Moving toward the Development and Effective Implementation of High-Quality Guidelines in Pediatric Surgery: A Review of the Literature

 

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Abstract

Applying evidence-based guidelines can enhance the quality of patient care. While robust guideline development methodology ensures credibility and validity, methodological variations can impact guideline quality. Besides methodological rigor, effective implementation is crucial for achieving improved health outcomes. This review provides an overview of recent literature pertaining to the development and implementation of guidelines in pediatric surgery. Literature was reviewed to provide an overview of sound guideline development methodologies and approaches to promote effective guideline implementation. Challenges specific to pediatric surgery were highlighted. A search was performed to identify published guidelines relevant to pediatric surgery from 2018 to June 2023, and their quality was collectively appraised using the AGREE II instrument. High-quality guideline development can be promoted by using methodologically sound tools such as the Guidelines 2.0 checklist, the GRADE system, and the AGREE II instrument. While implementation can be promoted during guideline development and post-publication, its effectiveness may be influenced by various factors. Challenges pertinent to pediatric surgery, such as limited evidence and difficulties with outcome selection and heterogeneity, may impact guideline quality and effective implementation. Fifteen guidelines were identified and collectively appraised as suboptimal, with a mean overall AGREE II score of 58%, with applicability being the lowest scoring domain. There are identified challenges and barriers to the development and effective implementation of high-quality guidelines in pediatric surgery. It is valuable to prioritize the identification of adapted, innovative methodological strategies and the use of implementation science to understand and achieve effective guideline implementation.

^* These authors contributed equally to the article and retain the first authorship.

Publication History

Received: 03 October 2023

Accepted: 20 October 2023

Article published online:
19 January 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

