A Systematic Critical Appraisal of Clinical Practice Guidelines in Juvenile Idiopathic Arthritis Using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) Instrument.

Christine A M Smith,Sabrina Cavallo,Karine Toupin-April,Lucie Brosseau,Prinon Rahman,Ciarán M Duffy,Jeffrey W Jutai,Michael Nurmohamed

doi:10.1371/journal.pone.0137180

Abstract

ObjectivesThe objectives of this review are to: 1) appraise the methodological quality of clinical practice guidelines (CPGs) in juvenile idiopathic arthritis (JIA) providing pharmacological and/or non-pharmacological intervention recommendations, and 2) summarize the recommendations provided by the included CPGs and compare them where possible.MethodsA systematic search was performed. Three trained appraisers independently evaluated the methodological quality of the CPGs using a validated and reliable instrument, the Appraisal of Guidelines in Research and Evaluation II. Six domains were considered: 1) score and purpose; 2) stakeholder involvement; 3) rigor of development; 4) clarity of presentation; 5) applicability; and 6) editorial independence. The domains consist of a total of 23 items each scored on a 7-point scale. High quality CPGs were identified if they had a domain score above 60% in rigor of development, and two other domains.ResultsOf the three included CPGs, the Royal Australian College of General Practitioners (RACGP) and American College of Rheumatology (ACR) CPGs were considered to be of high quality, but the German Society for Pediatric Rheumatology was of lower quality. Domains one to four had high domain scores across the guidelines (mean (standard deviation)): 72.76 (13.80); 66.67 (9.81); 64.67 (7.77); and 87.00 (9.64), respectively. Lower scores were obtained for applicability (14.00 (5.57)) and editorial independence (43.44 (7.02)). Recommendations varied across CPGs due to differences in context, target audience (general practitioners, rheumatologists, and other multidisciplinary healthcare professionals) and patients’ disease presentations. Despite this variability, progression of pharmacological treatment did not conflict between CPGs. Recommendations for non-pharmacological interventions were vague and the interventions considered varied between CPGs.ConclusionsOverall, recommendations were based on a paucity of evidence and weak study designs. Further research is needed on interventions in JIA, as well as higher quality CPGs to facilitate implementation of the best evidence-based recommendations in clinical practice.

Highlights

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood, with the precise etiology unknown and an incidence of 1 in 10,000 in children under 16 years of age [1,2]
Of the three included clinical practice guidelines (CPGs), the Royal Australian College of General Practitioners (RACGP) and American College of Rheumatology (ACR) CPGs were considered to be of high quality, but the German Society for Pediatric Rheumatology was of lower quality
Further research is needed on interventions in JIA, as well as higher quality CPGs to facilitate implementation of the best evidence-based recommendations in clinical practice

Summary

Introduction

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood, with the precise etiology unknown and an incidence of 1 in 10,000 in children under 16 years of age [1,2]. Non-pharmacological interventions, such as physiotherapy interventions (e.g. therapeutic exercises, massage), coupled with orthotics when required, may help patients maintain their joint range of motion and functional status while contributing to maintenance of an increase in bone mineral density, and to the prevention of osteopenia [12,13]. This combined multi-disciplinary approach to care is essential for overall better management of symptoms and leads to better ultimate outcomes [14,15]

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Conclusion