{"id":2363,"date":"2021-12-09T11:06:50","date_gmt":"2021-12-09T11:06:50","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjsrh\/?p=2363"},"modified":"2021-12-13T23:33:42","modified_gmt":"2021-12-13T23:33:42","slug":"agree-ii-is-an-agreeable-accessible-tool-to-assess-the-quality-of-trans-and-gender-minority-clinical-practice-guidelines","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjsrh\/2021\/12\/09\/agree-ii-is-an-agreeable-accessible-tool-to-assess-the-quality-of-trans-and-gender-minority-clinical-practice-guidelines\/","title":{"rendered":"AGREE II is an agreeable, accessible tool to assess the quality of trans and gender minority clinical practice guidelines"},"content":{"rendered":"

By Sara Dahlen, Dean Connolly, Isra Arif, Muhammad Hyder Junejo, Susan Bewley and Catherine Meads\u00a0<\/em><\/p>\n

Doctors trying to help their patients are bombarded with too much and often conflicting information. Well-developed clinical practice guidelines (CPGs) can help busy practitioners ground their real-world frontline care in properly considered, best available knowledge gained from high quality research. Nevertheless, CPGs vary, and doctors need to discern the good from the bad, the helpful from the promotional. A CPG emanating from the World Health Organization<\/a>, Britain\u2019s National Institute for Health and Care Excellence<\/a>, America\u2019s National Academy of Medicine<\/a> or Germany\u2019s Agency for Quality in Medicine<\/a> will likely have different and better methods, and thus authentic authority, compared to a consensus statement produced by, say, the International Society of Cosmetogynaecology<\/a>, an organisation \u201cdedicated to serving the needs of specialists\u201d and \u201cto enrich the member’s life both personally and professionally\u201d. CPGs may be subject to various forms of bias, vested interests, uncertainties, claims based on experts\u2019 eminence rather than scientific evidence, and they may lack methodological rigour. Thus, CPGs are worthy of quality assessment and scholarly scrutiny in-and-of themselves.<\/p>\n

What CPGs do is link the primary research studies that form the bedrock of evidence-based medicine<\/a> to clinical practice by making recommendations. They have a unique methodology. Thus, any appraisal of a CPG is not equivalent to the initial rigorous assessment of the scientific data that underpins the recommendations within said CPG; other frameworks such as GRADE<\/a> exist for this. CPG appraisal does not itself independently examine the strength and risks of bias of the evidence in the field within which a CPG sits, but it asks whether these guideline developers properly demonstrated that they<\/em> did so?<\/p>\n

One validated CPG appraisal tool is the revised Appraisal of Guidelines for Research and Evaluation instrument (AGREE II<\/a>). It was designed with the ordinary, interested clinician in mind.\u00a0 AGREE II allows structured evaluation of a CPG\u2019s quality through examination of 23 key items divided into 6 domains, plus an overall assessment. AGREE II assesses quality by giving higher scores to guideline developers who, for example: performed systematic reviews<\/a>, explicitly linked their recommendations to evidence, declared their interests and funding, included stakeholder views and considered resource implications. Guidelines are not \u2018tramlines\u2019 that tell doctors precisely how to practice. They are applicable most, but not all, of the time and must be applied judiciously. They are well developed in many countries as a means to drive up the quality of care and better outcomes, avoid overdiagnosis and overtreatment, promote financial and drug stewardship, as well as contain costs. There are many national<\/a> and<\/a> international producers<\/a> of guidelines, whose methods continuously \u00a0improve. In the UK, we even have a scheme whereby specialist societies can have their methods \u2018accredited\u2019 by NICE<\/a> – all working transparently for the patient\u2019s good.<\/p>\n

The blog authors came together as a team following what had started as a King\u2019s College London\u2019s medical student BSc<\/a> research training project. Working with a leading systematic reviewer<\/a>, one of the UK government\u2019s LGBT Health Taskforce<\/a> members, we wanted to find and assess the quality of international CPGs that covered any aspect of trans and gender minority people\u2019s healthcare and used AGREE II to do this. Gender transition related medical interventions are an area<\/a> of clinical<\/a> practice already acknowledged<\/a> to lack high quality<\/a> evidence<\/a> to inform CPGs. We were interested in all aspects of healthcare, throughout the life-course and assessed the quality of these CPGs as a whole. It is normal good practice for a systematic review to start broadly by looking for everything (as that identifies gaps), and with a pre-specified protocol<\/a> (as that minimises biases). We found a surprising variety of CPGs and sources<\/a>, but a paucity of CPGs covering more general aspects of trans and gender minority people\u2019s healthcare. Those CPGs that focused on transition-related interventions tended to be developed by special interest societies and scored lower on AGREE II. Those CPGs covering HIV and other blood-borne viral infections tended to be developed by the World Health Organisation and scored noticeably higher. \u00a0This led to our calling for better quality CPGs and research in the field, in order to cover a broader range of issues and address trans and gender minority people\u2019s holistic healthcare needs.<\/p>\n