• References

• 1 Djulbegovic B, Guyatt GH. Progress in evidence-based medicine: a quarter century on. Lancet 2017; 390 (10092): 415-423
  CrossrefPubMedGoogle Scholar
• 2 Burgers J, Smolders M, van der T, Davis D, Grol R. Clinical practice guidelines as a tool for improving patient care. In: Improving Patient Care. John Wiley & Sons, Ltd;; 2013: 91-114
  CrossrefGoogle Scholar
• 3 Graham R, Mancher M, Miller Wolman D, Greenfield S, Steinberg E. eds. Clinical Practice Guidelines We Can Trust. National Academies Press;; 2011
  CrossrefGoogle Scholar
• 4 AGREE Collaboration. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Qual Saf Health Care 2003; 12 (01) 18-23
  CrossrefPubMedGoogle Scholar
• 5 Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA 1999; 281 (20) 1900-1905
  CrossrefPubMedGoogle Scholar
• 6 Baraldini V, Spitz L, Pierro A. Evidence-based operations in paediatric surgery. Pediatr Surg Int 1998; 13 (5–6) 331-335
  CrossrefPubMedGoogle Scholar
• 7 Hardin Jr WD, Stylianos S, Lally KP. Evidence-based practice in pediatric surgery. J Pediatr Surg 1999; 34 (05) 908-912 , discussion 912–913
  CrossrefPubMedGoogle Scholar
• 8 Qaseem A, Forland F, Macbeth F, Ollenschläger G, Phillips S, van der Wees P. Board of Trustees of the Guidelines International Network. Guidelines International Network: toward international standards for clinical practice guidelines. Ann Intern Med 2012; 156 (07) 525-531
  CrossrefPubMedGoogle Scholar
• 9 Sullivan GA, Schäfer WLA, Raval MV, Johnson JK. Implementation science for quality improvement in pediatric surgery. Semin Pediatr Surg 2023; 32 (02) 151282
  CrossrefPubMedGoogle Scholar
• 10 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71
  CrossrefPubMedGoogle Scholar
• 11 Bono Vega M, Gavín Benavent P, Soledad Isern de Val M, Muñoz Fernández C, Prieto Remón L. European Reference Network: Clinical Practice Guidelines And Clinical Decision Support Tools Methodological Handbooks & Toolkit for Clinical Practice Guidelines and Clinical Decision Support Tools for Rare or Low Prevalence and Complex Diseases Introductory Document;. 2020 . Accessed October 30, 2023 at: https://ec.europa.eu/health/ern_en
  PubMedGoogle Scholar
• 12 Rosenfeld RM, Nnacheta LC, Corrigan MD. Clinical consensus statement development manual. Otolaryngol Head Neck Surg 2015; 153 (02) S1-S14
  PubMedGoogle Scholar
• 13 Schünemann HJ, Wiercioch W, Etxeandia I. et al. Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise. CMAJ 2014; 186 (03) E123-E142
  CrossrefPubMedGoogle Scholar
• 14 Howick J, Chalmers I, Lind J. et al. Oxford Centre for Evidence-Based Medicine. 2011 Levels of Evidence. Accessed October 30, 2023 at: http://www.cebm.net/index.aspx?o=5653
  PubMedGoogle Scholar
• 15 Guyatt GH, Oxman AD, Vist GE. et al; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336 (7650) 924-926
  CrossrefPubMedGoogle Scholar
• 16 Moberg J, Oxman AD, Rosenbaum S. et al; GRADE Working Group. The GRADE Evidence to Decision (EtD) framework for health system and public health decisions. Health Res Policy Syst 2018; 16 (01) 45
  CrossrefPubMedGoogle Scholar
• 17 Brouwers MC, Kho ME, Browman GP. et al; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010; 182 (18) E839-E842
  CrossrefPubMedGoogle Scholar
• 18 Shawyer AC, Livingston MH, Manja V, Brouwers MC. The quality of guidelines in pediatric surgery: can we all AGREE?. Pediatr Surg Int 2015; 31 (01) 61-68
  CrossrefPubMedGoogle Scholar
• 19 Adler M, Ziglio E. Gazing into the Oracle: The Delphi Method and Its Application to Social Policy and Public Health. Jessica Kingsley Publishers; 1996
  Google Scholar
• 20 Farid-Kapadia M, Askie L, Hartling L. et al. Do systematic reviews on pediatric topics need special methodological considerations?. BMC Pediatr 2017; 17 (01) 57
  CrossrefPubMedGoogle Scholar
• 21 Grigore B, Ciani O, Dams F. et al. Surrogate endpoints in health technology assessment: an international review of methodological guidelines. PharmacoEconomics 2020; 38 (10) 1055-1070
  CrossrefPubMedGoogle Scholar
• 22 Teunissen N, Brendel J, Eaton S. et al. Variability in the reporting of baseline characteristics, treatment, and outcomes in esophageal atresia publications: a systematic review. Eur J Pediatr Surg 2023; 33 (02) 129-137
  Article in Thieme ConnectPubMedGoogle Scholar
• 23 Allin BSR, Hall NJ, Ross AR, Marven SS, Kurinczuk JJ, Knight M. NETS1G Collaboration. Development of a gastroschisis core outcome set. Arch Dis Child Fetal Neonatal Ed 2019; 104 (01) F76-F82
  CrossrefPubMedGoogle Scholar
• 24 Allin BSR, Irvine A, Patni N, Knight M. Variability of outcome reporting in Hirschsprung's disease and gastroschisis: a systematic review. Sci Rep 2016; 6 (01) 38969
