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• Critical Appraisal in uveitis and eye diseases with fewer evidence-based clinical practice guidelines
  Nima Ghadiri
  Published on: 2 May 2023
• Clinical Practice Guidelines and positions statements critical appraisal in Uveitis
  Jose Galvez-Olortegui, Carmen Burgueño-Montañes, Miguel Zavaleta-Mercado, Tomas Galvez-Olortegui and Alfredo Adan
  Published on: 13 March 2023

• Published on: 2 May 2023

  Critical Appraisal in uveitis and eye diseases with fewer evidence-based clinical practice guidelines

  • Nima Ghadiri, Consultant Medical Ophthalmologist Department of Ophthalmology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK

  Dear Editor,

  Thank you for the opportunity to respond to the comments raised in the correspondence by Galvez-Olortegui et al. [1] regarding our recent publication "Systematic review of clinical practice guidelines for uveitis" [2]

  We thank the authors for a thoughtful and considered response to the paper and appreciate the interest shown in our work. The authors have highlighted additional factors beyond evidence when formulating recommendations for patient care, such as cost-effectiveness, feasibility, and equity.

  We agree with the point that although the Appraisal of Guidelines for Research and Evaluation (AGREE II) is a commonly used tool for critical appraisal of Clinical Practice Guidelines (CPGs), the exclusion of items in the evaluation process may limit the assessment of the entire CPG development process. We acknowledge the concern about the lack of consideration of applicability domain (domain 5) in the evaluation of CPGs. Indeed, a CPG with high methodological quality can score low in applicability domain, which can limit its implementation in specific environments.

  We also appreciate the suggestion of a more novel tool, the appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX), which focuses specifically on the quality of the recommendations of the CPG and its clinical credibility and implementability for health professionals, decision makers, and stakeholders. In combination with AGREE...

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  Dear Editor,

  Thank you for the opportunity to respond to the comments raised in the correspondence by Galvez-Olortegui et al. [1] regarding our recent publication "Systematic review of clinical practice guidelines for uveitis" [2]

  We thank the authors for a thoughtful and considered response to the paper and appreciate the interest shown in our work. The authors have highlighted additional factors beyond evidence when formulating recommendations for patient care, such as cost-effectiveness, feasibility, and equity.

  We agree with the point that although the Appraisal of Guidelines for Research and Evaluation (AGREE II) is a commonly used tool for critical appraisal of Clinical Practice Guidelines (CPGs), the exclusion of items in the evaluation process may limit the assessment of the entire CPG development process. We acknowledge the concern about the lack of consideration of applicability domain (domain 5) in the evaluation of CPGs. Indeed, a CPG with high methodological quality can score low in applicability domain, which can limit its implementation in specific environments.

  We also appreciate the suggestion of a more novel tool, the appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX), which focuses specifically on the quality of the recommendations of the CPG and its clinical credibility and implementability for health professionals, decision makers, and stakeholders. In combination with AGREE II, this can be a useful way to evaluate the clinical credibility and implementability of CPGs. Within the context of this paper, the use of AGREE II was principally to ensure that this review would correspond to the other reviews within the umbrella of the WHO Guideline Review Committee Secretariat and the WHO Package of Eye Care Interventions [3]

  Finally, we agree with your statement that the methodology used by Ghadiri et al. is applicable to eye diseases with a high number of evidence-based CPGs, and we appreciate your insights into the challenges of identifying and including consensus-based recommendations and panels of experts in the selection process. It is indeed unfortunate that the coverage of uveitis in CPGs is low, which can lead to challenges in guiding decision-making for optimum patient care. I appreciate the authors' efforts to identify gaps in evidence and propose strategies to handle them through systematic review, and thank you for your contribution to the discussion on improving the evaluation of CPGs for uveitis and other eye diseases.

  Once again, we appreciate the comments made by the authors and thank BMJ Ophthalmology for the opportunity to respond. We hope that our work will contribute to further research in this area and improve patient outcomes.

  References:

  [1] Galvez-Olortegui J, Burgueño-Montañes C, Zavaleta-Mercado M, Galvez-Olortegui T and Adan A "Clinical Practice Guidelines and positions statements critical appraisal in Uveitis." Rapid Response to: "Systematic review of clinical practice guidelines for uveitis" BMJ Open Ophthalmol. 2023;8(1):e001091. Doi: http://dx.doi.org/10.1136/bmjophth-2022-001091

  [2] Ghadiri N, Reekie IR, Gordon I, Safi S, Lingham G, Evans JR, et al. Systematic review of clinical practice guidelines for uveitis. BMJ Open Ophthalmol. 2023;8(1):e001091. Doi: http://dx.doi.org/10.1136/bmjophth-2022-001091

  [3] Keel S, Evans JR, Block S, et al. Strengthening the integration of eye care into the health system: methodology for the development of the who package of eye care interventions. BMJ Open Ophthalmol 2020;5:e000533.doi:10.1136/bmjophth-2020-000533pmid:http://www.ncbi.nlm.nih.gov/pubmed/32821853PubMedGoogle Scholar

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  Conflict of Interest:
  None declared.

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• Published on: 13 March 2023

  Clinical Practice Guidelines and positions statements critical appraisal in Uveitis

  • Jose Galvez-Olortegui, Physician, Ophthalmology Resident. Evidence Based Ophthalmology Unit (Oftalmoevidencia), Scientia Clinical and Epidemiological Research Institute, Trujillo, Peru
  • Other Contributors:
    • Carmen Burgueño-Montañes, Opthalmologist
    • Miguel Zavaleta-Mercado, Opthalmologist
    • Tomas Galvez-Olortegui, Opthalmologist
    • Alfredo Adan, Opthalmologist

  To the editor:
  We have carefully read the article “Systematic Review of Clinical Practice Guidelines for Uveitis” by Ghadiri et al., whose purpose is to present the results, including the quality and current state of evidence, of a systematic review of Clinical Practice Guidelines (CPG) for uveitis(1).

