From SARS and MERS to COVID-19: a review of the quality and responsiveness of clinical management guidelines in outbreak settings

Abstract

ObjectiveTo assess the responsiveness and quality of clinical management guidelines (CMGs) in SARS, MERS and COVID-19 and determine whether this has improved over time.DesignRapid literature review, quality assessment and focus group consultation.Data Sources– Google and Google Scholar were systematically searched from inception to 6th June 2020.This was supplemented with hand searches of national and international public health agency and infectious disease society websites as well as directly approaching clinical networks in regions where few CMGs had been identified via the primary search.Eligibility CriteriaCMGs for the treatment of COVID-19/SARS/MERS providing recommendations on supportive care and/or specific treatment.MethodsData extraction was performed using a standardised form. The Appraisal of Guidelines for Research and Evaluation (AGREE-II) tool was used to evaluate the quality of the CMGs. Six COVID-19 treatments were selected to assess the responsiveness of a subset of guidelines and their updates to 20th November 2020. We ran two sessions of focus groups with patient advocates to elicit their views on guideline development.ResultsWe 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 (only two MERS-CoV and four COVID-19 CMGs were recommended for use by both reviewers without modification) 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 at all. 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. Eight guidelines recommended that use of unproven agents should be considered on a case-by-case basis. Patient representatives expressed concern about the lack of engagement with them in CMG development and that these documents are not accessible to non-experts.ConclusionThe quality of most CMGs produced in coronaviridae outbreaks is poor and we have found no evidence of improvement over time, highlighting that current development frameworks must be improved. There is an need to strengthen the evidence base surrounding basic supportive care and develop methods to engage patients in CMG development from the beginning in outbreak settings.Systematic review registrationPROSPERO CRD42020167361

Availability, scope and quality of monkeypox clinical management guidelines globally: a systematic review

“…Similar variations in guidance was observed for PEP, with more recently updated guidelines advising use of the newer generation smallpox/MPX vaccines 44 49–51 53 55 56. This highlights a fundamental issue in the development of guidelines for the management of neglected infectious diseases, which was also observed in other reviews42 57 We observe a tendency of guidelines being developed rapidly in response to outbreaks, never to be revisited again, but still being available in public domains. Failure to recall out-of-date guidelines as new evidence emerges, pose a risk to patient care.…”

“…Two reviewers independently screened the guidelines for inclusion and extracted data using Rayyan systematic review software 40. Data were extracted using a standardised form, previously piloted for related reviews 41 42. For each guideline data on source, target population and clinical topics (treatment and supportive care) were extracted (online supplemental file 2).…”

Availability, scope, and quality of monkeypox clinical management guidelines globally: a systematic review

“…18 Similar variations in guidance, was observed for post-exposure prophylaxis, with more recently updated guidelines advising use of the newer generation smallpox/MPX vaccines. 44,49–51,53,55,56 This highlights a fundamental issue in the development of guidelines for the management of neglected infectious diseases, which was also observed in other reviews 42,58 We observe a tendency of guidelines being developed rapidly in response to outbreaks, never to be revisited again, but still being available in public domains. Failure to recall out of date guidelines as new evidence emerges, pose a risk to patient care.…”

“…40 Data were extracted using a standardised form, previously piloted for related reviews. 41,42 For each guideline data on source, target population, and clinical topics were extracted (Supplementary file 2). Disagreements were resolved via consensus or by a third reviewer.…”