Quality assessment of global obstructive sleep apnea guidelines

doi:10.3969/j.issn.1674-8115.2024.02.010

Abstract

Abstract:

Objective ·To evaluate the quality of clinical practice guidelines of obstructive sleep apnea (OSA) published worldwide. Methods ·The guidelines of OSA were retrieved in PubMed, Embase, China National Knowledge Infrastructure (CNKI), Wanfang Data, SinoMed, MedSci, The Cochrane Library, and the websites such as Medlive, U. S. Preventive Services Task Force (USPSTF), National Institute for Health and Care Excellence (NICE), New Zealand Guidelines Group (NZGG), Scottish Intercollegiate Guidelines Network (SIGN), and Guidelines International Network (GIN) from establishment to December 2022. Two reviewers screened the literature and extracted the main information independently, using the Appraisal of Guidelines for Research and Evaluation Ⅱ (AGREE Ⅱ) and Reporting Items for Practice Guidelines in Healthcare (RIGHT) to evaluate the quality of the included OSA guidelines. Subgroup analysis was performed according to the publication regions of guidelines. The inter-evaluator consistency test was also performed and the results were expressed as the intra-class correlation coefficient (ICC). All the included guidelines were read entirely and the clinical questions they raised were summarized. Results ·A total of 35 OSA guidelines were included. The ICC value of 0.975 showed a good inter-evaluator agreement. The results of AGREE Ⅱ showed that the average score of all guidelines was (63.60±16.45)%, with a minimum of 23.40% and a maximum of 91.67%. In the six domains, the scores of "Rigor of development" [(56.07±25.89)%] and "Applicability" [(53.57±15.52)%] were relative low. The average reporting rate of RIGHT of all the included guidelines was (67.84±20.03)%, with a minimum of 14.29% and a maximum of 94.29%, and the three domains with the lowest reporting rates were "Review and quality assurance" [(31.40±45.51)%], "Funding and conflict of interest declaration and management" [(56.43±33.95)%] and "Other aspects" [(56.19±36.85)%]. Subgroup analysis showed that guidelines in Asian had a lower score in "Rigor of development" and a lower overall score of AGREE Ⅱ than the guidelines in America and Europe (both P<0.05), and the reporting rates in the domains of "Evidence" and "Other information" of RIGHT of the Asian guidelines were also lower than those in the guidelines in America and Europe (P<0.05). These guidelines focused on 42 clinical questions which were classified to 3 aspects, i.e. screening and diagnosis, treatment and long-term management of OSA. Conclusion ·The quality of current global OSA guidelines varies a lot, and they need to be strengthened in terms of rigor of development, applicability, review and quality assurance, funding and conflict of interest declaration and management, especially those in Asia.

Key words: obstructive sleep apnea (OSA), clinical practice guideline, quality assessment, systematic review

CLC Number:

R762

GAO Yiqing, PENG Yu, XU Huajun, YI Hongliang, GUAN Jian, YIN Shankai. Quality assessment of global obstructive sleep apnea guidelines[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2024, 44(2): 237-249.

