From severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) to coronavirus disease 2019 (COVID-19): a systematic review of the quality and responsiveness of clinical management guidelines in outbreak settings

Abstract

Background: Clinical management guidelines (CMGs) can be useful tools to guide clinician’s decision making and enable consistent evidence-based high-quality care. Here, we assessed whether their objective quality has improved over time by considering CMGs for severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and from different timepoints for coronavirus disease 2019 (COVID-19). Methods: We performed a rapid literature review, quality assessment and focus group consultation. The Appraisal of Guidelines for Research and Evaluation (AGREE-II) tool was used to evaluate the quality of the CMGs. In total, six COVID-19 treatments were selected to assess the responsiveness of a subset of guidelines and their updates to 20th November 2020. We ran two sessions of focus groups with patient advocates to elicit their views on guideline development. Results: We included 37 COVID-19, six SARS, and four MERS CMGs. Evidence appraisals in CMGs generally focused on novel drugs rather than basic supportive care; where evidence for the latter was provided it was generally of a low quality. Most CMGs had major methodological flaws and there was no evidence of improvement in quality over time. CMGs scored lowest in the following AGREE-II domains: scope and purpose, editorial independence, stakeholder engagement, and rigour of development. Of the COVID-19 CMGs, only eight included specific guidance for the management of elderly patients and only ten for high-risk groups; a further eight did not specify the target patient group. Early in the pandemic, multiple guidelines recommended unproven treatments and whilst in general findings of major clinical trials were eventually adopted, this was not universally the case. Conclusions: The quality of most CMGs produced in coronaviridae outbreaks is poor and we have found limited evidence of improvement over time, highlighting that current development frameworks must be improved. PROSPERO registration: CRD42020167361 (17/02/2020)