Discussion
To the best of our knowledge, this is the primer review that
systematically evaluates the quality of recently published CPGs of SCD
in pregnancy using the AGREE II instrument.
Four CPGs addressing the management of pregnant women with SCD were
assessed using the AGREE II instrument. This AGREE II assessment
highlighted several areas of improvement in the methodological rigor of
the included CPGs. One CPG (ACOG) had significant gaps in its rigor of
development (Domain 3), which is the largest and core domain, and three
CPGs demonstrated areas for improvement in their applicability (Domain
5). The weight of these two domains has been emphasized. The NICE CPG
received the highest reviewer agreement ratings.22 All
of the four included CPGs had commonalities and differences in their
clinical recommendations and are summarized in Table 5. Commonalities
included genetic screening (ACOG, RCOG), genetic diagnosis (ACOG, NHLBI,
RCOG), counselling during pregnancy (all four CPGs), transfusion or
prophylactic exchange transfusion (ACOG, NICE, RCOG), fetal surveillance
(ACOG, NHLBI, RCOG), and contraception (NHLBI, RCOG).
One Discrepancy was observed in the form of a lack of clearly
articulated recommendations for vaccination status updated pre-pregnancy
in three CPGs (ACOG, NHLBI, NICE) where it was addressed in the RCOG CPG
only. PRISMA checklist was reported in Table 7.
Two CPGs (ACOG and RCOG) were more specific on pregnancy compared to the
other two CPGs that contained general recommendations on SCD with
smaller sections focused on pregnancy. Out of the two specific CPGs,
RCOG consistently scored higher in all domains of our assessment. This
systematic and objective assessment of the available CPGs is beneficial
to support the decision to adopt or adapt CPGs in clinical practice.
After reviewing these CPGs and given the appropriate rigor and
consistently high scores with RCOG and its relevance clinically, we
decided to adopt all the recommendations of this CPG in our clinical
practice.
The findings of our study revealed that the CPG assessment was accurate.
There was excellent/ very good inter-rater agreement between the four
assessors who evaluated the eligible four CPGs using AGREE II. In our
results, we were able to show that our proposed approach for quality
assessment could be seen as a significant example of similar systematic
reviews and assessments of CPGs.
Furthermore, our statistical analysis illustrates the practicability of
the AGREE II instrument as a valuable tool in the critical appraisal of
CPGs, without compromising quality. We trust in the experience of our
raters who participated in the inter-observer agreement. Conceivably,
inexperienced staff or non-professional reviewers would not have been
able to have similar agreement on clinical decision features or
characteristics in CPGs that could impact the judgement related to the
provision of care to pregnant women with SCD.
In the first half of 2019 only, more than eight systematic critical
appraisals of CPGs in obstetrics and gynecology have been published
using the AGREE II instrument. These included high priority health
topics like; induction of labor32, planned caesarean
section33, recurrent pregnancy
loss34, packed red cells versus whole blood
transfusion for severe pregnancy‐related anemia and obstetric
bleeding35, gestational diabetes
mellitus36-38, and bladder pain syndrome/interstitial
cystitis39. The studies mentioned above studies have
identified several gaps in the included CPGs, including differences,
discrepancies, lack of evidence-base, and inconsistencies in some
clinical recommendations in addition to commonalities and similarities
in other recommendations with future advice to improve these
variabilities in CPGs.32-39