREE-REX and RIGHT were all ≤ 60%, with values and preferences scoring the lowest (16.6%, SD = 11.9%). A total of 505 recommendations were identified. Strong recommendations accounted for 64.1%, and only 34.3% of strong recommendations were based on high-quality evidence.

CONCLUSION

The overall quality of CPGs for HP infection is poor, and CPG developers tend to neglect some domains, resulting in a wide variability in the quality of the CPGs. Additionally, CPGs for HP infection lack sufficient high-quality evidence, and the grading of recommendation strength should be based on the quality of evidence. The CPGs for HP infection have much room for improvement and further researches are required to minimize the evidence gap.

Impact of Healthcare Location Concordance on Receipt of Preventive Care Among Children Whose Parents have a Substance Use and/or Mental Health Diagnosis

AIMS

Children of parents with substance use and/or other mental health (SU/MH) diagnoses are at increased risk for health problems. It is unknown whether these children benefit from receiving primary care at the same clinic as their parents. Thus, among children of parents with >1 SU/MH diagnosis, we examined the association of parent-child clinic concordance with rates of well-child checks (WCCs) and childhood vaccinations.

DESIGN

Retrospective cohort study using electronic health record (EHR) data from the OCHIN network of community health organizations (CHOs), 2010-2018. Setting: 280 CHOs across 17 states.

PARTICIPANTS/CASES

41,413 parents with >1 SU/MH diagnosis, linked to 65,417 children aged 0 to 17 years, each with >1 visit to an OCHIN clinic during the study period.

MEASUREMENTS

Dependent variables: rates of WCCs during (1) the first 15 months of life, and (2) ages 3 to 17 years; vaccine completeness (3) by the age of 2, and (4) before the age of 18. Estimates were attained using generalized estimating equations Poisson or logistic regression.

FINDINGS

Among children utilizing the same clinic as their parent versus children using a different clinic (reference group), we observed greater WCC rates in the first 15 months of life [adjusted rate ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10]; no difference in WCC rates in ages 3 to 17; higher odds for vaccine completion before age 2 [adjusted odds ratio (aOR) = 1.12; 95% CI = 1.03-1.21]; and lower odds for vaccine completion before age 18 (aOR = 0.88; 95% CI = 0.81-0.95).

CONCLUSION

Among children whose parents have at least one SU/MH diagnosis, parent-child clinic concordance was associated with greater rates of WCCs and higher odds of completed vaccinations for children in the youngest age groups, but not the older children. This suggests the need for greater emphasis on family-oriented healthcare for young children of parents with SU/MH diagnoses; this may be less important for older children.

Quality appraisal of clinical practice guidelines for motor neuron diseases or related disorders using the AGREE II instrument

Objectives

This study aimed to systematically assess the quality of CPGs for motor neuron diseases (MNDs) or related disorders and identify the gaps that limit evidence-based practice.

Methods

Four scientific databases and six guideline repositories were searched for eligible CPGs. Three researchers assessed the eligible CPGs using the Appraisal of Guidelines Research and Evaluation II instrument. The distribution of the level of evidence and strength of recommendation of these CPGs were determined. The univariate regression analysis was used to explore the characteristic factors affecting the quality of CPGs.

Results

Fifteen CPGs met the eligibility criteria: 10 were for MND and 5 were for spinal muscular atrophy. The mean overall rating score was 44.5%, and only 3 of 15 CPGs were of high quality. The domains that achieved low mean scores were applicability (24.4%), rigor of development (39.9%), and stakeholder involvement (40.3%). Most recommendations were based on low-quality evidence and had a weak strength. The CPGs that were updated, meant for adults, and evidence based, and used a CPG quality tool and a grading system were associated with higher scores in certain specific domains and overall rating.

Conclusion

The overall quality of CPGs for MNDs or related disorders was poor and recommendations were largely based on low-quality evidence. Many areas still need improvement to develop high-quality CPGs, and the use of CPG quality tools should be emphasized. A great deal of research on MNDs or related disorders is still needed to fill the large evidence gap.

Review of clinical practice guidelines for postpartum hemorrhage according to AGREE II

BACKGROUND

Clinical practice guidelines for postpartum hemorrhage (PPH) are available worldwide, but no review has assessed the quality of these guidelines. Poor-quality guidelines for PPH may lead clinicians to follow incorrect approaches.

OBJECTIVES

High-quality guidelines for PPH are important in guiding the clinical diagnosis and treatment of PPH and decreasing maternal mortality. The aim of this study was to assess the quality of clinical guidelines for PPH.

METHODS

We collected studies from different countries through a literature search including PubMed (MEDLINE), Web of Science, the Cochrane library, websites of health institutions from multiple countries, and search sites, according to the criterion of clinical guidelines for treatment of PPH published between inception and October 2022. Four independent reviewers assessed the eligible guidelines by using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Agreement among reviewers of the guidelines was measured with the intra-class correlation coefficient (ICC). The number of recommendations, strength of recommendations, and level of evidence were determined.