Figures/Tables 6

TrendMD

References 46

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Guideline	Grading system	Evidence level	Grade of recommendation
AASM2006^[10]	AASM	Ⅰ, Ⅱ, Ⅲ, Ⅳ, Ⅴ	Standard, Guideline, Option
AASM2008^[12]	AASM	Ⅰ, Ⅱ, Ⅲ, Ⅳ, Ⅴ	Standard, Guideline, Option
AASM2009^[13]	AASM	1, 2, 3	Standard, Guideline, Option
CTS2011^[41]	OCEBM	A, B, C, D	1(1a, 1b, 1c), 2(2a, 2b, 2c), 3(3a, 3b, 3c), 4, 5
ACP2013^[14]	GRADE	High, Moderate, Low	Strong, Weak
ACP2014^[15]	GRADE	High, Moderate, Low	Strong, Weak
INOSA2015^[39]	AAP	A, B, C, D, X	Strong recommendation, Recommendation, Option, No recommendation
AASM-AADSM2015^[17]	GRADE	High, Moderate, Low, Very low	Standard, Guideline, Option
DG-HNO-KHC2016^[37]	OCEBM	A, B, C, D	A, B, C, D
SASM2016^[18]	GRADE	High, Moderate, Low, Very low	Strong, Weak
AASM2017^[19]	GRADE	High, Moderate, Low, Very low	Strong, Weak
ASMBS017^[20]	OCEBM	High, Moderate, Low, Very low	Strong, Weak
SASM2018^[22]	GRADE	High, Moderate, Low, Very low	Strong, Weak, No recommendation
CMDA2018^[32]	GRADE	High, Moderate, Low, Very low	Strongly recommended, Weakly recommended, Weakly against, Strongly against
ATS2018^[23]	GRADE	High, Moderate, Low, Very low	Strong, Conditional
AASM2019^[24]	GRADE	High, Moderate, Low, Very low	Strong, Conditional
VA-DoD2020^[25]	GRADE	Unreported	Strong, Weak
JRS2021^[42]	MINDS	A-Strong, B-Moderate, C-Weak, D-Very weak	Strong, Weak, No recommendation
AASM-2021^[27]	GRADE	High, Moderate, Low, Very low	Strong, Conditional
ERS2021^[44]	GRADE	High, Moderate, Low, Very low	Strong, Conditional
USPSTF2022^[28]	USPSTF	High, Moderate, Low	A, B, C, D, I
GSDSM2022^[38]	AWMF	1, 2, 3, 4	A, B, C, D
SFORL2022^[34]	GRADE	1, 2, 3, 4	A, B, C

Guideline	Grading system	Evidence level	Grade of recommendation
AASM2006^[10]	AASM	Ⅰ, Ⅱ, Ⅲ, Ⅳ, Ⅴ	Standard, Guideline, Option
AASM2008^[12]	AASM	Ⅰ, Ⅱ, Ⅲ, Ⅳ, Ⅴ	Standard, Guideline, Option
AASM2009^[13]	AASM	1, 2, 3	Standard, Guideline, Option
CTS2011^[41]	OCEBM	A, B, C, D	1(1a, 1b, 1c), 2(2a, 2b, 2c), 3(3a, 3b, 3c), 4, 5
ACP2013^[14]	GRADE	High, Moderate, Low	Strong, Weak
ACP2014^[15]	GRADE	High, Moderate, Low	Strong, Weak
INOSA2015^[39]	AAP	A, B, C, D, X	Strong recommendation, Recommendation, Option, No recommendation
AASM-AADSM2015^[17]	GRADE	High, Moderate, Low, Very low	Standard, Guideline, Option
DG-HNO-KHC2016^[37]	OCEBM	A, B, C, D	A, B, C, D
SASM2016^[18]	GRADE	High, Moderate, Low, Very low	Strong, Weak
AASM2017^[19]	GRADE	High, Moderate, Low, Very low	Strong, Weak
ASMBS017^[20]	OCEBM	High, Moderate, Low, Very low	Strong, Weak
SASM2018^[22]	GRADE	High, Moderate, Low, Very low	Strong, Weak, No recommendation
CMDA2018^[32]	GRADE	High, Moderate, Low, Very low	Strongly recommended, Weakly recommended, Weakly against, Strongly against
ATS2018^[23]	GRADE	High, Moderate, Low, Very low	Strong, Conditional
AASM2019^[24]	GRADE	High, Moderate, Low, Very low	Strong, Conditional
VA-DoD2020^[25]	GRADE	Unreported	Strong, Weak
JRS2021^[42]	MINDS	A-Strong, B-Moderate, C-Weak, D-Very weak	Strong, Weak, No recommendation
AASM-2021^[27]	GRADE	High, Moderate, Low, Very low	Strong, Conditional
ERS2021^[44]	GRADE	High, Moderate, Low, Very low	Strong, Conditional
USPSTF2022^[28]	USPSTF	High, Moderate, Low	A, B, C, D, I
GSDSM2022^[38]	AWMF	1, 2, 3, 4	A, B, C, D
SFORL2022^[34]	GRADE	1, 2, 3, 4	A, B, C

