Appraisal Of Guidelines Research And Evaluation Research Articles

Documentary analysis of national and international guidance for community clinicians referring patients with suspected chronic limb-threatening ischaemia

BackgroundDelayed referral of patients with chronic limb-threatening ischaemia (CLTI) from the community to vascular services may increase risk of amputation due to delayed revascularisation. Lack of appropriate guidance for clinicians...

Clinical practice guideline recommendations to improve the mental health of adult trauma patients: protocol for a systematic review

IntroductionMental disorders are common in adult patients with traumatic injuries. To limit the burden of poor psychological well-being in this population, recognised authorities have issued recommendations through clinical practice guidelines...

Quality Assessment of Clinical Guidelines for Preventing Falls in Hospitalized Elderly People in Iran Using the Appraisal of Guidelines, Research, and Evaluation (AGREE) Checklist

Objectives Hospitalization is a vulnerable period for the elderly. During this period, they are at risk of falling. There are various clinical guidelines for fall prevention, whose usefulness depends on their quality and clinical acceptance. This study was to evaluate the methodological quality of selected clinical guidelines for fall prevention in hospitalized elderly people in Iran using the Appraisal of Guidelines, Research, and Evaluation (AGREE) checklist. Methods & Materials A systematic search was conducted for clinical guidelines published from 2009 to 2020 using the keywords clinical guideline, falling, prevention, aged, and hospitalization. Of 351 clinical guidelines identified, 4 guidelines were selected based on the inclusion and exclusion criteria and by a purposive sampling method. The quality of the selected guidelines was evaluated by 5 experts independently using the AGREE II checklist. Based on the quality scores, the guidelines were categorized as “highly recommended” or “recommended with modifications”. Results The "Falls Assessment and Prevention of Falls in Older People", "Preventing Falls and Harm From Falls in Older People", and "Preventing Falls and Reducing Injury from Falls" were categorized as highly recommended, while the "Post Fall Multidisciplinary Management Guidelines for Western Australian Health Care Settings" was categorized as “recommended with modifications”. Therefore, they can be localized and used to reduce the risk of falls in hospitalized elderly people in Iran. The mean overall scores of 6 domains for the guidelines were as follows: 91. 1% for “clarity of presentation”, 86. 6% for “scope and purpose”, 83. 6% for “stakeholder involvement” 72. 08% for “editorial independence”, 71. 14% for “rigor of development”, and 66. 66% for “applicability”. Conclusion Evaluation of the methodological quality of clinical guidelines using the AGREE tool should be done to be able to be used in clinical practice. It is recommended to use these tools in updating the current or future clinical guidelines to ensure their methodological quality.

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review

Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations. We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses. We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO

IntroductionBreast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence. MethodsThese guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool. ResultsRecommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion. ConclusionsThese guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice.

A critical appraisal and recommendation synthesis of delirium clinical practice guidelines relevant to the care of older adults in the emergency department: An umbrella review.

Older adults are at high risk of developing delirium in the emergency department (ED);however, it is often missed or undertreated. Improving ED delirium care is challenging in part due to a lack of standards to guide best practice. Clinical practice guidelines (CPGs)translate evidence into recommendations to improve practice. To critically appraise and synthesize CPG recommendations for delirium care relevant to older ED patients. We conducted an umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations were critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II;and Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX)instruments. A threshold of 70% or greater in the AGREE-IIRigour of Development domain was used to define high-quality CPGs. Delirium recommendations from CPGs meeting this threshold were included in the synthesis and narrative analysis. AGREE-IIRigour of Development scores ranged from 37% to 83%, with 5 of 10 CPGs meeting the predefined threshold. AGREE-REXoverall calculated scores ranged from 44% to 80%. Recommendations were grouped into screening, diagnosis, risk reduction, and management. Although none of the included CPGs were ED-specific, many recommendations incorporated evidence from this setting. There was agreement that screening for nonmodifiable risk factors is important to define high-risk populations, and those at risk should be screened for delirium. The '4A's Test' was the recommended tool to use in the ED specifically. Multicomponent strategies were recommended for delirium risk reduction, and for its management if it occurs. The only area of disagreement was for the short-term use of antipsychotic medication in urgent situations. This is the first known review of delirium CPGs including a critical appraisal and synthesis of recommendations. Researchers and policymakers can use this synthesis to inform future improvement efforts and research in the ED. This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6OSF.IO/TG7S6.