RESULTS

Seven sets of PPH guidelines published from 2007 to 2022 were identified. An overall high agreement among reviewers in each domain was observed (ICC 0.74 to 0.95). The median scores and ranges for each AGREE II domain were as follows: (i) scope and purpose (median = 86.51%, range: 61.11%-94.44%); (ii) stakeholder involvement (median = 73.02%, range: 52.78%-90.28%); (iii) rigor of development (median = 76.49%, range: 66.15%-97.92%); (iv) clarity and presentation (median = 88.49%, range: 68.06%-100.00%); (v) applicability (median = 73.36%, range: 53.13%-93.75%); and (vi) editorial independence (median = 84.52%, range: 60.42%-95.83%). Three sets of PPH guidelines scored high in all domains and were classified as recommended for clinical practice. The other guidelines were classified as recommended with modifications.

CONCLUSION

The methodological and reporting quality of the guidelines for PPH included in this review was generally good, but the strength of the recommendations and the quality of the evidence varied, thus potentially leading to confusion among clinicians applying the guidelines. An urgent need exists for rigorous studies to close important evidence gaps to support the development of guidelines for PPH.

Best Practices for the Provision of Virtual Care: A Systematic Review of Current Guidelines

Background: Telemedicine has emerged as a feasible adjunct to in-person care in multiple clinical contexts, and its role has expanded in the context of the COVID-19 pandemic. However, there exists a general paucity of information surrounding best practice recommendations for conducting specialty or disease-specific virtual care. The purpose of this study was to systematically review existing best practice guidelines for conducting telemedicine encounters. Methods: A systematic review of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) of existing guidelines for the provision of virtual care was performed. Data were synthesized using the Synthesis Without Meta-Analysis (SWiM) guideline, and the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II) tool was used to evaluate the quality of evidence. Results: A total of 60 guidelines for virtual care encounters were included; 52% of these were published in the context of the COVID-19 pandemic. The majority (95%) of provider guidelines specified a type of virtual encounter to which their guidelines applied. Of included guidelines, 65% provided guidance regarding confidentiality/security, 58% discussed technology/setup, and 56% commented on patient consent. Thirty-one guidelines also provided guidance to patients or caregivers. Overall guideline quality was poor. Discussion: General best practices for successful telemedicine encounters include ensuring confidentiality and consent, preparation before a visit, and clear patient communication. Future studies should aim to objectively assess the efficacy of existing clinician practices and guidelines on patient attitudes and outcomes to further optimize the provision of virtual care for specific patient populations.

Association of Parent Preventive Care with their Child's Recommended Well-Child Visits

BACKGROUND

Receipt of recommended well-child care is lowest for children without insurance, many of whom receive care in community health centers (CHCs).

OBJECTIVE

To understand if there is an association between parent preventive care and their children's well-child visits.

METHODS

We used electronic health record data to identify children and link them to parents both seen in an OCHIN network (CHC; n = 363 clinics from 17 states), randomly selected a child aged 3 to 17 with ≥1 ambulatory visit between 2015 and 2018. We employed a retrospective, cohort study design and used general estimating equations Poisson regression to estimate yearly rates of well-child visits based on parent preventive care adjusted for relevant covariates and stratified by child age for 3 linked samples: mother only, father only, and two parents.

RESULTS

We included 75,398 linked mother only pairs, 12,438 in our father only, and 4,156 in our 2-parent sample. Children in the mother only sample had a 6% greater rate of yearly well-child visits when their mother received preventive care (adjusted rate ratio [ARR] = 1.06; 95% CI = 1.03-1.08) compared to no preventive care. Children in the father only sample had a 7% greater rate of yearly well-child visits when their father received preventive care (ARR = 1.07; 95% CI = 1.04-1.11) versus no preventive care. Children in the two parent sample had an 11% greater rate of yearly well-child visits when both parents received preventive care (ARR = 1.11; 95% CI = 1.03-1.19) compared to neither receiving preventive care.

CONCLUSIONS

These findings suggest focusing on receipt of healthcare for the whole family may improve well-child visit rates.

Clinical Practice Guidelines on Pediatric Gastroesophageal Reflux Disease: A Systematic Quality Appraisal of International Guidelines

PURPOSE

While regurgitation is a common and often benign phenomenon in infants and younger children, it can also be a presenting symptom of gastroesophageal reflux disease (GERD). If untreated, GERD can lead to dangerous or lifelong complications. Clinical practice guidelines (CPGs) have been published to inform clinical diagnosis and management of pediatric GERD, but to date there has been no comprehensive review of guideline quality or methodological rigor.

METHODS

A systematic literature search was performed, and a total of eight CPGs pertaining to pediatric GERD were identified. These CPGs were evaluated using the Appraisal of Guidelines for Research and Evaluation instrument.

RESULTS

Three CPGs were found to be "high" quality, with 5 of 6 domains scoring >60%, one "average" quality, with 4 of 6 domains meeting that threshold, and the remaining four "low" quality.

CONCLUSION

Areas of strength among the CPGs included "Scope and Purpose" and "Clarity and Presentation," as they tended to be well-written and easily understood. Areas in need of improvement were "Stakeholder Involvement," "Rigor of Development," and "Applicability," suggesting these CPGs may not be appropriate for all patients or providers. This analysis found that while strong CPGs pertaining to the diagnosis and treatment of pediatric GERD exist, many published guidelines lack methodological rigor and broad applicability.

