1Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
Open access
Reporting specifications regarding epilepsy practice guidelines based on the RIGHT reporting checklist: an analysis
Zhijie Wang,1,2 Yu Zhang,1 Wei Guo,3 Xiaoyang Mio Hu,2 Xiao Gao,4 Liming Lu1
To cite: Wang Z, Zhang Y, Guo W, et al. Reporting specifications regarding epilepsy practice guidelines based on the RIGHT reporting checklist: an analysis. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
► Prepublication history for this paper is available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2019- 029589).
ZW and YZ contributed equally.
Received 02 February 2019Revised 02 August 2019Accepted 23 September 2019
For numbered affiliations see end of article.
Correspondence toProfessor Xiao Gao; gaoxiaohlj@ 163. com
Dr Liming Lu; lulimingleon@ 126. com
Original research
© Author(s) (or their employer(s)) 2019. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.
AbstrACtObjective Clinical guidelines are designed to optimise patient care and provide efficient approaches for therapy. Epilepsy is a chronic brain disorder that continues to experience a considerable treatment gap due to non- standard recommendations. We assessed the reporting quality of clinical practice guidelines on epilepsy over the past 5 years to generate a reporting specification for this study.setting Seven databases were searched in May 2018 focusing on the period from 2013 to 2018. These included Medline, EMBASE, PubMed, Cumulative Index to Nursing and Allied Health Literature, China National Knowledge Infrastructure, Wanfang and Chinese Science and Technology Journal Database (VIP). Reporting quality of epilepsy guidelines was assessed by two independent authors using the Reporting Items for practice Guidelines in HealThcare (RIGHT) approach. Spearman’s correlation was used to assess inter- rater reliability.Participants Participants with epilepsy or seizure, not limited by age, gender, course of disease or cause of epilepsy, were included.Interventions There were no limitations with regard to intervention.Primary and secondary outcome measures The outcome was the ability of the RIGHT tool to measure reporting quality.results Twelve relevant guidelines were included in this study. The reporting quality was not high in any of the included guidelines. The highest reporting quality included a ‘yes’ proportion of 77.1%, whereas the worst included a corresponding proportion of 37.1%. Overall evaluation results showed that 16.7% of the included guidelines were of high quality, 75% were of medium quality and 8.3% were of low quality. The correlation between the two estimators was credible (ρ>0.7).Conclusions Appraisal of these guidelines using the RIGHT tool revealed that the quality of reporting varied among guidelines. Items that exhibited low quality in most included guidelines were healthcare questions, rationale/explanation for recommendations, quality assurance, funding source(s) and role(s) of the funder, and limitations of the guideline. Thus, these aspects should receive greater attention in future guideline reporting.
IntrOduCtIOnEpilepsy is a chronic, repeating, relapsing neurological brain disorder with high inci-dence and mortality rates, and the disorder can affect any individual irrespective of age, region and ethnicity.1 2 According to WHO in 2014, there are approximately 50 million patients with epilepsy worldwide, with the disease morbidity rate being 4‰−7‰. Compared with adults, children and adoles-cents have a higher prevalence but a lower mortality rate. An earlier study reported that mortality from the disorder was up to 3% in American children, but more than 30% in American adults.3 Although the disorder can be controlled in most patients by appro-priate therapy, some (especially those living in developing countries) are not able to receive appropriate treatment for reasons such as poor income, cognitive deficiencies and healthcare costs. In China, for example, the treatment gap is approximately 63%, implying that about four million patients do not receive the recommended treatment for epilepsy.4
strengths and limitations of this study
► To the best of our knowledge, no studies have assessed the quality of epilepsy guidelines us-ing the Reporting Items for practice Guidelines in HealThcare (RIGHT) checklist.
► The included guidelines were measured using the RIGHT tool, produced by the Practice Guidelines in Healthcare Group, a component of WHO.
► Twelve relevant guidelines, involving six regions, were included in this study.
► The study showed insufficient reporting quality in some areas.
► This study indicates that greater attention is needed with regard to healthcare questions, rationale/expla-nation for recommendations, quality assurance, and funding source(s) and role(s) of the funder in future guidelines reporting.