Involvement of methodological experts and the quality of clinical practice guidelines: a critical appraisal of clinical practice guidelines and a questionnaire survey of the development groups in Japan

ObjectiveTo evaluate whether the involvement of methodological experts improves the quality of clinical practice guidelines (CPGs) after adjusting for other factors.SettingThe quality of Japanese CPGs published in 2011–2019 was assessed...

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review.

Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations. We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework. We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence. We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma. Level II-therapeutic study.

A cross-sectional study of the endorsement proportion of reporting guidelines in 1039 Chinese medical journals

BackgroundReporting quality is a critical issue in health sciences. Adopting the reporting guidelines has been approved to be an effective way of enhancing the reporting quality and transparency of clinical research. In 2012, we found that only 7 (7/1221, 0.6%) journals adopted the Consolidated Standards of Reporting Trials (CONSORT) statement in China. The aim of the study was to know the implementation status of CONSORT and other reporting guidelines about clinical studies in China.MethodsA cross-sectional bibliometric study was conducted. Eight medical databases were systematically searched, and 1039 medical journals published in mainland China, Hong Kong, Macau, and Taiwan were included. The basic characteristics, including subject, language, publication place, journal-indexed databases, and journal impact factors were extracted. The endorsement of reporting guidelines was assessed by a modified 5-level evaluation tool, namely i) positive active, ii) positive weak, iii) passive moderate, iv) passive weak and v) none.ResultsAmong included journals, 24.1% endorsed CONSORT, and 0.8% endorsed CONSORT extensions. For STROBE (STrengthening the Reporting of Observational Studies in Epidemiology), PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), STARD (An Updated List of Essential Items for Reporting Diagnostic Accuracy Studies), CARE (CAse REport guidelines), the endorsement proportion were 17.2, 16.6, 16.4, and 14.8% respectively. The endorsement proportion for SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials), TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis), AGREE (Appraisal of Guidelines, Research, and Evaluation), and RIGHT (Reporting Items for Practice Guidelines in Healthcare) were below 0.7%.ConclusionsOur results showed that the implementation of reporting guidelines was low. We suggest the following initiatives including i) enhancing the level of journal endorsement for reporting guidelines; ii) strengthening the collaboration among authors, reviewers, editors, and other stakeholders; iii) providing training courses for stakeholders; iv) establishing bases for reporting guidelines network in China; v) adopting the endorsement of reporting guidelines in the policies of the China Periodicals Association (CPA); vi) promoting Chinese medical journals into the international evaluation system and publish in English.

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.

Prevention of breast cancer-related lymphoedema: Quality of clinical practice guidelines and variations in recommendations.

We aimed to evaluate the quality of clinical practice guidelines (CPGs) for breast cancer related lymphoedema (BCRL) and compare the similarities and differences in recommendations. Many CPGs of BCRL have been developed; however, their recommendations and quality are controversial. Relevant papers were retrieved from electronic databases, professional associations and guideline development organizations, from 1 January 2015 to 30 September 2021. The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. Intraclass correlation coefficient (ICC) analysis was used to evaluate the overall consistency among evaluators. Eight CPGs were included. The ICC values evaluation for CPGs ranged from 0.76 to 0.95, with good consensus among evaluators. The highest median score was 68.75% (61.46, 72.22%) for clarity, and the lowest was 37.50% (25.78, 51.30%) for applicability. The NICE, ACS/ACSO and APTA CPGs were rated well in most areas. Professional health education, individualized exercise programme and regular surveillance are the main methods to prevent lymphoedema. In the past 6years, the quality of BCRL guidelines has varied greatly, especially in the domains of rigour and applicability. Interrater agreement was excellent, but recommendation showed some inconsistencies in the details.

