4 Discussion
No relevant research was found in an extended search on April 23th, this
was the first study to systematically evaluate the quality of COVID-19
guidelines with the AGREE II instrument. The overall quality of the 20
guidelines for COVID-19 was highly variable, and significant variability
can be seen across domains within guidelines.
Domain scores of scope and purpose in most guidelines were below 60%,
indicating that the inclusion and exclusion criteria of target
populations and health question remained unclear for early published
guidelines.
Stakeholder involvement domains were poorly described, making those
guidelines less professional. The involvement of patients in making
decision might improve clinical outcomes and increase patients’
guideline adherence2. Therefore, collecting the views
and preferences of target populations is a necessary part of standard
guideline, and needs a period of time to carry out. However, considering
over 60000 people died, and COVID-19 continues to spread worldwide, no
guideline described related information in this item. More attention are
ought to paid on the composition of the guideline development team and
target population preferences by local and regional guideline
developers20.
Systematic reviews are expected to form the basis of high quality of
CPGs21. The importance had been demonstrated by the
guideline manuals published by WHO22. No guideline
involved review of outside methodological or health economic experts,
which explained all guidelines scored below 60% in the rigor of
development domain and suggested a fundamental methodology problem with
these CPGs.
Only six guidelines had moderate to high scores in the clarity of the
recommendations. This might result from the unclear audience and low
scores in stakeholder and rigour of development domain in documents
issued by government organizations. CPGs developers should provide a
concrete and precise description of different options in different
situations, as informed by the body of evidence, and make
recommendations easily identifiable to the first-line clinicians
audience.
In the applicability domain, most guidelines scored 0%, and did not
describe the facilitators and barriers to their application and definite
audit criteria. Some CPGs even lacked potential resource and educational
tools of applying the recommendations, which might have a great
influence on the speed and spread of adoption of guidelines. This
finding is inversely proportional to the need of developing guidelines
for user-friendliness and clarity suggested in some
studies4, 23 and should be taken into more
consideration when developing new guidelines or updating new versions.
Information on the domain of editorial independence was also neglected
in most guidelines. This is particularly important given that influences
of the founding body and conflicts of interest are the most common
source of bias in guideline development23, 24. Perhaps
some guideline developers did not realize the significance of editorial
independence disclosures and management. Studies showed that financial
conflicts of interest were prevalent among CPGs in a variety of clinical
areas24, and some evidence suggested that such
financial conflicts of interest might have an influence on guideline
recommendations25. Therefore, the guideline developers
can’t emphasize editorial independence domain enough.
Guideline 27,38 and
1914 can be recommended to guide clinical practice,
while 116, 49,
1813, 2015 were recommendable with
modification. In view of the urgency of the COVID-19 outbreak, the lower
quality and limitations of the early published guidelines are
understandable and acceptable. But they are expected to update more
evidence-based medical recommendations and modify nonstandard
methodology of guidelines to increase their credibility and
applicability promptly. And guidelines developers are supposed to focus
on not only high speed but also rigorous quality, especially in
stakeholder involvement, rigour of development, applicability, and
editorial independence domain.
This study had limitation as follows, first, the AGREE II instrument
established an appraisal system for methodological quality of
guidelines, but the evaluation of guideline recommendations was not
stated. Second, the excluded guidelines concerning mainly about
traditional Chinese medicine, the next research to work on in our team,
might cause this study not to be representative of all CPGs.
In conclusion, the overall quality of CPGs for COVID-19 was uneven.
Further research is needed for the appraisal of guideline
recommendations. The results of our study could contribute to improve
development of future guidelines, and affect the reasonable selection
and use of guidelines in clinical practice.