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2 Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
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Clinical guidelines based on high- quality systematic review evidence assessed the benefits and limitations of alternative care options for facilitating optimised patient care and effective therapy approaches.5 With increasing worldwide attention to epilepsy, a growing body of clin-ical guidelines are available. However, these guidelines are not standardised, varying in terms of the respective country’s definition of epilepsy. Although clinical guide-lines allow for standardising and improving the quality of clinical practice, questions on guideline development and reporting remain unanswered.6 7 Ineffective treat-ment methods for epilepsy persist because of unclear pathogenesis and lack of quality, standardised clinical guidelines. An instructive clinical guideline should be based on high- quality evidence- based systematic reviews and reporting. However, the reporting quality of clinical guidelines seems low,8 and the currently used tools do not accurately address quality assessment and reporting in a single statement. There are two reporting checklists avail-able for clinical guidelines: one is the Appraisal of Guide-lines, Research and Evaluation instrument (AGREE) and another is the Reporting Items for practice Guidelines in HealThcare (RIGHT). AGREE, developed by a small group, was produced for use in both quality assessment and reporting, although it was limited to items derived from the tool itself (rather than other assessments).9 To construct a specific clinical guideline and fill the gap in current assessment approaches, Chen and colleagues10 from the WHO established the RIGHT tool.
In this review, we analyse the reporting quality of epilepsy practice guidelines based on the RIGHT tool. This will help identify insufficient reporting section to better guide clinical control of epilepsy.
MethOdsstudy designThis study comprised a review of epilepsy clinical practice guidelines (CPG) using the RIGHT tool.
review protocolThis study was performed in accordance with the guide-lines of the Preferred Reporting Items for Systematic Reviews and Meta- Analyses.11
eligibility criteriaTypes of guidelinesGuidelines that focused on preventive and/or thera-peutic intervention in epilepsy were included, whereas those solely describing epidemiology, training, research methods or legal issues regarding epilepsy were excluded. Furthermore, summarised organisational guidelines, comments or correspondence studies were excluded.
Types of participants and public involvementThere were no patients involved in this study. In this study, we focused on guidelines and not participants them-selves, which needs no ‘Patient and Public Involvement’.
In those included guidelines, participants with epilepsy or seizure, regardless of age, gender, course of disease or cause of epilepsy (eg, caused by pregnancy or trauma), were included.
Types of interventionsThere were no limitations with regard to interventions. Drug therapies and non- drug therapies recommended in the guidelines were included.
Literature searchGuidelines meeting the eligibility criteria were searched in English and Chinese using a computer program to avoid subjective interpretation. Seven databases, Medline, EMBASE, PubMed, Cumulative Index to Nursing and Allied Health Literature, China National Knowledge Infrastructure, Wanfang and Chinese Science and Tech-nology Journal Database (VIP), were searched for articles published from January 2013 to December 2018. The search strategy used the terms ‘epilepsy’ or ‘seizure’ (‘癫痫’) AND ‘guideline’ or ‘guidance’ or ‘recommendation’ or ‘consensus’ or ‘policy’ (‘指南’ or ‘专家共识’). We also searched Medline, a publicly available repository of guide-lines in China (http:// guide. medlive. cn), using keyword searches based on the eligibility criterion of ‘epilepsy’ (‘癫痫’). Concomitantly, the National Guideline Clear-inghouse (http://www. guideline. gov), National Insti-tute for Health and Care Excellence (http://www. nice. org. uk), International League Against Epilepsy (ILAE) (http://www. ilae. org) and WHO (http://www. who. int) were searched using the terms ‘epilepsy’ or ‘seizure’ AND ‘guideline’. Two authors (ZW and YZ) screened the titles and abstracts independently to standardise screening, and selection differences, if any, were resolved through discussion. Full texts were screened to confirm eligibility.
data extractionThe following information was extracted from each guideline: title of the guideline, region(s) of guideline development, year of publication, source of publication, organisation(s) responsible for the guideline, number of authors, target population, funding, guideline focus and whether it was an update of a previous edition. Other information pertaining to guideline format included basic information, background, evidence, recommenda-tions, review and quality assurance, funding, declaration and management of interests, and other information (eg, suggestions for further research and limitations of the guideline).
