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. 2022 Dec;27(6):361-369.
doi: 10.1136/bmjebm-2021-111866. Epub 2022 Apr 15.

Which actionable statements qualify as good practice statements In Covid-19 guidelines? A systematic appraisal

Omar Dewidar  1   2 , Tamara Lotfi  3   4   5 , Miranda Langendam  6 , Elena Parmelli  7 , Zuleika Saz Parkinson  8 , Karla Solo  3   4   5 , Derek K Chu  3   9 , Joseph L Mathew  10 , Elie A Akl  3   11 , Romina Brignardello-Petersen  3   4 , Reem A Mustafa  3   12 , Lorenzo Moja  13 , Alfonso Iorio  3   4   9 , Yuan Chi  14   15 , Carlos Canelo-Aybar  16 , Tamara Kredo  17   18 , Justine Karpusheff  19 , Alexis F Turgeon  20   21 , Pablo Alonso-Coello  16 , Wojtek Wiercioch  3   4   5 , Annette Gerritsen  17 , Miloslav Klugar  22 , María Ximena Rojas  23 , Peter Tugwell  24   25 , Vivian Andrea Welch  1   2 , Kevin Pottie  26 , Zachary Munn  27 , Robby Nieuwlaat  3 , Nathan Ford  28 , Adrienne Stevens  3   4 , Joanne Khabsa  29 , Zil Nasir  3   4 , Grigorios I Leontiadis  4   9 , Joerg J Meerpohl  30   31 , Thomas Piggott  3   4   5 , Amir Qaseem  32 , Micayla Matthews  3   4   5 , Holger J Schünemann  33   4   5   9   34   35 ; eCOVID-19 recommendations map collaborators
Affiliations

Which actionable statements qualify as good practice statements In Covid-19 guidelines? A systematic appraisal

Omar Dewidar et al. BMJ Evid Based Med. 2022 Dec.

Abstract

Objectives: To evaluate the development and quality of actionable statements that qualify as good practice statements (GPS) reported in COVID-19 guidelines.

Design and setting: Systematic review . We searched MEDLINE, MedSci, China National Knowledge Infrastructure (CNKI), databases of Grading of Recommendations Assessment, Development and Evaluation (GRADE) Guidelines, NICE, WHO and Guidelines International Network (GIN) from March 2020 to September 2021. We included original or adapted recommendations addressing any COVID-19 topic.

Main outcome measures: We used GRADE Working Group criteria for assessing the appropriateness of issuing a GPS: (1) clear and actionable; (2) rationale necessitating the message for healthcare practice; (3) practicality of systematically searching for evidence; (4) likely net positive consequences from implementing the GPS and (5) clear link to the indirect evidence. We assessed guideline quality using the Appraisal of Guidelines for Research and Evaluation II tool.

Results: 253 guidelines from 44 professional societies issued 3726 actionable statements. We classified 2375 (64%) as GPS; of which 27 (1%) were labelled as GPS by guideline developers. 5 (19%) were labelled as GPS by their authors but did not meet GPS criteria. Of the 2375 GPS, 85% were clear and actionable; 59% provided a rationale necessitating the message for healthcare practice, 24% reported the net positive consequences from implementing the GPS. Systematic collection of evidence was deemed impractical for 13% of the GPS, and 39% explained the chain of indirect evidence supporting GPS development. 173/2375 (7.3%) statements explicitly satisfied all five criteria. The guidelines' overall quality was poor regardless of the appropriateness of GPS development and labelling.

Conclusions: Statements that qualify as GPS are common in COVID-19 guidelines but are characterised by unclear designation and development processes, and methodological weaknesses.

Keywords: COVID-19; Evidence-Based Practice; Health Services Research.

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Conflict of interest statement

Competing interests: HJS, AS, VAW report grants from Canadian Instituites of Health during the conduct of the study—FRN VR4-172741 & GA3-177732. RAM reports grants from WHO, grants from ASH, grants from ACR, other from Boehringer ingelheim international, grants from NIDDK, outside the submitted work. EA, PA-C and HJS report contribution to the development of the original five criteria for assessing the appropriateness of issuing good practice statements. The remaining authors have nothing else to declare.

Figures

Figure 1
Figure 1
PRISMA chart for guidelines eligible for the eCOVID-19RecMap. BIGG, International Database of Grade Guidelines; CCITC, Changes of Care in Times of COVID-19; CDC: Centers for Disease Control and Prevention; ECDC, European Centres for Disease Control and Prevention; GIN, Guidelines International Network, NICE, National Institute for Health and Care Excellence; PHAC, Public Health Agency of Canada; SIGN, Scottish Intercollegiate Guidelines Network; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Figure 2
Figure 2
Association of guideline and statement characteristics with issuing statements that qualify as good practice statements. Reference was issuing actionable statements other than good practice statements. Dashed line corresponds to univariate OR of 1.00. We were not able to evaluate associations for guideline regions: South Asia and East Asian Pacific and NICE guideline organisation with issuing good practice statements due to absence of other types of statements. CDC, Centers for Disease Control and Prevention; ECDC, European Centres for Disease Control and Prevention; GPS, good practice statement; NICE, National Institute for Health and Care Excellence; PHAC, Public Health Agency of Canada; SIGN, Scottish Intercollegiate Guideline Network.
Figure 3
Figure 3
Distribution of judgements for good practice statement (GPS) criteria. Annotations correspond to percentage of statements with their respective judgement. GDG, guideline development group.
Figure 4
Figure 4
AGREE II assessment (three domains) of guidelines stratified by labelling of good practice statements by guideline developers. Guidelines containing statements labelled by guideline developers as GPS (n=6) and guidelines containing statements that qualify as GPS (n=194). The thickness of the plot represents the kernal density estimation to show the distribution shape of the data. The three lines represent the median and lower (25%) and upper (75%) quartiles based on density estimates. Wider sections of the plot represent a higher probability that guidelines will take on the given value; the slimmer sections represent a lower probability. AGREE, Appraisal of Guidelines for Research and Evaluation; GDG, guideline development group; GPS, good practice statement.
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