Characteristics and quality of clinical practice guidelines addressing acupuncture interventions: a systematic survey of 133 guidelines and 433 acupuncture recommendations

OBJECTIVE

To systematically summarise acupuncture-related Clinical Practice Guidelines (CPGs)'s clinical and methodological characteristics and critically appraise their methodology quality.

DESIGN

We summarised the characteristics of the guidelines and recommendations and evaluated their methodological quality using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument.

DATA SOURCES

Nine databases were searched from 1 January 2010 to 20 September 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included the latest version of acupuncture CPGs, which must have used at least one systematic review addressing the benefits and harms of alternative care options to inform acupuncture recommendations.

DATA EXTRACTION AND SYNTHESIS

Reviewers, working in pairs, independently screened and extracted data. When there are statistical differences among types of CPGs, we reported the data by type in the text, but when not, we reported the overall data.

RESULTS

Of the 133 eligible guidelines, musculoskeletal and connective tissue diseases proved the most commonly addressed therapeutic areas. According to the AGREE II instrument, the CPG was moderate quality in the domain of clarity of scope and purpose, clarity of presentation, the rigour of development, stakeholder involvement and low quality in editorial independence, and applicability. The study identified 433 acupuncture-related recommendations; 380 recommended the use of acupuncture, 28 recommended against the use of acupuncture and 25 considered acupuncture but did not make recommendations. Of the 303 recommendations that used Grading of Recommendations Assessment, Development and Evaluation to determine the strength of recommendations, 152 were weak recommendations, 131 were strong recommendations, of which 104 were supported by low or very low certainty evidence (discordant recommendations).

CONCLUSION

In the past 10 years, a large number of CPGs addressing acupuncture interventions exist. Although these guidelines may be as or more rigorous than many others, considerable room for improvement remains.

An analysis of research quality underlying IDSA clinical practice guidelines: a cross-sectional study

Context

As a result of new developments in medicine, the need for evidence-based clinical practice guidelines (CPG) is of utmost importance. However, studies have shown that many medical societies are using low quality research to develop CPGs.

Objectives

To evaluate the quality of research underlying the CPGs issued by the Infectious Diseases Society of America (IDSA).

Methods

We examined 29 CPGs issued between January 1, 2012 and December 31, 2019 and classified each by research quality according to levels reported by the CPG authors and previously specified by the IDSA: Levels I through III, corresponding to high, moderate, and low quality of evidence, respectively. Each ranking was cross-checked with a second researcher to improve inter-rater reliability. To analyze evolution of research quality over time, three updated CPGs were randomly selected and compared to their original versions. Chi-square analysis was then performed to determine statistical significance.

Results

We evaluated the quality of research for 2,920 recommendations within the 29 CPGs that met our criteria and found that 418 (14%) were developed using high-quality (Level I) research from randomized, controlled trials. Of the remaining recommendations, 928 (32%) were based on moderate quality research (observational studies) and 1574 (54%) on low quality research (expert opinion). A Pearson chi-squared analysis indicated no-statistically significant difference between original guidelines or their subsequent updates for Clostridium difficile (χ2=0.323; n=85; degrees of freedom [df]=2; p=0.851), candidiasis (χ2=4.133; n=195; df=2; p=0.127), or coccidiomycosis (χ2=0.531; n=95; df=1; p=0.466).

Conclusions

The proportion of high-quality research underlying guideline recommendations is remarkably low, indicating that moderate and low quality evidence is still influencing infectious disease guidelines despite IDSA standards. Moreover, the quality of research has not significantly changed over time. IDSA CPGs are a formidable source of information for clinicians, but an increased number of quality studies should be utilized to further guide CPG development.

Quality of pediatric clinical practice guidelines

BACKGROUND

There is a lack of a comprehensive evaluation for pediatric clinical practice guidelines (CPGs) published in recent years. Here, we assessed the quality of pediatric CPGs, considering factors that might affect their quality. The aim of the study is to promote a more coherent development and application of CPGs.

METHODS

Pediatric CPGs published in PubMed, MedLive, Guidelines International Network, National Institute for Health and Care Excellence, and World Health Organization between 2017 and 2019 were searched and collected. Paired researchers conducted screening, data extraction, and quality assessment using the Appraisal of Guidelines for Research and Evaluation II (AGREE II). Linear regression analysis determined the factors affecting CPGs' quality.

RESULTS

The study included a total of 216 CPGs, which achieved a mean score of 4.26 out of 7 points (60.86%) in the AGREE II assessment. Only 6.48% of the CPGs reached the "recommend" level. The remaining 69.91% should have been modified before recommendation, while the other 23.61% did not reach the recommended level at all. The overall quality of recent pediatric CPGs was higher than previously, and the proportion of CPGs with low-quality decreased over time. However, there were still too few CPGs that reached a high-quality level. The "applicability" and "rigor of development" domains had generally low scores. CPGs formulated by developing countries or regions, those that are not under an organizations or groups responsibility, and those that used non-evidence-based methods were found to be associated with poorer quality in different domains as independent or combinational factors.

CONCLUSIONS

The quality of pediatric CPGs still needs to be improved. Specifically, a quality control before applying new CPGs should be essential to ensure their quality and applicability.