Readers should be very confident in our findings and their interpretation, given they were improved by seven rigorous BMJ reviewers followed by presenting the work at both World Professional Association of Transgender Health<\/a> and Endocrine Society<\/a> conferences. \u00a0There have been thousands of reads and downloads <\/a>\u00a0and no objections. Although a blogger<\/a> recently charged us with interpreting \u201cthe science of treating trans youths with puberty blockers as \u2018experimental\u2019 and \u2018unethical\u2019\u201d, this was incorrect. Our paper did not address that question, nor make any such claims. The blog has since been amended. \u00a0We realised there may be some confusion or unfamiliarity as to how CPGs and their appraisal work. We warmly encourage anyone interested in CPGs and evidence-based medicine<\/a> to familiarise themselves with AGREE II. It is a helpful and easy-to-use instrument for anyone currently using CPGs in their practice and\/or involved with developing CPGs. The website even provides free training tools<\/a>.\u00a0 Aspiring medical students, academics and high-flyer clinicians will all find it useful as part of their toolkit for developing critical thinking<\/a> skills. It could form the basis of presentations, audits, analysis and publications even at an early stage in your medical career.<\/p>\n

Our paper could also form the basis of an educational<\/a> journal club<\/a>. If it\u2019s held at a reasonable hour in the UK, we\u2019d even try to be available to join you anywhere in the world and answer questions. Background work could be shared amongst a few students or doctors dividing, looking up, circulating and presenting; (i) the AGREE II tool and website<\/a>, (ii) our protocol<\/a>, (iii) the paper<\/a>, (iv) the supplementary materials<\/a>, and, finally (v) examining the \u2018first evidence-based process\u2019 methodology for a forthcoming decennial guideline<\/a> which is out for consultation<\/a> from WPATH<\/a> until 16th<\/sup> December 2021. You might consider whether the identified methodological concerns have been allayed or remain. Scrutinize the composition of the CPG\u2019s panel, the publicly available prespecified protocol and published systematic review results. How did the committee gather evidence, assess its quality (especially where there was no systematic review) and devise recommendations (called \u2018statements\u2019) linked to the supporting evidence? Did they obtain independent external peer review, and what are the plans regarding open publication of this current round of stakeholder comments and their replies? \u00a0How will AGREE II judge this next version?<\/p>\n

Finally, a note of caution. We have used our paper here as an educational \u2018worked example\u2019 of AGREE II, but trans and gender minority healthcare is by no means unique in terms of ending in a call for higher quality standards for CPGs. One of us wrote a commentary<\/a> on a published systematic review<\/a> of CPGs on uncomplicated births, noting similar themes and recent papers<\/a> have severely criticised consensus cardiology guidelines<\/a> as inappropriate or \u2018just do it\u2019<\/a>, thus harming patients.<\/p>\n

It would benefit the medical profession, particularly those parts using science and evidence, but most of all it would benefit patients, if we all agreed to use AGREE II more widely.<\/p>\n

 <\/p>\n

Authors:<\/strong><\/em><\/p>\n

Sara Dahlen, Department of Global Health & Social Medicine,\u00a0King’s College London,\u00a0London, UK \u00a0http:\/\/orcid.org\/0000-0002-1798-1816<\/a><\/em><\/p>\n

Dean Connolly, Visiting Researcher, National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, KCL King\u2019s College London, London UK. Foundation Doctor, Newham Centre for Mental Health, East London Foundation Trust http:\/\/orcid.org\/0000-0002-3139-4263<\/a><\/em><\/p>\n

Isra Arif,\u00a0 Basingstoke and North Hampshire Hospitals, UK http:\/\/orcid.org\/0000-0002-8623-2069<\/a> \u00a0 <\/em><\/p>\n

Muhammad Hyder Junejo, Homerton Anogenital Neoplasia Service, Homerton University Hospital,\u00a0London, UK http:\/\/orcid.org\/0000-0003-2458-9991<\/a> \u00a0 \u00a0<\/em><\/p>\n

Susan Bewley Department of Women and Children\u2019s Health, School of Life Course Sciences,\u00a0King’s College London,\u00a0London, UK http:\/\/orcid.org\/0000-0001-8064-652X<\/a><\/em><\/p>\n

Catherine Meads Faculty of Health, Medicine, Education and Social Care,\u00a0Anglia Ruskin University – Cambridge Campus,\u00a0Cambridge, UK http:\/\/orcid.org\/0000-0002-2368-0665<\/a><\/em><\/p>\n

Correspondence<\/strong> to\u00a0Professor Susan Bewley susan.bewley@kcl.ac.uk<\/a><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

By Sara Dahlen, Dean Connolly, Isra Arif, Muhammad Hyder Junejo, Susan Bewley and Catherine Meads\u00a0 Doctors trying to help their patients are bombarded with too much and often conflicting information. Well-developed clinical practice guidelines (CPGs) can help busy practitioners ground their real-world frontline care in properly considered, best available knowledge gained from high quality research. […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":444,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1131,15154],"tags":[],"class_list":["post-2363","post","type-post","status-publish","format-standard","hentry","category-guidelines","category-transgender-health"],"yoast_head":"\nAGREE II is an agreeable, accessible tool to assess the quality of trans and gender minority clinical practice guidelines - BMJ Sexual & Reproductive Health blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmjsrh\/2021\/12\/09\/agree-ii-is-an-agreeable-accessible-tool-to-assess-the-quality-of-trans-and-gender-minority-clinical-practice-guidelines\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"AGREE II is an agreeable, accessible tool to assess the quality of trans and gender minority clinical practice guidelines - BMJ Sexual & Reproductive Health blog\" \/>\n<meta property=\"og:description\" content=\"By Sara Dahlen, Dean Connolly, Isra Arif, Muhammad Hyder Junejo, Susan Bewley and Catherine Meads\u00a0 Doctors trying to help their patients are bombarded with too much and often conflicting information. 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Well-developed clinical practice guidelines (CPGs) can help busy practitioners ground their real-world frontline care in properly considered, best available knowledge gained from high quality research. 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