  CPG provides recommendations to optimize patient care, based on a systematic review of evidence and, although the evidence is critical; additional factors should be considered when formulating recommendations, such as benefits and risks, use of resources, cost-effectivity, values and preferences of the patient, feasibility and equity, before recommendations are considered ultimate (2). Currently, there are several ways to critical appraise a CPG, and the most used is the Appraisal of Guidelines for Research and Evaluation (AGREE II).

  AGREE II has 23 items, with 6 domains, for evaluating the rigor or methodological quality and transparency with which a guide is developed; thus, the aim is to assess the entire CPG development process. However, a CPG with high methodological quality (domain 3) can score low in applicability domain (domain 5), because of it is difficulty to implement or adapt to a specific environment if the recommendations are not robust, troublesome to apply or of uncertain clinical validity. Ghadiri et al. specifically used 9 items of the AGREE II and none of them correspond to domain 5 (applicability). The AGREE II user manual itself advi...

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  To the editor:
  We have carefully read the article “Systematic Review of Clinical Practice Guidelines for Uveitis” by Ghadiri et al., whose purpose is to present the results, including the quality and current state of evidence, of a systematic review of Clinical Practice Guidelines (CPG) for uveitis(1).

  CPG provides recommendations to optimize patient care, based on a systematic review of evidence and, although the evidence is critical; additional factors should be considered when formulating recommendations, such as benefits and risks, use of resources, cost-effectivity, values and preferences of the patient, feasibility and equity, before recommendations are considered ultimate (2). Currently, there are several ways to critical appraise a CPG, and the most used is the Appraisal of Guidelines for Research and Evaluation (AGREE II).

  AGREE II has 23 items, with 6 domains, for evaluating the rigor or methodological quality and transparency with which a guide is developed; thus, the aim is to assess the entire CPG development process. However, a CPG with high methodological quality (domain 3) can score low in applicability domain (domain 5), because of it is difficulty to implement or adapt to a specific environment if the recommendations are not robust, troublesome to apply or of uncertain clinical validity. Ghadiri et al. specifically used 9 items of the AGREE II and none of them correspond to domain 5 (applicability). The AGREE II user manual itself advise against the exclusion of items in the evaluation process.

  Recently, a new tool has been developed, the appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX), focused specifically on the quality of the recommendations of the CPG when evaluating clinical credibility and implementability for health professionals, decision makers and stakeholders. It comprises 9 items, grouped in 3 categories: clinical applicability, values and preferences, and implementability (3,4). The use of the AGREE-REX tool as a complement to AGREE II, might help to perform a better evaluation of the CPGs and to support the development of the Package of Eye Care Interventions (PECI) of the WHO (5).

  Uveitis has been identified as one of the fifteen priority ocular pathologies for inclusion in the PECI, and through systematic reviews it is sought to determine gaps in evidence and propose strategies to handle them. We agree with Ghadiri et al. in the low coverage of the uveitis in the CPG, with the implications that this has to guide the decision making for the optimum patient care. We also consider that the methodology used by Ghadiri et al., is applicable to eye diseases with a high number of evidence-based CPG. The majority of articles with recommendations for the diagnosis and management of uveitis (a broad group of multidiciplinary or heterogeneous pathologies), are recommendations based on consensus, panel of experts, etc.; many of which were eliminated during authors selection process.

  In summary, Ghadiri et al, performed an important analysis, which must be replicated mainly in eye diseases with a large number of CPG; however, not using AGREE-REX, in the context of few GPC in Uveitis, can lead to a rigor bias, excluding relevant content that point out evidence gaps that would allow the stablishment of strategies and future lines of research according to the objectives of the PECI.

  References:
  1. Ghadiri N, Reekie IR, Gordon I, Safi S, Lingham G, Evans JR, et al. Systematic review of clinical practice guidelines for uveitis. BMJ Open Ophthalmol. 2023;8(1):e001091. Doi: http://dx.doi.org/10.1136/bmjophth-2022-001091
  2. Wachholz PA, Stein AT, Melo DO de, Mello RGB de, Florez ID. Recommendations for the development of Clinical Practice Guidelines. Geriatr Gerontol Aging. 2022;16:e0220016. Doi: http://dx.doi.org/10.53886/gga.e0220016
  3. Brouwers MC, Spithoff K, Kerkvliet K, Alonso-Coello P, Burgers J, Cluzeau F, et al. Development and Validation of a Tool to Assess the Quality of Clinical Practice Guideline Recommendations. JAMA Netw Open. 2020;3(5):e205535. Doi: http://dx.doi.org/10.1001/jamanetworkopen.2020.5535
  4. Florez ID, Brouwers MC, Kerkvliet K, Spithoff K, Alonso-Coello P, Burgers J, 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(1):79. Doi: https://doi.org/10.1186/s13012-020-01036-5
  5. Keel S, Evans JR, Block S, Bourne R, Calonge M, Cheng CY, et al. Strengthening the integration of eye care into the health system: methodology for the development of the WHO package of eye care interventions. BMJ Open Ophthalmol. 2020;5(1):e000533. Doi: http://dx.doi.org/10.1136/bmjophth-2020-000533

  Funding Sources
  The authors declare no financial support for the performance of this study.

  Disclosures:
  None.

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  Conflict of Interest:
  None declared.

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