A critical review to grading systems and recommendations of traditional Chinese medicine guidelines

Objectives

To investigate how many traditional Chinese medicine (TCM) guidelines adopted a grading system and the differences among them, and the distribution of level of evidence used to support TCM recommendations.

Methods

A comprehensive search of relevant guideline webpages and literature databases were undertaken from inception to August 2018 to identify guidelines including TCM interventions. Two independent reviewers extracted the information about grading systems and recommendations.

Results

One hundred forty-two TCM guidelines were included, among which, 68 (47.9%) adopted a total of eight grading systems. The definitions, letters, and codes among these systems varied significantly. A total of 1284 recommendations were extracted from included TCM guidelines. More than 60% recommendations were based on a low and very low level of evidence (level C:33.4% and level D: 30.2%). Only 7.8% recommendations were rated as strong recommendation (grade I), while 76.2% recommendations were rated as conditional recommendation (grade II).

Conclusions

Various grading systems were used in TCM guidelines, which might confuse guideline users. The low proportion of high level of evidence in TCM recommendations might downgrade the confidence to TCM interventions.

Quality assessment of kidney cancer clinical practice guidelines using AGREE II instrument: A critical review

BACKGROUND

Evidence-based guidelines are expected to provide clinicians with explicit recommendations on how to manage health conditions and bridge the gap between research and clinical practice. However, the existing practice guidelines(CPGs) vary in quality. This study aimed to evaluate the quality of CPGs of kidney cancer.

METHODS

We systematically searched PubMed, Embase, China Biology Medicine disc, and relevant guideline websites from their inception to April, 2018. We identified CGPs that provided recommendations on kidney cancer; 4 independent reviewers assessed the eligible CGPs using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. The consistency of evaluations was calculated using intraclass correlation coefficients (ICC).

RESULTS

A total of 13 kidney cancer CGPs were included. The mean scores for each AGREEII domain were as follows: scope and purpose-76.9%; clarity and presentation-76.4%; stakeholder involvement-62.8%; rigor of development-58.7%; editorial independence-53.7%; and applicability-49.4%. Two CPGs were rated as "recommended"; 8 as "recommended with modifications"; and 3 as "not recommended." Seven grading systems were used by kidney cancer CGPs to rate the level of evidence and the strength of recommendation.

CONCLUSIONS

Overall, the quality of CPGs of kidney cancer is suboptimal. AGREE II assessment results highlight the need to improve CPG development processes, editorial independence, and applicability in this field. It is necessary to develop a standardized grading system to provide clear information about the level of evidence and the strength of recommendation for future kidney cancer CGPs.

Assessment of the quality and content of clinical practice guidelines for post-stroke rehabilitation of aphasia

OBJECTIVES

The purpose of this study was to evaluate the quality of guidelines for rehabilitation of post-stroke aphasia using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument and identify consistency of different guidelines.

METHODS

A systematic search was undertaken from inception to October 2018. Two reviewers independently screened all titles and abstracts, and assessed eligible guidelines using the AGREE-II. Agreement among reviewers was measured by using intra-class correlation coefficient (ICC).

RESULTS

From 5008 records screened, 8 guidelines met the inclusion criteria. The quality of guidelines was heterogeneous. Three guidelines were rated high (6.5) across; the highest rated domain was "scope and purpose' (median score 95.8%); the lowest rated domain was "rigor of development' (median score 67.2%). An overall high degree of agreement among reviewers to each domain was observed (ICC ranged from 0.60 to 0.99). The speech language therapy was recommended in 3 guidelines. Four guidelines described group treatment was beneficial for the continuum of care. However, other therapies for aphasia varied in the level of detail across guidelines.

CONCLUSIONS

Our study indicated the quality of guidelines for post-stroke aphasia needed to be improved. Moreover, the treatment recommendations of aphasia existed discrepancy among the included guidelines. Therefore, it is suggested to pay more attention on the rigor of methodology and applicability during the process of the formulation of guideline. Future research should focus on the effectiveness, intensity, and duration of treatment measures.

How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II)

OBJECTIVES

To summarise recommendations and appraise the quality of international clinical practice guidelines (CPGs) for rehabilitation after ACL reconstruction.

DESIGN

Systematic review of CPGs (PROSPERO number: CRD42017020407).

DATA SOURCES

Pubmed, EMBASE, Cochrane, SPORTDiscus, PEDro and grey literature databases were searched up to 30 September 2018.

ELIGIBILITY CRITERIA

English-language CPGs on rehabilitation following ACL reconstruction that used systematic search of evidence to formulate recommendations.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report the systematic review. Two appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to report comprehensiveness, consistency and quality of CPGs. We summarised recommendations for rehabilitation after ACL reconstruction.

RESULTS

Six CPGs with an overall median AGREE II total score of 130 points (out of 168) and median overall quality of 63% were included. One CPG had an overall score below the 50% (poor quality score) and two CPGs scored above 80% (higher quality score). The lowest domain score was 'applicability' (can clinicians implement this in practice?) (29%) and the highest 'scope and purpose' (78%) and 'clarity of presentation' (75%). CPGs recommended immediate knee mobilisation and strength/neuromuscular training. Early full weight-bearing exercises, early open and closed kinetic-chain exercises, cryotherapy and neuromuscular electrostimulation may be used according individual circumstances. The CPGs recommend against continuous passive motion and functional bracing.

