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A Systematic Review of the Quality of Clinical Practice Guidelines for Chronic Limb-Threatening Ischemia
Adele Hwee Hong Lee1, Adele Philippa Wright2, Mark J Westcott3
1Department of Vascular Surgery, Austin Health, Melbourne, Australia.
Insights
The Global Vascular Guidelines (GVG) for chronic limb-threatening ischemia (CLTI) are high-quality and recommended for clinical use. This systematic review assessed four guidelines using the Appraisal of Guidelines for Research and Evaluation II instrument.
Area of Science:
- Vascular Surgery
- Clinical Practice Guidelines
- Health Technology Assessment
Background:
- Chronic limb-threatening ischemia (CLTI) requires high-quality clinical practice guidelines (CPGs) for optimal patient management.
- Assessing the quality of existing CLTI CPGs is crucial for evidence-based medical practice.
- The Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument provides a standardized method for CPG quality assessment.
Approach:
- A systematic literature review identified four key CPGs for CLTI: Global Vascular Guidelines (GVG), European Society of Cardiology (ESC), American College of Cardiology, and National Institute for Health and Care Excellence.
- Two independent reviewers utilized the AGREE II instrument to rigorously evaluate the identified CPGs across 23 items and 6 domains.
- Guideline quality was determined by domain scores (≥50%) and an overall average domain score (≥80%) indicating adequacy for clinical use.
Key Points:
- The GVG (2019) achieved the highest overall quality score (82.9%), meeting the criteria for recommendation.
- The European Society of Cardiology (ESC) guideline scored lowest (50.2%), with multiple domains below the 50% threshold.
- Key areas for improvement across guidelines included the rigor of development, applicability, clarity of systematic review methods, bias mitigation, and plans for guideline updates.
Conclusions:
- The 2019 Global Vascular Guidelines for CLTI are deemed high-quality and recommended for clinical implementation.
- This quality assessment aids clinicians in making informed decisions and guides the development of future, improved CLTI CPGs.
- Enhancing transparency in methodology and applicability will strengthen future guideline development for CLTI.
Background:
To assess the quality of clinical practice guidelines (CPGs) for chronic limb-threatening ischemia (CLTI) using the Appraisal of Guidelines for Research and Evaluation II instrument.
Methods:
A systematic review of Medline, Embase, and online CPG databases was carried out. Four CPGs on CLTI were identified: Global Vascular Guidelines (GVG), European Society of Cardiology (ESC), American College of Cardiology, and National Institute for Health and Care Excellence guidelines on lower limb peripheral arterial disease. Two independent appraisers analyzed the 4 CPGs using the Appraisal of Guidelines for Research and Evaluation II instrument. CPGs were ranked across 6 domains with 23 items that ranged from 1 (strongly disagree) to 7 (strongly agree). A scaled domain score was calculated as a percentage of the maximum possible score achievable. A domain score of ≥50% and an overall average domain score of ≥80% reflected a CPG of adequate quality recommended for use.
Results:
GVG had the highest overall score (82.9%), as an average of all domains, and ESC had the lowest score (50.2%). GVG and National Institute for Health and Care Excellence guidelines had all domains scoring >50%, while American College of Cardiology had 5 and ESC had 3. Two domains, rigor of development and applicability, scored the lowest among the CPGs. There was a lack of detail in describing systematic methods used in the literature review, how guidelines were formulated with minimal bias, and the planned procedure for updating the guidelines. Implications of guideline application and monitoring of outcomes after implementations were not explicitly discussed.
Conclusions:
The GVG guideline published in 2019 discussing CLTI is assessed to be of high quality and recommended for use. This review helps to improve clinical decision-making and quality of future CPGs for CLTI.
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