Elsevier

Journal of Clinical Epidemiology

Volume 139, November 2021, Pages 149-159
Journal of Clinical Epidemiology

Original article
The UpPriority tool supported prioritization processes for updating clinical guideline questions

https://doi.org/10.1016/j.jclinepi.2021.07.022Get rights and content

Highlights

  • Updating strategies can be optimized with prioritization processes that help identify CGs, CG sections, CQs, or recommendations in the greatest need for updating.

  • We recently developed the UpPriority tool, a pragmatic tool for prioritizing CG questions for updating. The tool was based on a published methodological systematic review and a multistep process involving relevant stakeholders.

  • We applied the UpPriority tool to a set of CGs using a step-by-step process that included: 1) establishment of the UpPriority Implementation Working Group, 2) mapping of the CG questions and recommendations, 3) development of a survey to prioritize CQs, 4) assessment of CQ's priority according to six items, 5) calculation and ranking of priority scores, 6) decision of prioritized CQs for updating, and 7) development of the priority report. We assessed the tool implementation process (appraisers’ experience when using the tool) and the inter-observer reliability of the tool, and we provided suggestions for improvement.

  • The UpPriority is a useful tool to identify which CQs within a CG need to be prioritized for update in a real-world scenario.

Abstract

Objective

We aim to 1) use the UpPriority tool to identify which clinical questions (CQs) within the clinical guidelines (CGs) need to be prioritized for updating and 2) assess the implementation of the tool in a real-world set of CGs.

Study Design and Setting

We systematically assessed CQs from a sample of CGs developed in the Spanish National Health System CG program. We applied the UpPriority tool to each CG using a step-by-step process that included: 1) establishment of the UpPriority Implementation Working Group, 2) mapping of the original CG questions and recommendations, 3) development of a survey to prioritize CQs, 4) assessment of CQ's priority according to six items, 5) calculation and ranking of priority scores, 6) decision of prioritized CQs for updating, and 7) development of the priority report. We assessed the tool implementation process (appraisers’ experience when using the tool) and the inter-observer reliability of the tool, and we provided suggestions for improvement.

Results

We included four CGs with a total of 107 CQs on the following topics: chronic heart failure (10 CQs), inherited retinal dystrophies (39 CQs), menopause (20 CQs), and open-angle glaucoma (38 CQs). We included a total of 30 participants, most of them clinicians that were members of the original CG development groups. CQs were classified in three groups: 1) high priority (CQs prioritized for updating [16/107; 15.0%]), 2) medium priority (CQs that could be prioritized for updating [47/107; 43.9%]), and low priority (CQs that were not prioritized for updating [44/107; 41.1%]). The mean time each appraiser needed to assess the CQs with the tool was 3.8 hours (range 0.5 to 10). Agreement among the appraisers varied among the CGs. Appraisers considered that the tool was useful. We suggest some areas for consideration when using the tool including: 1) identification of key appraisers, 2) customization of training materials, 3) establishment of priority thresholds, and 4) provision of methodological support.

Conclusion

The UpPriority is a useful tool to identify which CQs within a CG need to be prioritized for update in a real-world scenario. Recruitment and training of topic experts are the main challenges when using the tool.

Introduction

Prioritizing clinical questions (CQs) for update in the clinical guidelines (CG) can ensure that the limited resources available are invested in those areas more likely to benefit the health care system [1], [2], [3]. An update prioritization process is defined as the “assessment and ranking of CGs, within a defined collection of CGs, according to the need for updating” [4]. Updating strategies can be optimized by prioritization processes that help identify CGs, CG sections, CQs, or recommendations in the greatest need for update [3]. Recent reviews have summarized different prioritization processes and criteria across systematic reviews, health technology assessments and CGs [3], [4], [5], [6]. However, to date, there is suboptimal reporting of prioritization processes for updating [3].

We recently developed the UpPriority tool, a pragmatic tool for prioritizing CG questions for updating [7]. The tool consists of six priority items that must be assessed against all CQs in a CG. The six items are: 1) impact of outdated recommendations on safety, 2) availability of new relevant evidence, 3) context relevance of the CQ, 4) methodological applicability of the CQ, 5) users’ interest, and 6) impact on access to health care. The tool also includes guidance for using the tool and reporting the results.

Although the UpPriority tool has been already included in some methodological handbooks and methodological studies [8], [9], [10], it has not been yet formally implemented. We aim to 1) use the tool to identify which CQs within CGs need to be prioritized for updating and 2) assess the implementation of the tool in a real-world set of CGs.