CONCLUSION

The quality of the CPGs in ACL postoperative rehabilitation was good, but all CPGs showed poor applicability. Immediate knee mobilisation and strength/neuromuscular training should be used. Continuous passive motion and functional bracing should be eschewed.

Screening for osteoporosis: A systematic assessment of the quality and content of clinical practice guidelines, using the AGREE II instrument and the IOM Standards for Trustworthy Guidelines

BACKGROUND

Numerous clinical practice guidelines (CPGs) are published to guide management of osteoporosis. Little is known about their quality or how recommendations have changed over time.

OBJECTIVE

To systematically assess the quality and content of the guidelines on screening for osteoporosis, using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool, and the Institute of Medicine (IOM) standards for trustworthy guidelines.

METHODS

We conducted a systematic search for osteoporosis CPGs published between 2002-2016, using multiple databases and guideline websites. Two reviewers appraised the quality of eligible CPGs using the AGREE II. High quality CPGs were considered if they scored ≥ 60 in four or more domains including the domain for rigor of development. Non-parametric tests were used to test for the change of quality over time. One reviewer assessed the guidelines with IOM standards. We summarized the different evidence grading systems and extracted and compared the recommendations.

RESULTS

A total of 33 CPGs were identified. The mean scores for AGREE II differed by domain (range: 42% to 71%). CPGs scored higher on domains for clarity of presentation, scope and purpose, and rigor of development. CPGs scored lower on domains for stakeholder involvement, editorial independence and applicability. Assessment of CPGs by IOM standards showed that CPGs scored better on standards for systematic review, establishing evidence foundation and rating strength of recommendation, articulation of recommendation, and establishing transparency. While scored lower on standards for updating, external review, and the development group composition. There was no difference in AGREE II and IOM defined guidelines' quality before and after the introduction of the two tools (P values >0.05). The IOM identified four more guidelines as high quality compared to the AGREE II. Examining these additional guidelines indicated that the two tools may give conflicting results especially for the rigor of development domain. Recommendations in certain areas showed substantial differences between guidelines.

CONCLUSION

Osteoporosis screening CPGs are of variable quality, and their recommendations often differ. Guideline quality as measured by AGREE II and IOM standards has not improved overtime. Guideline developers should work together to improve the quality and consistency of recommendations to improve the likelihood that their guidelines will be used in practice.

Appraising the Evidence Supporting Choosing Wisely® Recommendations

Despite the growing enthusiasm surrounding the Choosing Wisely® campaign, little is known regarding the evidence underlying these recommendations. We extracted references for all 320 recommendations published through August, 2014, including the 10 adult and pediatric recommendations published by the Society for Hospital Medicine. We then categorized each item by evidence strength, and then assessed a sample of referenced clinical practice guidelines (CPGs) using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Among all recommendations, 70.3% cited CPGs, whereas 22.2% cited primary research as their highest level of evidence. Moreover, 7.8% cited case series, review articles, editorials, or lower quality data as their highest level of evidence. Hospital medicine recommendations were more likely to cite CPGs (90%) as their highest level of evidence. Among the sampled CPGs, the median overall score obtained using AGREE II was 54.2% (IQR 33.3%-70.8%), whereas among hospital medicine-referenced CPGs, the median overall score was 58.3% (IQR 50.0%-83.3%). These findings suggest that Choosing Wisely® recommendations vary in terms of evidence strength.

A critical review of recent clinical practice guidelines on management of cryptorchidism

BACKGROUND/PURPOSE

Limited efforts have been made in assessing the qualities of clinical practice guidelines (CPGs) on cryptorchidism (UDT). This appraisal aims to determine the quality of recent CPGs on the management of UDT.

METHODS

After systematic literature search, all English-based CPGs providing recommendations for the management of UDT from 2012 to 2017 were reviewed. Using the AGREE II (Appraisal of Guidelines and Research Evaluation) instrument, eligible CPGs were independently appraised by 5 reviewers. Domain scores were calculated and summarized. Intraclass coefficient (ICC) was used to assess for interrater reliability.

RESULTS

Five CPGs from Agency for Healthcare Research and Quality (AHRQ), American Urological Association (AUA), British Association of Pediatric Surgeons/British Association of Urologic Surgeons (BAPS/BAUS), Canadian Urological Association (CUA), and European Association of Urology/European Society for Pediatric Urology (EAU/ESPU) were assessed. There was a solid agreement (ICC: 0.749) among the 5 reviewers (p<0.001). Most recommendations for diagnostic and treatment approaches were consistent across CPGs. For most guidelines, the domains of 'clarity of presentation,' 'scope and purpose,' 'stakeholder involvement,' and 'rigor of development' were high, while 'applicability' was low.

CONCLUSION

Most guidelines on UDT score high in the AGREE II domains and have consistent recommendations. To improve the 'applicability' domain, future guidelines should improve on aspects that facilitate implementation of the recommendations.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

V (based on the lowest level of evidence utilized by the assessed guidelines).

Quality assessment of cancer cachexia clinical practice guidelines

OBJECTIVES

The aim of this study was to investigate the quality of clinical practice guidelines of cancer cachexia and identify gaps limiting knowledge.