Guideline	Domain						Total score/%	Recommended level
Guideline	Scope and purpose/%	Stakeholder involvement/%	Rigor of development/%	Clarity of presentation/%	Applicability/%	Editorial independence/%	Total score/%	Recommended level
Mean score (x±s)	79.68±20.38	60.71±22.87	56.07±25.89	75.63±15.61	53.57±15.52	68.52±23.25	63.60±16.45	‒
AASM2006^[10]	61.11	25.00	47.92	77.78	33.33	55.00	49.36	C
AASM2007^[11]	91.67	63.89	56.25	66.67	39.58	73.33	63.14	A
AASM2008^[12]	100.00	44.44	64.58	72.22	37.50	80.00	66.03	A
AASM2009^[13]	61.11	41.67	54.17	66.67	66.67	80.00	61.86	A
CSOHNS 2009^[29]	33.33	0	10.42	63.89	33.33	20.00	23.40	D
CTS2011^[41]	100.00	44.44	48.96	66.67	64.58	75.00	63.78	A
CMA-CTS2012^[30]	44.44	11.11	6.25	66.67	54.17	30.00	30.13	D
ACP2013^[14]	100.00	44.44	60.42	97.22	39.58	90.00	69.87	A
ACP2014^[15]	100.00	50.00	64.58	97.22	64.58	90.00	75.64	A
ASA2014^[16]	66.67	58.33	80.21	72.22	14.58	53.33	59.94	B
INOSA2015^[39]	44.44	50.00	38.54	72.22	54.17	80.00	54.81	B
AASM-AADSM2015^[17]	100.00	75.00	89.58	94.44	47.92	100.00	85.26	A
CMA2015^[31]	55.56	41.67	7.29	63.89	43.75	30.00	33.33	C
DG-HNO-KHC2016^[37]	50.00	38.89	65.63	72.22	37.50	80.00	59.94	B
SASM2016^[18]	100.00	61.11	75.00	97.22	62.50	100.00	81.73	A
AASM2017^[19]	100.00	58.33	75.00	86.11	70.83	76.67	76.92	A
ASMBS017^[20]	94.44	69.44	75.00	100.00	54.17	66.67	74.68	A
AASM-2017^[21]	66.67	66.67	15.63	38.89	54.17	60.00	44.55	B
SASM2018^[22]	100.00	55.56	75.00	72.22	43.75	90.00	73.40	A
CMDA2018^[32]	75.00	66.67	41.67	72.22	31.25	35.00	49.04	B
ATS2018^[23]	100.00	97.22	81.25	94.44	68.75	60.00	80.77	A
CMA-2018^[33]	58.33	55.56	9.38	66.67	52.08	55.00	42.31	C
AASM2019^[24]	72.22	83.33	67.71	88.89	68.75	60.00	71.15	A
VA-DoD2020^[25]	77.78	77.78	65.63	72.22	72.92	66.67	70.51	A
NICE2021^[43]	100.00	58.33	31.25	100.00	62.50	43.33	57.37	C
RRSDI2021^[40]	88.89	63.89	16.67	63.89	64.58	50.00	49.68	A
JRS2021^[42]	100.00	100.00	86.46	75.00	68.75	100.00	88.14	A
AASM2021^[26]	63.89	66.67	25.00	58.33	50.00	75.00	51.60	B
AASM-2021^[27]	69.44	100.00	79.17	58.33	64.58	88.33	77.56	A
ERS2021^[44]	100.00	100.00	85.42	83.33	87.50	100.00	91.67	A
GSDSM2022^[38]	66.67	75.00	72.92	38.89	70.83	80.00	69.55	A
SFORL2022^[34]	75.00	58.33	75.00	83.33	39.58	85.00	70.51	A
USPSTF2022^[28]	88.89	83.33	75.00	80.56	54.17	100.00	79.81	A
SPLF2010^[35]	100.00	66.67	57.29	72.22	37.50	30.00	56.73	B
SPLF2014^[36]	83.33	72.22	82.29	94.44	64.58	40.00	71.79	A

