Analysis of COVID-19 Guideline Quality and Change of Recommendations: A Systematic Review.

Health data science Pub Date : 2021-07-22 eCollection Date: 2021-01-01 DOI:10.34133/2021/9806173
Siya Zhao, Shuya Lu, Shouyuan Wu, Zijun Wang, Qiangqiang Guo, Qianling Shi, Hairong Zhang, Juanjuan Zhang, Hui Liu, Yunlan Liu, Xianzhuo Zhang, Ling Wang, Mengjuan Ren, Ping Wang, Hui Lan, Qi Zhou, Yajia Sun, Jin Cao, Qinyuan Li, Janne Estill, Joseph L Mathew, Hyeong Sik Ahn, Myeong Soo Lee, Xiaohui Wang, Chenyan Zhou, Yaolong Chen
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Abstract

Background: Hundreds of coronavirus disease 2019 (COVID-19) clinical practice guidelines (CPGs) and expert consensus statements have been developed and published since the outbreak of the epidemic. However, these CPGs are of widely variable quality. So, this review is aimed at systematically evaluating the methodological and reporting qualities of COVID-19 CPGs, exploring factors that may influence their quality, and analyzing the change of recommendations in CPGs with evidence published.

Methods: We searched five electronic databases and five websites from 1 January to 31 December 2020 to retrieve all COVID-19 CPGs. The assessment of the methodological and reporting qualities of CPGs was performed using the AGREE II instrument and RIGHT checklist. Recommendations and evidence used to make recommendations in the CPGs regarding some treatments for COVID-19 (remdesivir, glucocorticoids, hydroxychloroquine/chloroquine, interferon, and lopinavir-ritonavir) were also systematically assessed. And the statistical inference was performed to identify factors associated with the quality of CPGs.

Results: We included a total of 92 COVID-19 CPGs developed by 19 countries. Overall, the RIGHT checklist reporting rate of COVID-19 CPGs was 33.0%, and the AGREE II domain score was 30.4%. The overall methodological and reporting qualities of COVID-19 CPGs gradually improved during the year 2020. Factors associated with high methodological and reporting qualities included the evidence-based development process, management of conflicts of interest, and use of established rating systems to assess the quality of evidence and strength of recommendations. The recommendations of only seven (7.6%) CPGs were informed by a systematic review of evidence, and these seven CPGs have relatively high methodological and reporting qualities, in which six of them fully meet the Institute of Medicine (IOM) criteria of guidelines. Besides, a rapid advice CPG developed by the World Health Organization (WHO) of the seven CPGs got the highest overall scores in methodological (72.8%) and reporting qualities (83.8%). Many CPGs covered the same clinical questions (it refers to the clinical questions on the effectiveness of treatments of remdesivir, glucocorticoids, hydroxychloroquine/chloroquine, interferon, and lopinavir-ritonavir in COVID-19 patients) and were published by different countries or organizations. Although randomized controlled trials and systematic reviews on the effectiveness of treatments of remdesivir, glucocorticoids, hydroxychloroquine/chloroquine, interferon, and lopinavir-ritonavir for patients with COVID-19 have been published, the recommendations on those treatments still varied greatly across COVID-19 CPGs published in different countries or regions, which may suggest that the CPGs do not make sufficient use of the latest evidence.

Conclusions: Both the methodological and reporting qualities of COVID-19 CPGs increased over time, but there is still room for further improvement. The lack of effective use of available evidence and management of conflicts of interest were the main reasons for the low quality of the CPGs. The use of formal rating systems for the quality of evidence and strength of recommendations may help to improve the quality of CPGs in the context of the COVID-19 pandemic. During the pandemic, we suggest developing a living guideline of which recommendations are supported by a systematic review for it can facilitate the timely translation of the latest research findings to clinical practice. We also suggest that CPG developers should register the guidelines in a registration platform at the beginning for it can reduce duplication development of guidelines on the same clinical question, increase the transparency of the development process, and promote cooperation among guideline developers all over the world. Since the International Practice Guideline Registry Platform has been created, developers could register guidelines prospectively and internationally on this platform.

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COVID-19 指南质量和建议变更分析:系统回顾。
背景:自 2019 年冠状病毒病(COVID-19)疫情爆发以来,已制定并发布了数百份临床实践指南(CPG)和专家共识声明。然而,这些临床实践指南的质量参差不齐。因此,本综述旨在系统评估 COVID-19 临床实践指南的方法和报告质量,探讨可能影响其质量的因素,并分析临床实践指南中的建议与已发表证据的变化情况:我们检索了 2020 年 1 月 1 日至 12 月 31 日期间的五个电子数据库和五个网站,以检索所有 COVID-19 CPG。使用 AGREE II 工具和 RIGHT 检查表对 CPGs 的方法学和报告质量进行评估。此外,还系统评估了COVID-19 CPGs中关于COVID-19的一些治疗方法(雷米替韦、糖皮质激素、羟氯喹/氯喹、干扰素和洛匹那韦-利托那韦)的推荐意见和用于提出推荐意见的证据。并进行了统计推断,以确定与 CPGs 质量相关的因素:结果:我们共纳入了 19 个国家制定的 92 份 COVID-19 CPGs。总体而言,COVID-19 CPGs 的 RIGHT 检查表报告率为 33.0%,AGREE II 领域得分率为 30.4%。在 2020 年期间,COVID-19 CPGs 的总体方法学和报告质量逐步提高。方法学和报告质量高的相关因素包括循证开发流程、利益冲突管理以及使用既定评级系统评估证据质量和推荐强度。只有 7 份(7.6%)中央方案指南的建议是通过系统性的证据回顾获得的,这 7 份中央方案指南的方法和报告质量相对较高,其中 6 份完全符合医学研究所(IOM)的指南标准。此外,世界卫生组织(WHO)制定的快速建议 CPG 在方法学(72.8%)和报告质量(83.8%)方面获得了最高的总分。许多 CPG 涉及相同的临床问题(指关于 COVID-19 患者使用雷米替韦、糖皮质激素、羟氯喹/氯喹、干扰素和洛匹那韦-利托那韦治疗效果的临床问题),由不同国家或组织发布。尽管关于雷米替韦、糖皮质激素、羟氯喹/氯喹、干扰素和洛匹那韦-利托那韦对COVID-19患者治疗效果的随机对照试验和系统综述已经发表,但不同国家或地区发表的COVID-19 CPG对这些治疗方法的推荐仍然存在很大差异,这可能表明CPG没有充分利用最新证据:结论:随着时间的推移,COVID-19 国家方案指南的方法和报告质量都有所提高,但仍有进一步改进的空间。缺乏对现有证据的有效利用和对利益冲突的管理是 CPG 质量不高的主要原因。在 COVID-19 大流行的背景下,使用正式的证据质量和建议力度评级系统可能有助于提高国家方案指南的质量。在大流行期间,我们建议制定一份活的指南,其中的建议应得到系统综述的支持,因为这有助于及时将最新研究成果转化为临床实践。我们还建议,临床实践指南制定者在制定指南之初就应在注册平台上进行注册,这样可以减少就同一临床问题重复制定指南的情况,增加制定过程的透明度,并促进世界各地指南制定者之间的合作。国际实践指南注册平台已经建立,指南制定者可以在该平台上对指南进行前瞻性和国际性注册。
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