METHODS

A systematic search of relevant guideline websites and literature databases (including PubMed, NCCN, NGC, SIGN, NICE, and google) was undertaken from inception to March 2017 to identify and select clinical guidelines related to cancer cachexia. Four independent reviewers assessed the eligible guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Agreement among reviewers of the guidelines was measured by using intra-class correlation coefficient (ICC). The number of recommendations, strength of recommendation, and levels of evidence were determined.

RESULTS

Nine cancer cachexia guidelines published from 2006 to 2017 were identified. An overall high degree of agreement among reviewers to each domain was observed (ICC ranged from 0.75 to 0.91). The median scores and range for each AGREE II domain were as follows: (i) scope and purpose (median = 61.1%, range: 13.9% to 80.7%); (ii) stakeholder involvement (median = 26.4%, range: 8.3% to 81.9%); (iii) rigour of development (median = 35.9%, range: 3.6% to 84.4%); (iv) clarity and presentation (median = 56.9%, range: 30.6% to 76.4%); (v) applicability (median = 19.8%, range: 0% to 77.1%) and (vi) editorial independence (median = 27.1%, range: 0% to 85.4%). Two cancer cachexia guidelines (ESPEN, 2017 and University of Queensland, 2013) scored higher on all domains and were classified as recommended for clinical practice, among which, one was developed by European Society for Parenteral and Enteral Nutrition and European Partnership for Action Against Cancer, and the other was developed by University of Queensland. In addition, more than a half recommendations were based on nonrandomized studies (Level C, 50.0%) and expert opinion (Level D, 8.2%).

CONCLUSIONS

The quality of cancer cachexia guidelines was highly heterogeneous among different domains even within the same guideline. There is significant room for improvement to develop high quality cancer cachexia guidelines, which urgently warrants first-class research to minimize the vital gaps in the evidence for formulation of cancer cachexia guidelines.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Eliminating Undesirable Variation in Neonatal Practice: Balancing Standardization and Customization

Consistency of care and elimination of unnecessary and harmful variation are underemphasized aspects of health care quality. This article describes the prevalence and patterns of practice variation in health care and neonatology; discusses the potential role of standardization as a solution to eliminating wasteful and harmful practice variation, particularly when it is founded on principles of evidence-based medicine; and proposes ways to balance standardization and customization of practice to ultimately improve the quality of neonatal care.

Range and Heterogeneity of Outcomes in Randomized Trials of Pediatric Chronic Kidney Disease

OBJECTIVE

To determine the range and heterogeneity of outcomes reported in randomized controlled trials of interventions for children with chronic kidney disease (CKD).

STUDY DESIGN

The Cochrane Kidney and Transplant Specialized Register was searched to March 2016. Randomized trials involving children across all stages of CKD were selected. All outcome domains and measurements were extracted from included trials. The frequency and characteristics of the outcome domains and measures were evaluated.

RESULTS

From 205 trials included, 6158 different measurements of 100 different outcome domains were reported, with a median of 22 domains per trial (IQR 13-41). Overall, 52 domains (52%) were surrogate, 38 (38%) were clinical, and 10 (10%) were patient-reported. The 5 most commonly reported domains were blood pressure (76 [37%] trials), relapse/remission (70 [34%]), kidney function (66 [32%]), infection (61 [30%]), and height/pubertal development (51 [25%]). Mortality (14%), cardiovascular disease (4%), and quality of life (1%) were reported infrequently. The 2 most frequently reported outcomes, blood pressure and relapse/remission, had 56 and 81 different outcome measures, respectively.

CONCLUSIONS

The outcomes reported in clinical trials involving children with CKD are extremely heterogeneous and are most often surrogate outcomes, rather than clinical and patient-centered outcomes such as cardiovascular disease and quality of life. Efforts to ensure consistent reporting of outcomes that are important to patients and clinicians will improve the value of trials to guide clinical decision-making. In our study, non-English articles were excluded.

A Systematic Review and Appraisal of Clinical Practice Guidelines for Musculoskeletal Soft Tissue Injuries and Conditions

BACKGROUND

Clinical practice guidelines (CPGs) are published by several sports medicine institutions. A systematic evaluation can help identify the highest quality CPGs for clinical use and identify any deficiencies that remain.

PURPOSE

To identify and appraise CPGs relevant to clinical sports medicine professionals.

STUDY DESIGN

Systematic review.

METHODS

Predetermined selection criteria were utilized by 2 reviewers who independently identified published CPGs before January 1, 2014. CPGs were excluded if they focused on injured workers, radiological criteria, medical pathology, or the axial skeleton (back/neck). The remaining guidelines were scored by 6 reviewers with different clinical backgrounds using the Appraisal of Guidelines for Research and Evaluation II (AGREE II). Scores lower than 50% indicated deficiency. Scores were also stratified by the publishing institution and anatomic location and compared using Kruskal-Wallis tests. The Spearman correlation coefficient was used to assess the range of interobserver agreement between the evaluators.

