The methodological rigor of Evidence-based clinical practice guidelines in Africa should be improved
Posted on 10 January 2016 // Clinical practice guidelines
The purpose of evidence-based clinical practice guidelines (CPGs) is to enable health practitioners especially those at the front line of patient care, to follow best practices guided by the best available evidence about the management of health problems and to reduce variability in practice. Best practices are clinical strategies that health practitioners are confident that beneficial consequences of implementing them outweigh potential harms. As a consequence adherence to evidence-based CPGs can improve the processes and outcomes of health care.
The quality of evidence-based CPGs is critical to ensure their full benefits. It is only with high quality evidence based CPGs that we can be confident that the benefits outweigh the risks. However, available evidences suggest that the quality of available evidence-based CPGs is variable. In Africa, one study (Kredo T et al., 2012) has highlighted important quality gaps in available clinical guidelines. The authors of this study have systematically reviewed and evaluated the quality of 30 clinical guidelines from 13 countries published on five priorities diseases: HIV, malaria, pre-eclampsia, diarrhea and hypertension.
The “rigor of development’, ‘applicability of recommendations’ to African context, and ‘editorial independence’ were the most inadequately addressed quality dimensions of current evidence-based CPG in Africa (figure). Furthermore, alignment with best evidence was highly variable across guidelines. These gaps on important quality dimensions increase the risk of bias in the guidelines development process and therefore reduce the confidence of clinicians and health policy makers that the overall benefits of implementing CPGs outweigh the potential risks.
Figure adapted from Kredo et al. 2012.
To increase quality of evidence-based CPGs developed in Africa, new structural and collaborative approaches build on the strength of all relevant stakeholders are needed. The approaches should implement rigorous methodology aligned with international standards, develop evidenced-based guidelines that are applicable in African context, ensure alignment of evidence and recommendations, and acknowledge and evaluate potential conflict of interests that may threaten the validity of guidelines.
The Guidelines Advisory Network (GANEO) aims to work with African professional health organizations, NGOs and governments to build and implement an innovative multidisciplinary and collaborative framework for development of high quality evidence-based CPG. The core of GANEO’s methodology is based on the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) (www.gradeworkinggroup.org) approach. GRADE approach was adopted by more than 70 organizations to develop their evidence-based CPG, including WHO. GRADE is the current standard for evidence-based CPG methodology.
*AGREE-II: Appraisal of Guidelines for Research and Evaluation. A validated and most widely accepted tool to evaluate the quality of clinical practice guidelines. The tool contains 23 key quality items categorized in six domains scored with a 7-point Likert scale.
Kredo T, Gerritsen A, van Heerden J, Conway S, Siegfried N. Clinical practice guidelines within the Southern African Development Community: a descriptive study of the quality of guideline development and concordance with best evidence for five priority diseases. Health Res Policy Syst. 2012 Jan 5;10:1.