Assessment of the quality of reportingThe RIGHT tool is a checklist that can be used to assess the reporting quality of CPG, and aids in understanding and implementation of clinical guidelines, serves as a standard for guideline reporting in peer reviews (ie, for reviewers and journal editors), and assists developers in guideline reporting.10 The RIGHT tool consists of seven sections: basic information (items 1–4), background (items 5–9), evidence (items 10–12), recommendation (items 13–15),
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3Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
Open access
Figure 1 PRISMA flow diagram for this study. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta- Analyses; RIGHT, Reporting Items for practice Guidelines in HealThcare.
review and quality assurance (items 16–17), funding and declaration and management of interests (items 18–19), and other information (items 20–22). Assessment was performed by two authors (ZW and YZ); ‘yes’ indicated full reporting of necessary information, whereas ‘no’ indi-cated partial or no reporting. We defined reporting to be of high quality if the ‘yes’ responses were >70%, medium quality if they were 40%–70% and low quality if they were 0.7 indicated good inter- rater reli-ability). If opinions differed, a third author (LL) made a final decision. The percentage of fully reported items was expressed to assess reporting quality of guidelines.
data analysis and investigation of heterogeneityData were analysed using SPSS V.19.0 and Microsoft Excel (Microsoft, Redmond, Washington, USA). The descrip-tive results are shown in tables. Inter- rater reliability was calculated for each domain of the RIGHT instrument using intraclass correlation coefficient with a ρ value.
resuLtsOf the total 938 potentially relevant articles identified, 883 were excluded after title and abstract screening. The remaining 55 were retrieved and full texts were read,
resulting in 12 guidelines that met the inclusion criteria (figure 1).
Guideline characteristicsThe characteristics of the included guidelines12–23 are detailed in table 1. Of the included guidelines, one16 produced by the ILAE was an international guideline, one20 established by the ILAE- Commission on European Affairs focused on women and girls with epilepsy in Europe, one19 was published for neonatal seizure in Australia, two were published in the USA (one15 focused on vagus nerve stimulation and the other17 focused on convulsive status epilepticus), two were published in the UK (one14 was published in Scotland not focused on epilepsy in pregnancy and the other18 placed emphasis on epilepsy in pregnancy all over the UK), and four were published in China (three12 21 22 were produced in mainland China and one14 was produced in Hong Kong). One22 guide-line referred to treatments involving traditional Chinese medicine (TCM), but was limited to a summary of this approach; another was a guideline established for TCM clinical diagnosis and treatment of paediatric patients, including a detailed description of TCM treatments for children with epilepsy; and one23 guideline focused on presurgical epilepsy work- up. The correlation between the
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4 Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
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Tab
le 1
G
uid
elin
e ch
arac
teris
tics
Tit
le o
f g
uid
elin
eR
egio
n(s)
of
pub
licat
ion
Year
of
pub
licat
ion
So
urce
of
pub
licat
ion
Org
anis
atio
n(s)
re
spo
nsib
le f
or
gui
del
ine
Aut
hors
(n)
Targ
et
po
pul
atio
nFu
ndin
g
Pre
vio
us
edit
ion
upd
atin
g
Clin
ical
pra
ctic
e gu
idel
ine1
2C
hina
2015
Jour
nal o
f Ep
ilep
sy, P
eop
le’s
Med
ical
Pub
lishi
ng H
ouse
CA
AE
63A
dul
tN
RYe
s, 2
006
An
upd
ate
of t
he H
ong
Kon
g E
pile
psy
Gui
del
ine:
co
nsen
sus
stat
emen
t on
th
e us
e of
ant
iep
ilep
tic
dru
gs in
Hon
g K
ong1
3
Chi
na, H
ong
Kon
g20
17H
ong
Kon
g M
edic
al J
ourn
al (h
ttp
s://
ww
w.h
kmj.o
rg)
HK
ES
14A
dul
t an
d
child
ren
Hon
g K
ong
Ep
ilep
sy
Soc
iety
Yes,
200
9
Dia
gnos
is a
nd
man
agem
ent
of e
pile
psy
in
adul
ts. A
nat
iona
l clin
ical
gu
idel
ine1
4
Sco
tland
, UK
2015
SIG
N p
ublic
atio
n no
143
(htt
ps:
//w
ww
.sig
n.ac
.uk/
guid
elin
es/f
ullte
xt/5
0/in
dex
.htm
l)S
IGN
26A
dul
tN
RN
o
Evi
den
ce- b
ased
gu
idel
ine
upd
ate:
va
gus
nerv
e st
imul
atio
n fo
r th
e tr
eatm
ent
of
epile
psy
: rep
ort
of t
he
Gui
del
ine
Dev
elop
men
t S
ubco
mm
ittee
of t
he
Am
eric
an A
cad
emy
of
Neu
rolo
gy15
US
A20
13N
euro
logy
(htt
p:/
/ww
w.n
euro
logy
.org
/con
tent
/ear
ly/2
013/
08/2
8/W
NL.