Guideline	Domain						Total score/%	Recommended level
Guideline	Scope and purpose/%	Stakeholder involvement/%	Rigor of development/%	Clarity of presentation/%	Applicability/%	Editorial independence/%	Total score/%	Recommended level
Mean score (x±s)	79.68±20.38	60.71±22.87	56.07±25.89	75.63±15.61	53.57±15.52	68.52±23.25	63.60±16.45	‒
AASM2006^[10]	61.11	25.00	47.92	77.78	33.33	55.00	49.36	C
AASM2007^[11]	91.67	63.89	56.25	66.67	39.58	73.33	63.14	A
AASM2008^[12]	100.00	44.44	64.58	72.22	37.50	80.00	66.03	A
AASM2009^[13]	61.11	41.67	54.17	66.67	66.67	80.00	61.86	A
CSOHNS 2009^[29]	33.33	0	10.42	63.89	33.33	20.00	23.40	D
CTS2011^[41]	100.00	44.44	48.96	66.67	64.58	75.00	63.78	A
CMA-CTS2012^[30]	44.44	11.11	6.25	66.67	54.17	30.00	30.13	D
ACP2013^[14]	100.00	44.44	60.42	97.22	39.58	90.00	69.87	A
ACP2014^[15]	100.00	50.00	64.58	97.22	64.58	90.00	75.64	A
ASA2014^[16]	66.67	58.33	80.21	72.22	14.58	53.33	59.94	B
INOSA2015^[39]	44.44	50.00	38.54	72.22	54.17	80.00	54.81	B
AASM-AADSM2015^[17]	100.00	75.00	89.58	94.44	47.92	100.00	85.26	A
CMA2015^[31]	55.56	41.67	7.29	63.89	43.75	30.00	33.33	C
DG-HNO-KHC2016^[37]	50.00	38.89	65.63	72.22	37.50	80.00	59.94	B
SASM2016^[18]	100.00	61.11	75.00	97.22	62.50	100.00	81.73	A
AASM2017^[19]	100.00	58.33	75.00	86.11	70.83	76.67	76.92	A
ASMBS017^[20]	94.44	69.44	75.00	100.00	54.17	66.67	74.68	A
AASM-2017^[21]	66.67	66.67	15.63	38.89	54.17	60.00	44.55	B
SASM2018^[22]	100.00	55.56	75.00	72.22	43.75	90.00	73.40	A
CMDA2018^[32]	75.00	66.67	41.67	72.22	31.25	35.00	49.04	B
ATS2018^[23]	100.00	97.22	81.25	94.44	68.75	60.00	80.77	A
CMA-2018^[33]	58.33	55.56	9.38	66.67	52.08	55.00	42.31	C
AASM2019^[24]	72.22	83.33	67.71	88.89	68.75	60.00	71.15	A
VA-DoD2020^[25]	77.78	77.78	65.63	72.22	72.92	66.67	70.51	A
NICE2021^[43]	100.00	58.33	31.25	100.00	62.50	43.33	57.37	C
RRSDI2021^[40]	88.89	63.89	16.67	63.89	64.58	50.00	49.68	A
JRS2021^[42]	100.00	100.00	86.46	75.00	68.75	100.00	88.14	A
AASM2021^[26]	63.89	66.67	25.00	58.33	50.00	75.00	51.60	B
AASM-2021^[27]	69.44	100.00	79.17	58.33	64.58	88.33	77.56	A
ERS2021^[44]	100.00	100.00	85.42	83.33	87.50	100.00	91.67	A
GSDSM2022^[38]	66.67	75.00	72.92	38.89	70.83	80.00	69.55	A
SFORL2022^[34]	75.00	58.33	75.00	83.33	39.58	85.00	70.51	A
USPSTF2022^[28]	88.89	83.33	75.00	80.56	54.17	100.00	79.81	A
SPLF2010^[35]	100.00	66.67	57.29	72.22	37.50	30.00	56.73	B
SPLF2014^[36]	83.33	72.22	82.29	94.44	64.58	40.00	71.79	A