  CrossrefPubMedGoogle Scholar
• 25 Hatakeyama Y, Seto K, Onishi R. et al. Involvement of methodological experts and the quality of clinical practice guidelines: a critical appraisal of clinical practice guidelines and a questionnaire survey of the development groups in Japan. BMJ Open 2023; 13 (05) e063639
  CrossrefPubMedGoogle Scholar
• 26 de Campos Vieira Abib S, Chui CH, Cox S. et al. International Society of Paediatric Surgical Oncology (IPSO) Surgical Practice Guidelines. Ecancermedicalscience 2022; 16: 1356
  CrossrefPubMedGoogle Scholar
• 27 Udayakumaran S, Pillai S, Dwarakanath S. et al. Indian Society of Pediatric Neurosurgery Consensus Guidelines on Preventing and Managing Shunt Infection: Version 2020–21. Neurol India 2021; 69 (08) S526-S555
  CrossrefPubMedGoogle Scholar
• 28 Alphonso N, Angelini A, Barron DJ. et al; ( Chairman HLHS Guidelines Task Force. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58 (03) 416-499
  CrossrefPubMedGoogle Scholar
• 29 Hagedorn JC, Fox N, Ellison JS. et al. Pediatric blunt renal trauma practice management guidelines: collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. J Trauma Acute Care Surg 2019; 86 (05) 916-925
  CrossrefPubMedGoogle Scholar
• 30 Coté CJ, Wilson S. American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. Pediatrics 2019; 143 (06) e20191000
  CrossrefPubMedGoogle Scholar
• 31 Oliva S, Romano C, De Angelis P. et al; Italian Society of Pediatric Gastroenterology Hepatology and Nutrition (SIGENP), and The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO). Foreign body and caustic ingestions in children: a clinical practice guideline. Dig Liver Dis 2020; 52 (11) 1266-1281
  CrossrefPubMedGoogle Scholar
• 32 Brindle ME, McDiarmid C, Short K. et al. Consensus guidelines for perioperative care in neonatal intestinal surgery: Enhanced Recovery After Surgery (ERAS^®) Society Recommendations. World J Surg 2020; 44 (08) 2482-2492
  CrossrefPubMedGoogle Scholar
• 33 Doherty C, Neal R, English C. et al; Paediatric Working Party of the National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies. Anaesthesia 2018; 73 (11) 1400-1417
  CrossrefPubMedGoogle Scholar
• 34 Kyrklund K, Sloots CEJ, de Blaauw I. et al. ERNICA guidelines for the management of rectosigmoid Hirschsprung's disease. Orphanet J Rare Dis 2020; 15 (01) 164
  CrossrefPubMedGoogle Scholar
• 35 Saadai P, Trappey AF, Goldstein AM. et al; American Pediatric Surgical Association Hirschsprung Disease Interest Group. Guidelines for the management of postoperative soiling in children with Hirschsprung disease. Pediatr Surg Int 2019; 35 (08) 829-834
  CrossrefPubMedGoogle Scholar
• 36 Williams RF, Grewal H, Jamshidi R. et al. Updated APSA Guidelines for the management of blunt liver and spleen injuries. J Pediatr Surg 2023; 58 (08) 1411-1418
  CrossrefPubMedGoogle Scholar
• 37 Baird R, Lal DR, Ricca RL. et al. Management of long gap esophageal atresia: a systematic review and evidence-based guidelines from the APSA Outcomes and Evidence Based Practice Committee. J Pediatr Surg 2019; 54 (04) 675-687
  CrossrefPubMedGoogle Scholar
• 38 Turner D, Ruemmele FM, Orlanski-Meyer E. et al. Management of paediatric ulcerative colitis, Part 1: Ambulatory care - an evidence-based guideline from European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67 (02) 257-291
  CrossrefPubMedGoogle Scholar
• 39 Pratt JSA, Browne A, Browne NT. et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg Obes Relat Dis 2018; 14 (07) 882-901
  CrossrefPubMedGoogle Scholar
• 40 Puligandla PS, Skarsgard ED, Offringa M. et al; Canadian Congenital Diaphragmatic Hernia Collaborative. Diagnosis and management of congenital diaphragmatic hernia: a clinical practice guideline. CMAJ 2018; 190 (04) E103-E112
  CrossrefPubMedGoogle Scholar
• 41 Bryant EA, Scott AM, Greenwood H, Thomas R. Patient and public involvement in the development of clinical practice guidelines: a scoping review. BMJ Open 2022; 12 (09) e055428
  CrossrefPubMedGoogle Scholar
• 42 Wilson P, Kislov R. Implementation Science;. 2022 . Accessed October 30, 2023 at: https://books.google.nl/books?hl=nl&lr=&id=q62aEAAAQBAJ&oi=fnd&pg=PT11&dq=16.%09Wilson
  PubMedGoogle Scholar
• 43 Eccles MP, Mittman BS. Welcome to implementation science. Implementation Sci 2006; 1 (01) DOI: 10.1186/1748-5908-1-1.
  CrossrefPubMedGoogle Scholar
• 44 Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci 2015; 10 (01) 53
  CrossrefPubMedGoogle Scholar
• 45 Brooke BS, Finlayson SRG. What surgeons can learn from the emerging science of implementation. JAMA Surg 2015; 150 (10) 1006-1007
  CrossrefPubMedGoogle Scholar