RESULTS

Seventeen CPGs met the inclusion criteria. The majority of guidelines pertained to the knee, ankle, or shoulder. Interobserver agreement was strong ( r = 0.548-0.740), and mean total scores between nonsurgical (107.8) and surgical evaluators (109.3) were not statistically different. Overall guideline quality was variable but not deficient for 16 of 17 guidelines (>50%), except regarding clinical "applicability" and "editorial independence." No difference was found between CPGs of the knee, shoulder, foot/ankle, or chronic conditions. However, CPG publishing institutions had significantly different scores; the American Academy of Orthopaedic Surgeons (AAOS) guidelines scored significantly higher (141.4) than the total mean score (108.0).

CONCLUSION

The overall quality of sports medicine CPGs was variable but generally not deficient, except regarding applicability and editorial independence. Bias through poor editorial independence is a concern. To improve future guideline quality, authors should pay particular attention to these areas and use existing highest quality guidelines, or the AGREE II instrument, as templates. CPGs dedicated to anatomic areas other than the knee, ankle, and shoulder are needed.

Methodological quality, completeness of reporting and use of systematic reviews as evidence in clinical practice guidelines for paediatric overweight and obesity

Paediatric obesity rates remain high despite extensive efforts to prevent and treat obesity in children. We investigated the quality of the methodology and reporting within systematic reviews (SRs) underpinning paediatric content in US clinical practice guidelines (CPGs). In June 2016 we searched guideline clearinghouses and professional organization websites for guidelines published by national or professional organizations in the United States from January 2007 onwards. In our primary, a priori analysis, we used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) instruments to score SRs and meta-analyses that included paediatric populations and were cited by included CPGs. In a secondary, post hoc analysis, we determined the extent to which US CPGs use available, relevant SRs and meta-analyses compared with non-US CPGs. Eight US-based CPGs with 27 references to 22 unique SRs were found. AMSTAR and PRISMA scores were low overall, with only three SRs having 'high' methodological quality. Items dealing with bias assessments and search strategies had especially low scores. US CPGs were also older on average and cited fewer SRs than their international counterparts. Low quality scores and dated guidelines should be a cause for concern among practicing clinicians and a call to action for future guideline developers, publishers and research institutions.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LINKING EVIDENCE TO ACTION

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

Supporting primary healthcare professionals to care for people with intellectual disability: a research agenda

BACKGROUND

The vast health inequities experienced by people with intellectual disability remain indisputable. Persistent and contemporary challenges exist for primary healthcare providers and researchers working to contribute to improvements to the health and well-being of people with intellectual disability. Over two decades after the only review of supports for primary healthcare providers was published, this paper contributes to an evolving research agenda that aims to make meaningful gains in health-related outcomes for this group.

METHODS

The present authors updated the existing review by searching the international literature for developments and evaluations of multinational models of care.

RESULTS

Based on our review, we present three strategies to support primary healthcare providers: (i) effectively using what we know, (ii) considering other strategies that offer support to primary healthcare professionals and (iii) researching primary health care at the system level.

CONCLUSIONS

Strengthening primary care by supporting equitable provision of health-related care for people with intellectual disability is a much needed step towards improving health outcomes among people with intellectual disability. More descriptive quantitative and qualitative research, as well as intervention-based research underpinned by rigorous mixed-methods evaluating these strategies at the primary care level, which is sensitive to the needs of people with intellectual disability will assist primary care providers to provide better care and achieve better health outcomes.

ACCESSIBLE ABSTRACT

Many people with intellectual disability have poor health. The authors reviewed what has been written by other researchers about how to improve the health of people with intellectual disability. In the future, people who support adults with intellectual disability should continue doing what they do well, think of other ways to improve health, and do more research about health. At all times, the needs of people with intellectual disability should be the greatest concern for those trying to support them.

[Clinical Practice Guidelines for Management of Schizophrenia: Evaluation Using AGREE II]

INTRODUCTION

Colombia is developing multiple national practice guidelines from a range of diseases. Clinical practice guidelines represent a very useful tool to be able to take decision over a patient care that is widely available for the clinician. In psychiatry there are a good number of international clinical guidelines for the treatment of schizophrenia nevertheless there is no article that evaluate them scientifically

METHODS

In the settings of developing a Colombian schizophrenia practice guideline, a systematic search was performed in multiple databases and the results were then evaluated by two trained persons. We present the results globally and by domains.

RESULTS

We found 164 matches for possible guidelines. After screening 7 guidelines were evaluated with the AGREE II instrument. Globally and by the different domains, the National Institute for Health and Care Excellence (NICE) was the guideline that got the best score. From the guidelines that were reviewed, 4 were from Europe and only 2 were from Latin America. None of the guidelines used GRADE methodology for the recommendations.

CONCLUSION

The diversity of the schizophrenia treatment guidelines does not allow an easy adoption of the recommendation by a psychiatrist in Colombia.

High methodologic quality but poor applicability: assessment of the AAOS guidelines using the AGREE II instrument

BACKGROUND

The American Academy of Orthopaedic Surgeons (AAOS) is a globally recognized leader in musculoskeletal and orthopaedic education. Clinical guidelines are one important focus of the AAOS' educational efforts. Although their recommendations sometimes generate controversy, a critical appraisal of the overall quality of these guidelines has not, to our knowledge, been reported.

QUESTIONS/PURPOSES

We wished to assess the overall quality of the AAOS guidelines using the AGREE II (Advancing Guideline Development, Reporting and Evaluation in Health Care) instrument.

