Global Guidelines in Dermatology Mapping Project (GUIDEMAP), a systematic review of atopic dermatitis clinical practice guidelines: are they clear, unbiased, trustworthy and evidence based (CUTE)?

Abstract

Background: Clinical practice guidelines (CPGs) are essential in delivering optimum healthcare, such as for atopic dermatitis (AD), a highly prevalent skin disease. Although many CPGs are available for AD, their quality has not been critically appraised.

Objectives: To identify CPGs on AD worldwide and to assess with validated instruments whether those CPGs are clear, unbiased, trustworthy and evidence based (CUTE).

Methods: We searched MEDLINE, Embase, PubMed, Web of Science, Cochrane Library, Emcare, Epistemonikos, PsycINFO and Academic Search Premier for CPGs on AD published between 1 April 2016 and 1 April 2021. Additionally we hand searched prespecified guideline resources. Screening, data extraction and quality assessment of eligible guidelines were independently carried out by two authors. Instruments used for quality assessment were the AGREE II Reporting Checklist, the US Institute of Medicine (IOM) criteria of trustworthiness and Lenzer's Red Flags.

Results: Forty CPGs were included, mostly from countries with a high sociodemographic index. The reporting quality varied enormously. Three CPGs scored 'excellent' on all AGREE II domains and three scored 'poor' on all domains. We found no association between AGREE II scores and a country's gross domestic product. One CPG fully met all nine IOM criteria and two fully met eight. Three CPGs had no red flags. 'Applicability' and 'rigour of development' were the lowest scoring AGREE II domains; 'external review', 'updating procedures' and 'rating strength of recommendations' were the IOM criteria least met; and most red flags were for 'limited or no involvement of methodological expertise' and 'no external review'. Management of conflicts of interest (COIs) appeared challenging. When constructs of the instruments overlapped, they showed high concordance, strengthening our conclusions.

Conclusions: Overall, many CPGs are not sufficiently clear, unbiased, trustworthy or evidence based (CUTE) and lack applicability. Therefore improvement is warranted, for which using the AGREE II instrument is recommended. Some improvements can be easily accomplished through robust reporting. Others, such as transparency, applicability, evidence foundation and managing COIs, might require more effort.

Figure 1

PRISMA 2020 flow diagram for new systematic reviews that included searches of databases, registers and other sources. ECRI, Emergency Care Research Institute; G‐I‐N, Guidelines International Network; GP, general practitioner; ILDS, International League of Dermatological Societies; NICE, National Institute for Health and Care Excellence; SIGN, Scottish Intercollegiate Guidelines Network; TRIP, Turning Research into Practice.

Figure 2

Gross domestic product (GDP) per capita vs. AGREE II sum‐of‐domain scores. Scatter plot with a simple linear regression line. Source GDP: https://data.worldbank.org/indicator/NY.GDP.PCAP.CD; GDP data for Taiwan and Asia were unavailable; the funding source is based on how it was reported in the guideline.