A critical appraisal of delirium clinical practice guidelines relevant to the care of older adults in the emergency department with a synthesis of recommendations: an umbrella review protocol

BackgroundUp to 35% of older adults present to the emergency department (ED) with delirium or develop the condition during their ED stay. Delirium associated with an ED visit is independently linked to poorer outcomes such as loss of independence, increased length of hospital stay, and mortality. Improving the quality of delirium care for older ED patients is hindered by a lack of knowledge and standards to guide best practice. High-quality clinical practice guidelines (CPGs) have the power to translate the complexity of scientific evidence into recommendations to improve and standardize practice. This study will identify and synthesize recommendations from high-quality delirium CPGs relevant to the care of older ED patients.MethodsWe will conduct a multi-phase umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations will be critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation – Recommendations Excellence (AGREE-REX) instruments, respectively. We will also synthesize and conduct a narrative analysis of high-quality CPG recommendations.DiscussionThis review will be the first known evidence synthesis of delirium CPGs including a critical appraisal and synthesis of recommendations. Recommendations will be categorized according to target population and setting as a means to define the bredth of knowledge in this area. Future research will use consensus building methods to identify which are most relevant to older ED patients.Trial registrationThis study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6.

Quality assessment of clinical practice guidelines for the management of wheezing disorders in children.

BACKGROUND: The quality of available clinical practice guidelines (CPGs) for childhood wheezing disorders have not been systematically evaluated.METHODS: CPGs were systematically evaluated by four independent reviewers using Appraisal of Guidelines Research and Evaluation (AGREE) II instrument and the Reporting Items for Practice Guidelines in HealTHcare (RIGHT) checklist. We calculated the overall agreement among reviewers with the intraclass correlation coefficient (ICC).RESULTS: A total of 35 CPGs published between January 2000 and December 2020 were evaluated. The overall agreement among reviewers was good (ICC 0.85, 95% CI 0.83-0.87). The average CPGs score was 42% (range: 25-79). The mean scores of four domains were low: 37% for Stakeholder Involvement (range: 10-85), 28% for Rigour of Development (range: 42-81), 35% for Applicability (range: 11-73) and 24% for Editorial Independence (range: 0-83). The mean reporting rate of the RIGHT checklist was 31%. The Basic Information domain had the highest reporting rate (65%); the Review and Quality Assurance domain had the lowest rate (3%).CONCLUSIONS: The quality of the CPGs was poor. Greater efforts are needed to improve quality in domains to provide high-quality guidelines that can be used as reliable tools for clinical decision-making.

Appraising the quality of guidelines for caries management using AGREE II: a systematic review

Abstract Background Caries is one among the most prevalent dental disease and its prevention and treatment are crucial from both dental care and public health perspectives. Yet, caries’ management greatly varies across contexts according to the availability of specific Clinical Practice Guidelines (CPGs). Here, we present the results of a systematic review aimed at the appraisal of the current available CPGs on caries prevention and treatment. Methods A literature search was performed in PubMed, EMBASE, SCOPUS, and seven relevant guidelines databases up to March 2022, exploring CPGs published from 2012. The literature review was conducted in accordance with PRISMA guidelines. The Appraisal of Guidelines, Research and Evaluation (AGREE) II checklist was used to measure the methodological rigour and quality of the retrieved CPGs. Results The systematic search resulted in a total of 1403 records, and 21 CPGs met the inclusion criteria. Overall, these considered different aspects of caries prevention and treatment. Regarding the appraisal through the AGREE II tool, the overall median score was 60.2% and 11 out of 21 CPGs were classified as “Recommended”, while the others as “Recommended with modification”. The domain analysis showed that the highest median scores were reached for Scope and Purpose (88.9%), Clarity of Presentation (86.9%), and Rigor of Development (67.8%), while the lowest were seen for Stakeholder Involvement (63.3%), Applicability (17.5%), and Editorial Independence (50%). Conclusions This systematic review showed that the rigor of CPGs for caries prevention and treatment remained suboptimal according to AGREE II evaluation, and highlighted that more efforts are needed to improve their quality. The AGREE II checklist is a comprehensive and easy-to-use tool for the development of CPGs, and its use ensures that evidence-based approaches are incorporated into consistent recommendations for the translation of evidence into practice. Key messages • The rigor of CPGs for caries prevention and treatment is suboptimal according to AGREE II evaluation, however, more efforts are needed to improve their quality. • The AGREE II checklist is a comprehensive and easy-to-use tool for the development of CPGs.

