Accessibility, inclusivity, and implementation of COVID-19 clinical management guidelines early in the pandemic: a global survey

Abstract

Background: With a rapidly changing evidence base, high-quality clinical management guidelines (CMGs) are key tools for aiding clinical decision making and increasing access to best available evidence-based care. A rapid review of COVID-19 CMGs found most lacked methodological rigour, overlooked at-risk populations, and varied in treatment recommendations. Furthermore, social science literature highlights the complexity of implementing guidelines in local contexts where they were not developed and the resulting potential to compound health inequities. This study aimed to evaluate access to, inclusivity of, and implementation of COVID-19 CMGs in different settings. Methods: A cross-sectional survey of clinicians worldwide was conducted from 15th June to 20th July 2020, to explore access to and implementation of COVID-19 CMGs, and treatment and supportive care recommendations provided. Data on accessibility, inclusivity, and implementation of CMGs were analysed by geographic location. Results: 76 clinicians from 27 countries responded: 82% from high-income countries, 17% from lower middle-income countries (LMICs). Most respondents reported access to COVID-19 CMGs and confidence in their implementation. However, many respondents, particularly from LMICs, reported barriers to implementation, including limited access to treatment and equipment. Only 20% of respondents reported having access to CMGs covering care for children, 25% for pregnant women, and 50% for older adults (>65 years). Identified themes were for CMGs to include recommendations for at-risk populations and settings, include supportive care guidance, and be updated as evidence emerges, and for clinicians to have training and access to recommended treatments to support implementation. Conclusion: Our findings highlight important gaps in COVID-19 CMG development and implementation challenges during a pandemic, particularly affecting at-risk populations and lower resourced settings. This study identifies an urgent need for an improved CMG development framework that is inclusive and adaptable to emerging evidence and considers contextual implementation support, to improve access to evidence-based care globally.

‘Involve those, who are managing these outbreaks’– Identifying barriers and facilitators to the implementation of clinical management guidelines for High-Consequence Infectious Diseases in Uganda

“…Many of our results were reminiscent of previous findings, highlighting the limited awareness of existing guidelines by HCP [26], limited access to treatments and equipment [1], as well as limitations of availability, inclusivity, and applicability of HCID CMGs across global LMIC contexts [1][2][3][4][5][6].…”

“…

Prior research highlighting the complexity of clinical management guidelines (CMG) implementation, has suggested that limited access to treatments and equipment [1] and substantial issues regarding availability, inclusivity, quality, and applicability [2][3][4][5][6] hinder the implementation of CMGs in Low-and Middle-Income Countries (LMICs). This in-depth case study of Uganda -coincidentally occurring during the 2022 Sudan Virus Disease outbreak -aimed to explore contextual and supplementary factors which hinder or facilitate CMG development and implementation.

…”

Preparing for pandemics: a systematic review of pandemic influenza clinical management guidelines

“…There were limited CMGs identified from lower-resourced settings which are particularly vulnerable to influenza outbreaks, due to limited healthcare systems and high burden of co-existing diseases such as HIV [98]. During the COVID-19 pandemic, we witnessed how limited infrastructure and lack of access to new technologies and resources, was a barrier for implementation of supportive care, particularly in lowerresourced settings [99]. Additionally, how any setting and healthcare system can become lower resourced during a pandemic [99].…”

“…During the COVID-19 pandemic, we witnessed how limited infrastructure and lack of access to new technologies and resources, was a barrier for implementation of supportive care, particularly in lowerresourced settings [99]. Additionally, how any setting and healthcare system can become lower resourced during a pandemic [99]. There is a lack of CMGs providing supportive care and treatment recommendations for different at-risk populations such as infants, children, pregnant women, older people and people living with HIV, populations often at higher risk of more severe illness and complications [100].…”

“…Further consideration, especially in lower-resourced settings is the utility cost of recommending ineffective treatments. A survey on the implementation of COVID-19 CMGs early during the pandemic identified limited access to supportive care, such as oxygen, especially in low-income countries [99]. For emerging infections where the evidence base may be limited, effective supportive care can improve survival rates, therefore, it is important that CMGs providing evidence-based supportive care recommendations for whole populations are accessible and implementation-supported [18].…”