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Quality of systematic reviews underpinning recommendations in hypertension guidelines.

Blog entry written on: Quality of systematic reviews supporting the 2017 ACC/AHA and 2018 ESC/ESH guidelines for the management of hypertension, (bmjebm-2021-111675.R1).

Authors: Raju Kanukula, Rupasvi Dhurjati, Vidyasagar Kota, Nusrath Rehana, Talari Arun, Abdul Salam, Anthony Rodgers, Matthew J Page.

Systematic reviews (SRs) and meta-analyses (MAs) play a crucial role in informing clinical practice guidelines, and are considered high-quality evidence to answer health care questions. Over time, efforts have been made to continuously improve the methodology and reporting of both SRs and clinical practice guidelines. Guideline developers such as the European Society of Cardiology (ESC), the European Society of Hypertension, the American College of Cardiology (ACC) and the American Heart Association (AHA) Task Force review, update and improve the methodology they use on an ongoing basis. In the last five years, developments in guidance for SRs have included updates to the AMSTAR critical appraisal tool, the PRISMA reporting checklist and conduct guidance by organisations such as Cochrane, Joanna Briggs Institute and the Campbell Collaboration. We were interested in investigating how well SRs of studies on the management of hypertension adhere to best-practice standards for SRs.

In our study, we assessed the methodological and reporting quality of SRs that were used to inform recommendations in the 2017 ACC/AHA and 2018 ESC/ESH guidelines for the management of hypertension. We found 40 SRs and MAs that informed Class 1 recommendations in both guidelines. We used the AMSTAR-2 checklist to assess methodological quality and the PRISMA 2009 checklist to assess reporting quality.

Based on the AMSTAR-2 assessment, only 7.5% of SRs were found to be of high methodological quality, 47.5% were of moderate quality, and 45% were of low or critically low quality. Based on the PRISMA 2009 checklist assessment, a mean of 24 out of 27 items (standard deviation 2.76) were reported, but only 9 items were reported in all reviews and only five of the 40 reviews reported all 27 items appropriately. Common methodological and reporting issues were the absence of protocol registration or publication, lack of an excluded studies list, lack of information on the source of funding for included studies and no integration of risk of bias assessments while interpreting the findings.

In addition, we found that the year of publication was associated with an increase in both AMSTAR-2 index scores and PRISMA 2009 index scores, suggesting that quality is improving over time.

Our study highlights opportunities to improve the strength of clinical practice guidelines by continuing to improve the evidence on which they are based. We recommend that all systematic review authors seek to use methods that minimise risk of bias in review findings (as described in appraisal tools such as AMSTAR-2 and ROBIS), and ensure they report the review in detail by addressing all PRISMA items to ensure their work can be correctly appraised and understood by guideline developers.

Image of hands writing in a notepad


Raju Kanukula

Image of editor Raju Kanukula. Raju is wearing a navy blazer with a white shirt with the top button open.

PhD Student
School of Public Health and Preventive Medicine, Monash University
Level 4, 553 St Kilda Road, Melbourne VIC 3004, Australia

COI: None to declare.


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