0b01
3e31
82a3
93d
1.fu
ll.ht
ml)
AA
N6
Ad
ult
and
ch
ildre
nA
AN
Yes,
199
9
Up
dat
ed IL
AE
evi
den
ce
revi
ew o
f ant
iep
ilep
tic d
rug
effic
acy
and
effe
ctiv
enes
s as
initi
al m
onot
hera
py
for
epile
ptic
sei
zure
s an
d
synd
rom
es16
Inte
rnat
iona
l20
13E
pile
psi
aIL
AE
10A
dul
t an
d
child
ren
ILA
E, N
IH,
Ep
ilep
sy
Res
earc
h Fo
und
atio
n
Yes,
200
6
Evi
den
ce- b
ased
gui
del
ine:
tr
eatm
ent
of c
onvu
lsiv
e st
atus
ep
ilep
ticus
in
child
ren
and
ad
ults
: rep
ort
of t
he G
uid
elin
e C
omm
ittee
of
the
Am
eric
an E
pile
psy
S
ocie
ty17
US
A20
16E
pile
psy
Cur
rent
sA
ES
16A
dul
t an
d
child
ren
Ep
ilep
sy
Foun
dat
ion,
C
hild
N
euro
logy
S
ocie
ty,
Am
eric
an
Col
lege
of
Em
erge
ncy
Phy
sici
ans,
A
ssoc
iatio
n of
Chi
ld
Neu
rolo
gy
Nur
ses,
A
mer
ican
A
ssoc
iatio
n of
N
euro
scie
nce
Nur
ses
No
Con
tinue
d
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https://%20www.hkmj.orghttps://www.sign.ac.uk/guidelines/fulltext/50/index.html.http://www.neurology.org/content/early/2013/08/28/WNL.0b013e3182a393d1.full.htmlhttp://www.neurology.org/content/early/2013/08/28/WNL.0b013e3182a393d1.full.htmlhttp://bmjopen.bmj.com/
5Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
Open access
Tit
le o
f g
uid
elin
eR
egio
n(s)
of
pub
licat
ion
Year
of
pub
licat
ion
So
urce
of
pub
licat
ion
Org
anis
atio
n(s)
re
spo
nsib
le f
or
gui
del
ine
Aut
hors
(n)
Targ
et
po
pul
atio
nFu
ndin
g
Pre
vio
us
edit
ion
upd
atin
g
Ep
ilep
sy in
pre
gnan
cy.
Gre
en- t
op G
uid
elin
e N
o 68
18
UK
2016
http
s://
ww
w.n
ice.
org.
