A methodologic assessment of lymphedema clinical practice guidelines

The objective of this review was to determine the methodologic quality of current lymphedema clinical practice guidelines (CPGs) to assist health care professionals in selecting accessible, high-quality guidance and to identify areas for improvement in future CPGs.

MEDLINE, Embase, online CPG databases, and reference lists of included guidelines were searched up to January 31, 2020. Full-text CPGs reporting on evidence-based recommendations in lymphedema diagnosis or management in English were included. CPGs based on expert consensus, CPG summaries, or CPGs that were not freely available were excluded. Two reviewers identified eligible CPGs, extracted data, and assessed their quality independently using the Appraisal of Guidelines for Research and Evaluation II instrument. Significant scoring discrepancies were discussed with a third reviewer. An overall scaled quality score of ≥80% was the threshold to recommend guideline use.

Six relevant CPGs were identified. One was subsequently excluded as its full text could not be obtained. Overall, there was very good inter-reviewer reliability of scores with intraclass correlation coefficient of 0.952 (95% confidence interval, 0.921-0.974). No single CPG scored highest in all domains, with methodologic heterogeneity observed. Poor performance was noted in domain 5 (mean scaled score, 23.8% ± 17.1%) and domain 6 (22.9% ± 26.7%). No CPG achieved an overall scaled quality score of ≥80%, with the top CPG scoring 79.2%.

According to the defined threshold, no lymphedema CPG was considered adequate for use in clinical practice. All current lymphedema CPGs have areas for improvement with elements of methodologic quality lacking, particularly with respect to rigor of development. A structured approach, guided by the use of CPG creation tools and checklists such as the Appraisal of Guidelines for Research and Evaluation II instrument, should help CPG development groups in improving the quality of future CPGs. This is of particular importance in a complex, multidisciplinary condition such as lymphedema.