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

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 20th 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)

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

“…This may indicate inequity in inclusion of these populations in treatment trials [101]. This is in line with findings from systematic reviews of SARS, MERS and COVID-19 CMGs [33].…”

“…Guideline development frameworks recommend regular reviews and CMG updates, every three to 5 years [109]. For emerging infectious diseases, such as influenza and COVID-19 where the epidemiology and new evidence may change rapidly, guidelines need to be flexible and adaptive [33]. Moreover, it is important to not overlook the quality of the CMGs.…”

“…The early stages of emerging pandemics place a burden on CMGs to be responsive despite limited evidence and to be regularly updated and disseminated as new evidence rapidly emerges. Reviews of CMGs for other high-consequence infectious diseases have identified concerning variation in availability and quality of CMGs and in inclusivity of recommendations targeted at different atrisk populations [29,32,33].…”

‘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

“…For example, a recent survey of 76 clinicians from 27 countries conducted during the COVID-19 pandemic identified issues in the implementation of COVID-19 CMGs, including limited access to treatments and equipment and lack of guidance for at-risk populations and resource-constrained settings [1]. These findings are supported by a series of systematic evidence reviews of existing CMGs, for viral haemorrhagic fevers (VHFs), chikungunya, mpox and severe acute respiratory syndrome (SARS), which found similar issues regarding availability, inclusivity, quality, and applicability of CMGs [2][3][4][5][6], particularly in Low-and Middle-Income Countries (LMICs).…”

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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.

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