AGREE-S: AGREE II extension for surgical interventions: appraisal instrument.

The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument was developed to evaluate the quality of clinical practice guidelines. Evidence suggests that development, reporting, and appraisal of guidelines on surgical interventions may be better informed by modification of the instrument. We aimed to develop an AGREE II extension specifically designed for appraisal of guidelines of surgical interventions. In a three-part project funded by the United European Gastroenterology and the European Association for Endoscopic Surgery, (i) we identified factors that were associated with higher quality of surgical guidelines, (ii) we statistically calibrated the AGREE II instrument in the context of surgical guidelines using correlation, reliability, and factor analysis, and (iii) we undertook a Delphi consensus process of stakeholders to inform the development of an AGREE II extension instrument for surgical interventions. Several features were prioritized by stakeholders as of particular importance for guidelines of surgical interventions, including development of a guideline protocol, consideration of practice variability and surgical expertise in different settings, and specification of infrastructures required to implement the recommendations. The AGREE-S-AGREE II extension instrument for surgical interventions has 25 items, compared to the 23 items of the original AGREE II instrument, organized into the following 6 domains: Scope and purpose, Stakeholders, Evidence synthesis, Development of recommendations, Editorial independence, and Implementation and update. As the original instrument, it concludes with an overall appraisal of the quality of the guideline and a judgement on whether the guideline is recommended for use. Several items were amended and rearranged among domains, and an item was deleted. The Rigor of Development domain of the original AGREE II was divided into Evidence Synthesis and Development of Recommendations. Items of the AGREE II domain Clarity of Presentation were incorporated in the new domain Development of Recommendations. Three new items were introduced, addressing the development of a guideline protocol, support by a guideline methodologist, and consideration of surgical experience/expertise. The AGREE-S appraisal instrument has been developed to be used for assessment of the methodological and reporting quality of guidelines on surgical interventions.

Quality and clinical applicability of recommendations for incontinence-associated dermatitis: A systematic review of guidelines and consensus statements.

The aim of this study was to assess methodological quality of all currently available guidelines and consensus statements for IAD using the Appraisal of Guidelines, Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence (AGREE-REX) instruments. Globally, incontinence-associated dermatitis (IAD) is a significant health challenge. IAD is a complex healthcare problem that reduces quality of life of patients, increases healthcare costs and prolongs hospital stays. Several guidelines and consensus statements are available for IAD. However, the quality of these guidelines and consensus statements remains unclear. A systematic review of guidelines and consensus statements. Our study was undertaken using PRISMA guidelines. We searched seven electronic databases. Guidelines and consensus statements had to be published in English, Chinese or German languages. Five independent reviewers assessed the methodological quality of guidelines and consensus statements using the AGREE II and AGREE-REX instruments. Mean with standard deviation (SD) and median with interquartile range (IQR) were calculated for descriptive analyses. We generated bubble plots to describe the assessment results of each domain of each guideline and consensus statement. We included ten guidelines and consensus statements. The NICE guidelines, obtained the highest scores, fulfilled 86.11%-98.61% of criteria in AGREE II and 76.67%-91.11% for AGREE-REX. In the domains 'Stakeholder Involvement' (4.39±1.64), 'Rigor of Development' (3.38±1.86), 'Applicability' (3.62±1.64), 'Editorial Independence' (3.91±2.56) and 'Values and Preferences' (2.98±1.41), the remaining guidelines and consensus statements showed deficiencies. Altogether, this study demonstrated that the currently available guidelines and consensus statements for IAD have room for methodological improvement. NICE guidelines on faecal incontinence and urinary incontinence have better quality. Remaining guidelines and consensus statements showed substantial methodological weaknesses, especially the domains of 'Stakeholder Involvement', 'Rigor of Development', 'Applicability', 'Editorial independence' and 'Values and Preferences'. This study was registered on INPLASY. (Registration number: INPLASY202190078). The currently available guidelines and consensus statements on IAD have room for methodological improvement.

Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review

IntroductionEvidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence...

Evidence-basing for quality improvement; bringing clinical practice guidelines closer to their promise of improving care practices.

Clinical practice guidelines (CPGs) have become central to efforts to change clinical practice and improve the quality of health care. Despite growing attention forrigorous development methodologies, it remains unclear whatcontribution CPGs make to quality improvement. This mixed methods study examines guideline quality in relation to the availability of certain types of evidence and reflects on the implications of CPGs' promise to improve the quality of care practices. The quality of 62 CPGs was assessed with the Appraisal of Guidelines, Research, and Evaluation (AGREE) instrument. Findings were discussed in 19 follow-up interviews to examine how different quality aspects were considered during development. The AGREE assessment showed that while some quality criteria were met, CPGs have limited coverage of domains such as stakeholder involvement and applicability, which generally lack a 'strong' evidence base (e.g., randomized controlled trials [RCT]). Qualitative findings uncovered barriers that impede the consolidation of evidence-based guideline development and quality improvement including guideline scoping based on the patient-intervention-comparison-outcome (PICO) question format and a lack of clinical experts involved in evidence appraisal. Developers used workarounds to include quality considerations that lack a strong base of RCT evidence, which often ended up in separate documents or appendices. Findings suggest that CPGs mostly fail to integrate different epistemologies needed to inform the quality improvement of clinical practice. To bring CPGs closer to their promise, guideline scoping should maintain a focus on the most pertinent quality issues that point developers toward the most fitting knowledge for the question at hand, stretching beyond the PICO format. To address questions that lack a strong evidence base, developers actually need to appeal to other sources of knowledge, such as quality improvement, expert opinion, and best practices. Further research is needed to develop methods for the robust inclusion of other types of knowledge.

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

ObjectivesTo 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 SettingWe 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). ResultsWe 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. ConclusionRehabilitation 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.

The Italian Society for Rheumatology recommendations for the management of axial spondyloarthritis.

Over the last few years, the landscape of treatments for axial spondyloarthritis (SpA) has been rapidly evolving, urging international scientific societies to draft or update existing clinical practice guidelines (CPGs) on the management of axial SpA. The Italian Society for Rheumatology (SIR) committed to provide revised and adapted evidence- and expert-based recommendations for the management of patients with axial SpA in Italy. A systematic approach to the adaptation of existing CPGs - the ADAPTE methodology - was adopted to obtain updated recommendations suitable for the Italian context. A systematic literature search was performed in Medline and Embase databases to find international CPGs and consensus statements with recommendations for the management of axial SpA published in the previous five years. A working group composed of rheumatologists with proven experience in the management of axial SpA and methodologists identified the key research questions which guided study selection and data extraction. Guideline quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The Italian recommendations were developed by endorsing or adapting and rewording some existing recommendations. The draft of the recommendations was sent to a multidisciplinary group of external reviewers for comment and rating. Six original CPGs were selected and used to create this SIR CPG, which includes a final set of 14 recommendations covering the management of patients with axial SpA across the following domains: assessment, pharmacological and non-pharmacological treatment, and follow-up. The dissemination and implementation of these SIR recommendations are expected to support an evidencebased clinical approach to the management of patients with axial SpA in Italy.