• 46 Smith AB, Brooke BS. How implementation science in surgery is done. JAMA Surg 2019; 154 (10) 891-892
  CrossrefPubMedGoogle Scholar
• 47 Lamoshi A, Gibbons A, Williams S, Ponsky T. Barriers to the implementation of new guidelines among pediatric surgeons: online survey. Pediatr Surg Int 2020; 36 (09) 1103-1109
  CrossrefPubMedGoogle Scholar
• 48 Kocken PL, van Kesteren NMC, van Zoonen R, Reijneveld SA. Availability and implementation of guidelines in European child primary health care: how can we improve?. Eur J Public Health 2022; 32 (05) 670-676
  CrossrefPubMedGoogle Scholar
• 49 Gittus M, Chong J, Sutton A, Ong ACM, Fotheringham J. Barriers and facilitators to the implementation of guidelines in rare diseases: a systematic review. Orphanet J Rare Dis 2023; 18 (01) 140
  CrossrefPubMedGoogle Scholar
• 50 Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implement Sci 2013; 8 (01) 139
  CrossrefPubMedGoogle Scholar
• 51 Powell BJ, Waltz TJ, Chinman MJ. et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci 2015; 10 (01) 21
  CrossrefPubMedGoogle Scholar
• 52 Mazza D, Bairstow P, Buchan H. et al. Refining a taxonomy for guideline implementation: results of an exercise in abstract classification. Implement Sci 2013; 8 (01) 32
  CrossrefPubMedGoogle Scholar
• 53 Gagliardi AR, Alhabib S. Members of Guidelines International Network Implementation Working Group. Trends in guideline implementation: a scoping systematic review. Implement Sci 2015; 10 (01) 54
  CrossrefPubMedGoogle Scholar
• 54 Effective Practice and Organisation of Care (EPOC). Accessed October 30, 2023 at: epoc.cochrane.org/epoc-taxonomy
  PubMedGoogle Scholar
• 55 Peters S, Sukumar K, Blanchard S. et al. Trends in guideline implementation: an updated scoping review. Implement Sci 2022; 17 (01) 50
  CrossrefPubMedGoogle Scholar
• 56 Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 1995; 153 (10) 1423-1431
  PubMedGoogle Scholar
• 57 Powell BJ, Fernandez ME, Williams NJ. et al. Enhancing the impact of implementation strategies in healthcare: a research agenda. Front Public Health 2019; 7 (03) 3
  CrossrefPubMedGoogle Scholar
• 58 Wensing Grimshaw G. Process evaluation of implementation strategies. In: Improving Patient Care: The Implementation of Change in Healthcare. 3rd ed. Bohn Stafleu van Loghum;; 2020
  CrossrefGoogle Scholar
• 59 Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Medical Research Council Guidance. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008; 337 (29) a1655
  CrossrefPubMedGoogle Scholar
• 60 Kastner M, Bhattacharyya O, Hayden L. et al. Guideline uptake is influenced by six implementability domains for creating and communicating guidelines: a realist review. J Clin Epidemiol 2015; 68 (05) 498-509
  CrossrefPubMedGoogle Scholar
• 61 Brouwers MC, Makarski J, Kastner M, Hayden L, Bhattacharyya O. GUIDE-M Research Team. The Guideline Implementability Decision Excellence Model (GUIDE-M): a mixed methods approach to create an international resource to advance the practice guideline field. Implement Sci 2015; 10 (01) 36
  CrossrefPubMedGoogle Scholar
• 62 Gupta S, Tang R, Petricca K, Florez ID, Kastner M. The Guideline Language and Format Instrument (GLAFI): development process and international needs assessment survey. Implement Sci 2022; 17 (01) 47
  CrossrefPubMedGoogle Scholar
• 63 Florez ID, Brouwers MC, Kerkvliet K. et al. Assessment of the quality of recommendations from 161 clinical practice guidelines using the Appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX) instrument shows there is room for improvement. Implement Sci 2020; 15 (01) 79
  CrossrefPubMedGoogle Scholar
• 64 Watine J, Friedberg B, Nagy E. et al. Conflict between guideline methodologic quality and recommendation validity: a potential problem for practitioners. Clin Chem 2006; 52 (01) 65-72
  CrossrefPubMedGoogle Scholar
• 65 Nuckols TK, Lim YW, Wynn BO. et al. Rigorous development does not ensure that guidelines are acceptable to a panel of knowledgeable providers. J Gen Intern Med 2008; 23 (01) 37-44
  CrossrefPubMedGoogle Scholar
• 66 Brouwers MC, Spithoff K, Kerkvliet K. et al. Development and validation of a tool to assess the quality of clinical practice guideline recommendations. JAMA Netw Open 2020; 3 (05) e205535
  CrossrefPubMedGoogle Scholar
• 67 Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg 2011; 128 (01) 305-310
  CrossrefPubMedGoogle Scholar
• 68 About the EPSA. Accessed October 30, 2023 at: https://dica.nl/epsa/about-epsa#:~:text=The%20primary%20aim%20of%20the,international%20experts%20in%20the%20field
  PubMed

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