From severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) to coronavirus disease 2019 (COVID-19): a systematic review of the quality and responsiveness of clinical management guidelines in outbreak settings

  1. Samuel Lipworth
  2. Ishmeala Rigby
  3. Vincent Cheng
  4. Peter Bannister
  5. Eli Harriss
  6. Karen Cook
  7. Erhui Cai
  8. Mais Tattan
  9. Terrence Epie
  10. Lakshmi Manoharan
  11. Kate Lambe
  12. Melina Michelen
  13. Anna Vila-Gilibets
  14. Peter Hart
  15. Helen Groves
  16. Andrew Dagens
  17. Louise Sigfrid
  18. Peter Horby

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Abstract

Background : Clinical management guidelines (CMGs) can be useful tools to guide clinician’s decision making and enable consistent evidence-based high-quality care. Here, we assessed whether their objective quality has improved over time by considering CMGs for severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and from different timepoints for coronavirus disease 2019 (COVID-19).

Methods: We performed a rapid literature review, quality assessment and focus group consultation. The Appraisal of Guidelines for Research and Evaluation (AGREE-II) tool was used to evaluate the quality of the CMGs. In total, six COVID-19 treatments were selected to assess the responsiveness of a subset of guidelines and their updates to 20 th November 2020. We ran two sessions of focus groups with patient advocates to elicit their views on guideline development.

Results: We included 37 COVID-19, six SARS, and four MERS CMGs. Evidence appraisals in CMGs generally focused on novel drugs rather than basic supportive care; where evidence for the latter was provided it was generally of a low quality. Most CMGs had major methodological flaws and there was no evidence of improvement in quality over time. CMGs scored lowest in the following AGREE-II domains: scope and purpose, editorial independence, stakeholder engagement, and rigour of development. Of the COVID-19 CMGs, only eight included specific guidance for the management of elderly patients and only ten for high-risk groups; a further eight did not specify the target patient group. Early in the pandemic, multiple guidelines recommended unproven treatments and whilst in general findings of major clinical trials were eventually adopted, this was not universally the case.

Conclusions: The quality of most CMGs produced in coronaviridae outbreaks is poor and we have found limited evidence of improvement over time, highlighting that current development frameworks must be improved.

PROSPERO registration: CRD42020167361 (17/02/2020)

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  1. Version published to 10.12688/wellcomeopenres.16735.1
  2. ScreenIT

    SciScore for 10.1101/2021.01.12.21249654: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    5 Search strategy: In a previous review, we found that most CMGs were not published in peer-reviewed journals and rarely indexed in the electronic databases.1 We therefore focussed our efforts on extensive hand-searches of the grey literature using a combination of systematic Google and Google Scholar searches and by specifically searching Ministry of Health, national public health agency institutions
    Google
    suggested: (Google, RRID:SCR_017097)
    Google Scholar
    suggested: (Google Scholar, RRID:SCR_008878)

    Results from OddPub: Thank you for sharing your data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strengths and weaknesses of the study: The inclusion of CMGs from a wide range of countries and organisations over a period of time is a strength of this study. This allowed us to evaluate the response of guideline committees to new emerging evidence. Our review is skewed towards countries in higher income classifications and we only identified one CMG from a low-income country (LIC).48-50 The AGREE-II tool is not specifically designed to appraise infectious disease CMGs produced during a pandemic, which may have caused us to underestimate the quality of some guidelines.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  3. Version published to 10.1101/2021.01.12.21249654 on medRxiv