Section snippets

Study design

We assessed CQs from a sample of CGs developed in the Spanish National Health System (NHS) CG Program (“section 2.2 Selection of the clinical guidelines”). We applied the UpPriority tool to each CG using a step-by-step process that included (“section 2.3 Assessment of clinical questions using UpPriority tool”): 1) establishment of the UpPriority Implementation Working Group (WG), 2) mapping of the original CG questions and recommendations, 3) development of a survey to prioritize CQs, 4)

Role of the funding source

The funding sources had no role in the study design, interpretation of data, writing of the manuscript, or submission for publication.

Institutional review board approval

This project received a waiver of approval from the Clinical Research Ethics Committee at the Hospital de la Santa Creu i Sant Pau (Barcelona, Spain).

Selection of the clinical guidelines

A total of eight CGs were included in the Spanish NHS CG Program portfolio between 2016 and 2017. Four CGs met the inclusion criteria: CG on chronic heart failure [12], CG on inherited retinal dystrophies [13], CG on management of vasomotor and vaginal symptoms associated with menopause and postmenopause [14], and CG on open-angle glaucoma [15]. The main characteristics of included CGs are described in Appendix A.

UpPriority Implementation Working Group

We contacted all the original GDG members (n = 54) and further new members (n

Discussion

We applied and tested the UpPriority tool in four CGs from the Spanish NHS and identified their prioritization needs for updating. The UpPriority Implementation WGs included a total of 30 participants who assessed 107 CQs within the included CGs. A total of 16 CQs were considered to have high priority for updating, 47 medium priority, and 44 low priority. The mean time each appraiser spent evaluating CQs with the tool was 3.8 hours (range 0.5 to 10). The degree of agreement among the appraisers

Conclusion

The UpPriority tool can be used to identify which clinical questions within a CG need to be prioritized for updating in a real-world scenario. Identification and training of appraisers is the main challenge to optimize the update prioritization process using the tool.

Up Priority Implementation Working Group

Alcocer Yuste, Pablo; Ayuso García, Carmen; Benatar Haserfaty, Jacobo; Blasco Suñé, Cristina; Bover Freire, Ramón; Carlos Gil, Ana María; Carreño Salas, Ester; Castany Aregall, Marta; Castellanos Rodríguez, Ángel; Duch, Susana; Gamarra Ortiz, Javier; Hernández Verdejo, José Luis; Jiménez Rolando, Belén; Llaneza Coto, Ángel Plácido; Martínez Férez, Isabel María; Martínez Sanz, Henar; Mendieta Rasós, Núria; Millán, José María; Mingorance Moya, Ester; Montilla Ortega, Manuel; Navero Rodríguez,

Data availability

Data will be made available on request — [email protected]

Grant support

This study has been funded by the Instituto de Salud Carlos III through the project “PI15/00325” (cofunded by the European Regional Development Fund/European Social Fund, “Investing in your future”). Laura Martínez García is funded by a Miguel Servet contract (CP18/00007) from the Instituto de Salud Carlos III (cofunded by the European Regional Development Fund/European Social Fund, “Investing in your future”).

Reproducible research statement

Study protocol: Available from Andrea Juliana Sanabria (e-mail: [email protected]). Statistical code used to generate results: Not applicable. Data set: Available from Andrea Juliana Sanabria (e-mail: https://[email protected]).

Acknowledgments

Andrea Juliana Sanabria Uribe is a doctoral candidate at the Pediatrics, Obstetrics and Gynecology and Preventive Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain. We want to acknowledge Judith Solà for her technical support with the online survey and Paloma Arriola, José Luis Castro, Dolores Estrada, Patricia Gavin, and Mar Trujillo for their support during the recruitment phase of the project.

References (20)

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Declaration of competing interest: Authors have disclosed no conflicts relevant of interest. The views expressed in this article are solely the authors’ and do not reflect those of their professional affiliations.

Author statement: Andrea Juliana Sanabria: Conceptualization, Methodology, Funding acquisition, Investigation, Data curation, Formal analysis, Visualization, Writing (original draft), Writing (review & editing). Pablo Alonso-Coello: Funding acquisition, Investigation, Writing (original draft), Writing (review & editing). Emma McFarlane: Funding acquisition, Investigation, Writing (original draft), Writing (review & editing). Ena Niño de Guzman: Funding acquisition, Investigation, Writing (original draft), Writing (review & editing). Marta Roqué: Funding acquisition, Investigation, Writing (original draft), Writing (review & editing). Laura Martínez García: Conceptualization, Methodology, Funding acquisition, Investigation, Formal analysis, Supervision, Visualization, Writing (original draft), Writing (review & editing).

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