Guideline	Section							Total reporting rate/%	General level
Guideline	Basic information/%	Background/%	Evidence/ %	Recommendations/%	Review and quality assurance/%	Funding and declaration and management of interests/%	Other information/%	Total reporting rate/%	General level
Mean reporting rate (x±s)	73.81±16.81	85.36± 18.56	60.60±31.99	69.80± 27.23	31.40± 45.51	56.43± 33.95	56.19±36.85	67.84±20.03	‒
AASM2006^[10]	50.00	87.50	60.00	85.71	0	25.00	100.00	65.71	Moderate
AASM2007^[11]	66.67	87.50	60.00	71.43	50.00	50.00	33.33	65.71	Moderate
AASM2008^[12]	83.33	87.50	60.00	57.14	0	50.00	33.33	62.86	Moderate
AASM2009^[13]	83.33	87.50	60.00	57.14	0	50.00	33.33	62.86	Moderate
CSOHNS2009^[29]	50.00	12.50	0	14.29	0	0	0	14.29	Low
CTS2011^[41]	83.33	75.00	100.00	71.43	0	100.00	66.67	77.14	High
CMA-CTS2012^[30]	83.33	62.50	0	28.57	0	0	0	34.29	Low
ACP2013^[14]	83.33	100.00	80.00	85.71	0	100.00	66.67	82.86	High
ACP2014^[15]	83.33	100.00	100.00	85.71	0	50.00	33.33	77.14	High
ASA2014^[16]	66.67	62.50	60.00	57.14	100.00	50.00	66.67	62.86	Moderate
INOSA2015^[39]	66.67	100.00	60.00	42.86	0	50.00	33.33	60.00	Moderate
AASM-AADSM2015^[17]	100.00	87.50	80.00	100.00	100.00	50.00	100.00	88.57	High
CMA2015^[31]	66.67	100.00	0	28.57	0	0	33.33	42.86	Moderate
DG-HNO-KHC2016^[37]	83.33	50.00	60.00	28.57	0	50.00	66.67	51.43	Moderate
SASM2016^[18]	83.33	100.00	80.00	100.00	0	75.00	100.00	85.71	High
AASM2017^[19]	83.33	100.00	100.00	100.00	0	75.00	100.00	88.57	High
ASMBS017^[20]	83.33	100.00	80.00	85.71	0	100.00	100.00	85.71	High
AASM-2017^[21]	66.67	87.50	0	57.14	0	75.00	0	51.43	Moderate
SASM2018^[22]	83.33	87.50	80.00	71.43	0	75.00	66.67	74.29	High
CMDA2018^[32]	66.67	87.50	60.00	42.86	0	0	0	48.57	Moderate
ATS2018^[23]	83.33	87.50	100.00	85.71	100.00	50.00	66.67	82.86	High
CMA-2018^[33]	83.33	62.50	0	14.29	0	25.00	0	34.29	Low
AASM2019^[24]	83.33	87.50	80.00	100.00	50.00	50.00	33.33	77.14	High
VA-DoD2020^[25]	100.00	100.00	80.00	85.71	0	75.00	66.67	82.86	High
NICE2021^[43]	16.67	62.50	40.00	57.14	0	0	33.33	37.14	Low
RRSDI2021^[40]	66.67	87.50	0	57.14	100.00	100.00	66.67	65.71	Moderate
JRS2021^[42]	66.67	100.00	80.00	100.00	100.00	100.00	33.33	85.71	High
AASM2021^[26]	83.33	87.50	40.00	85.71	0	50.00	100.00	71.43	High
AASM-2021^[27]	83.33	87.50	60.00	100.00	100.00	100.00	100.00	88.57	High
ERS2021^[44]	66.67	100.00	100.00	100.00	100.00	100.00	100.00	94.29	High
GSDSM2022^[38]	83.33	87.50	80.00	85.71	100.00	75.00	33.33	80.00	High
SFORL2022^[34]	66.67	100.00	60.00	85.71	100.00	75.00	100.00	82.86	High
USPSTF2022^[28]	83.33	100.00	80.00	85.71	0	100.00	100.00	85.71	High
SPLF2010^[35]	33.33	75.00	60.00	28.57	0	0	0	37.14	Low
SPLF2014^[36]	66.67	100.00	80.00	100.00	100.00	50.00	100.00	85.71	High