New Approach Minimizes Time, Resources for Guidelines Assessment

By Marilynn Larkin

June 14, 2019

NEW YORK (Reuters Health) - A new approach that minimizes the time and resources required to appraise existing guidelines can be applied to any condition and across various settings, researchers say.

"For organizations and clinicians who currently use clinical guidelines, the process of guideline appraisal is beneficial to identify areas for improvement and highlight considerations for implementation," Dr. Misel Trajanovska of The Royal Children's Hospital in Melbourne told Reuters Health by email.

"Our experience of undertaking the appraisal, followed by consensus review, has resulted in the addition of a pediatric enuresis guideline for our hospital and community providers," she noted. "It has also demonstrated the value of identification and adaptation of existing guidelines as opposed to de novo development."

As part of a larger project to identify quality guidelines rather than develop new ones, Dr. Trajanovska and colleagues studied guidelines for managing children with nocturnal enuresis, assessing methodological quality using a two-stage approach with two appraisal instruments.

As reported online May 23 in the Journal of Pediatric Urology, the team first undertook a grey literature search that included guideline databases, targeted websites, Google search engines, and Medline. Guideline documents included clinical practice guidelines, consensus documents, position statements, and other clinical review documents.

Each document was appraised by two independent assessors using the International Centre for Allied Health Evidence (iCAHE) Guideline Quality Checklist.

The iCAHE highlighted an overall lack of information regarding underlying evidence and dates (mean score 36% and 41%, respectively).

Documents that (1) had an iCAHE quality score of 10 or more; (2) used a systematic search strategy; and (3) linked evidence to their recommendations underwent an additional appraisal using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

Only three documents met basic quality criteria and progressed to this second stage: guidelines produced by the Paediatric Society of New Zealand (PSNZ) and National Clinical Guideline Centre (NCGC), and a position statement from the Canadian Paediatric Society (CPS).

All three guidelines presented clear and unambiguous recommendations (mean score 80%). However, information regarding stakeholder involvement was lacking (mean score 50%).

Examples of specific scores included: scope and purpose: 67% for PSNZ; 100% for NCGC; and 39% for CPS. Corresponding scores for stakeholder engagement were 44%, 89%; and 17%; for clarity of presentation, 72%, 89% and 78%; and for applicability, 67%, 88% and 42%, respectively.

The NCGC guideline had the highest quality rating and was recommended for adoption and implementation.

"As part of our health services quality-improvement project, we also appraised pediatric constipation guidelines and daytime incontinence (wetting) guidelines," Dr. Trajanovska said. Findings are expected to be published by the end of 2019.

Dr. Darcy Weidemann, a pediatric nephrologist at Children's Mercy Kansas City, commented by email, "Nocturnal enuresis can be a very challenging condition to treat for both physicians and families as it takes consistent adherence to treatment plan for several weeks to months. The true benefit of...therapies is limited by (lack of) evidence-based trials and remains in question due to the natural history of spontaneous resolution of enuresis over time."

"This unique approach (to guideline assessment) allows for a more rapid, yet systematic appraisal of current literature, which can be accomplished in a few short months," she told Reuters Health.

"The recent explosion of CPGs from various institutions and organizations has led to a crucial need for physicians to be able to critically evaluate guidelines for their validity, impact, and also applicability to their own patient population," she noted.

"Physicians (need) to know when a CPG may or may not apply to the patient sitting in front of them and be able to translate that information into a coherent treatment plan that is acceptable for both the treating physician and the patient," she said.

"Physicians must compete with the myriad of information sources patients seek out that may be subject to bias or misinformation, such as various social media platforms and online sources," she added. "CPGs serve as a crucial resource for practicing clinicians to educate themselves on current best practices grounded in scientific rigor, but they will never replace the clinical experience necessary to translate that information into an acceptable treatment plan for their patients."


J Ped Urol 2019.