METHODS

All 14 guidelines available on the AAOS website as of August 2, 2013 were evaluated. Appraisal was performed by three reviewers, independently, using the AGREE II instrument. This is an internationally recognized and validated assessment tool for evaluating guideline quality. Interrater reliability was calculated and descriptive statistics were performed. Strong interrater reliability was shown using a Spearman's Rho test (correlation coefficient ≥ 0.95).

RESULTS

The overall results for AGREE II domains across all 14 guidelines were: scope and purpose (median score, 95%), stakeholder involvement (median score, 83%), rigor of development (median score, 94%), clarity of presentation (median score, 92%), applicability (median score, 48%), and editorial independence (median score, 79%).

CONCLUSIONS

This study showed that the overall quality of the AAOS guidelines is high, however their applicability was found to be poor. The value of guidelines that have a high quality but that are difficult for clinicians to implement is questionable. Numerous suggestions have been proposed to improve applicability including; health economist involvement in guideline production, implementation of pilot studies and audit to monitor uptake of the guidelines and clinician feedback sessions and barrier analysis studies. Future AAOS guidelines should consider and implement steps that can improve their applicability.

Methodological quality of national guidelines for pediatric inpatient conditions

BACKGROUND

Guidelines help inform standardization of care for quality improvement (QI). The Pediatric Research in Inpatient Settings network published a prioritization list of inpatient conditions with high prevalence, cost, and variation in resource utilization across children's hospitals. The methodological quality of guidelines for priority conditions is unknown.

OBJECTIVE

To rate the methodological quality of national guidelines for 20 priority pediatric inpatient conditions.

DESIGN

We searched sources including PubMed for national guidelines published from 2002 to 2012. Guidelines specific to 1 organism, test or treatment, or institution were excluded. Guidelines were rated by 2 raters using a validated tool (Appraisal of Guidelines for Research and Evaluation) with an overall rating on a 7-point scale (7 = the highest). Inter-rater reliability was measured with a weighted kappa coefficient.

RESULTS

Seventeen guidelines met inclusion criteria for 13 conditions; 7 conditions yielded no relevant national guidelines. The highest methodological-quality guidelines were for asthma, tonsillectomy, and bronchiolitis (mean overall rating 7, 6.5, and 6.5, respectively); the lowest were for sickle cell disease (2 guidelines) and dental caries (mean overall rating 4, 3.5, and 3, respectively). The overall weighted kappa was 0.83 (95% confidence interval 0.78-0.87).

CONCLUSIONS

We identified a group of moderate to high methodological-quality national guidelines for priority pediatric inpatient conditions. Hospitals should consider these guidelines to inform QI initiatives.

Lifestyle Habits: Diet, physical activity and sleep duration among Omani adolescents

OBJECTIVES

This study aimed to investigate the lifestyle habits-physical activity (PA), eating habits (EH), and sleep duration (SD)-of Omani adolescents, and to examine gender differences in such variables.

METHODS

802 Omani adolescents (442 females and 360 males), aged 15-18 years were randomly recruited. Anthropometric indices, PA level, and EH and SD were evaluated by the Arab Teenage Lifestyle questionnaire. A semi-quantitative food frequency questionnaire for dietary assessment was also administered.

RESULTS

The results showed that although the study subjects had a sedentary lifestyle (lack of PA, average of 6.7 hours sleep, and consumption of high calorie foods), they maintained a normal body mass (less than 25 Kg/m(2)). Males were more than twice as active as females. With respect to EH, there were few gender differences, except in dairy and meat consumption where 62.5% and 55.5% of males consumed more than 3 servings, respectively, compared to 18.78 % and 35.2% of females, respectively. In addition, waist/height ratio, height, reasons for being active, energy drinks, potato consumption, eating sweets, vigorous PA and breakfast EHs were statistically significant independent predictors for BMI, P <0.05 for both males and females.

CONCLUSION

This study revealed a high prevalence of sedentary behaviors and a low level of physical activity, especially among females. Unhealthy dietary habits were also widely found among both genders. There is an urgent need for more research as well as a national policy promoting active living and healthy eating and discouraging sedentary behaviour among Omani adolescents.

The Red Book through the ages

The first edition of the Red Book was published in 1938. Since then, there have been numerous advances in the fields of infectious diseases and public health that have decreased morbidity and mortality of infants, children, and adolescents. Over the years, emerging pathogens and disease complexes have been described, sophisticated diagnostic techniques developed, advances in antimicrobial therapy have occurred, and immunizations have been implemented to prevent previously deadly diseases. Of the 18 diseases or organisms in the 1938 edition, 13 are now vaccine-preventable. Since inception of the Red Book, the aims of the editors have been to keep pace with these innovations and to continue to inform the medical community. These goals have made the Red Book a fundamental resource for pediatricians and other health care professionals in terms of guiding diagnosis, therapy, and prevention of infectious diseases. The list of 18 diseases or organisms originally described in the 1938 Red Book has expanded to include over 160 diseases or organisms in the 2012 edition. The pace of biomedical discovery, as well as the amount of information available and the number of methods for its delivery, will continue to accelerate in the future. Integration of information into future editions of the Red Book will ensure that practitioners continue to rely on the Red Book in its various electronic formats for clinical guidance and support.