ukR
CO
G6
Wom
en in
p
regn
ancy
Ass
ocia
tion
of B
ritis
h N
euro
logi
sts,
E
pile
psy
A
ctio
n, R
oyal
C
olle
ge o
f G
ener
al
Pra
ctiti
oner
s,
Roy
al C
olle
ge
of M
idw
ives
an
d t
he R
oyal
C
olle
ge o
f P
hysi
cian
s
No
Que
ensl
and
Clin
ical
G
uid
elin
es: n
eona
tal
seiz
ure1
9
Aus
tral
ia20
17ht
tps:
//w
ww
.hea
lth.q
ld.g
ov.a
u/q
cgQ
CG
37N
eona
tal
Hea
lthca
re
Imp
rove
men
t U
nit,
Q
ueen
slan
d
Hea
lth
Yes,
201
1
Valp
roat
e in
the
tr
eatm
ent
of e
pile
psy
in
girl
s an
d w
omen
of
child
bea
ring
pot
entia
l: re
com
men
dat
ions
from
a
join
t ta
sk fo
rce
of IL
AE
- C
omm
issi
on o
n E
urop
ean
Affa
irs a
nd E
AN
20
Eur
opea
n20
15E
pile
psi
aIL
AE
- C
omm
issi
on o
n E
urop
ean
Affa
irs,
EA
N
8W
omen
and
gi
rlsC
EA
- ILA
E,
EA
NN
o
Exp
ert
cons
ensu
s: lo
ng-
term
man
agem
ent
of
epile
psy
in c
hild
ren2
1
Chi
na20
13C
hine
se J
ourn
al o
f Pae
dia
tric
s(h
ttp
://d
.wan
fang
dat
a.co
m.c
n/P
erio
dic
al_z
hek2
0130
9016
.asp
x)C
MA
29C
hild
ren
NR
No
Gui
del
ine
for
TCM
p
edia
tric
s cl
inic
al d
iagn
osis
an
d t
reat
men
t p
edia
tric
ep
ilep
sy (a
men
dm
ent)2
2
Chi
na20
17Jo
urna
l of P
aed
iatr
ics
of T
CM
CA
CM
12C
hild
ren
SAT
CM
Yes,
201
4
Rev
ised
ver
sion
of q
ualit
y gu
idel
ines
for
pre
surg
ical
ep
ilep
sy e
valu
atio
n an
d
surg
ical
ep
ilep
sy t
hera
py
issu
ed b
y th
e A
ustr
ian,
G
erm
an a
nd S
wis
s w
orki
ng
grou
p o
n p
resu
rgic
al
epile
psy
dia
gnos
is
and
op
erat
ive
epile
psy
tr
eatm
ent2
3
Aus
tria
, G
erm
any
and
S
witz
erla
nd
2016
Ep
ilep
sia
WG
14P
resu
rgic
al
epile
psy
NR
Yes,
201
4
AA
N, A
mer
ican
Aca
dem
y of
Neu
rolo
gy; A
ES
, Am
eric
an E
pile
psy
Soc
iety
; CA
AE
, Chi
na A
ssoc
iatio
n A
gain
st E
pile
psy
; CA
CM
, Chi
na A
ssoc
iatio
n of
Chi
nese
Med
icin
e; C
EA
- ILA
E, C
omm
issi
on o
f Eur
opea
n A
ffairs
of t
he In
tern
atio
nal L
eagu
e A
gain
st
Ep
ilep
sy; C
MA
, Chi
nese
Med
ical
Ass
ocia
tion;
EA
N, E
urop
ean
Aca
dem
y of
Neu
rolo
gy; H
KE
S, H
ong
Kon
g E
pile
psy
Soc
iety
; ILA
E, I
nter
natio
nal L
eagu
e A
gain
st E
pile
psy
; NIH
, Nat
iona
l Ins
titut
es o
f Hea
lth; N
R, n
ot r
epor
ted
; QC
G, Q
ueen
slan
d C
linic
al
Gui
del
ines
; RC
OG
, Roy
al C
olle
ge o
f Ob
stet
ricia
ns a
nd G
ynae
colo
gist
s; S
ATC
M, S
tate
Ad
min
istr
atio
n of
Tra
diti
onal
Chi
nese
Med
icin
e; S
IGN
, Sco
ttis
h In
terc
olle
giat
e G
uid
elin
es N
etw
ork;
TC
M, t
rad
ition
al C
hine
se m
edic
ine;
WG
, exe
cutiv
e b
oard
of
the
wor
king
gro
up (W
G) o
n p
resu
rgic
al e
pile
psy
dia
gnos
is a
nd o
per
ativ
e ep
ilep
sy t
reat
men
t.
Tab
le 1
C
ontin
ued
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6 Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
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Table 2 Assessment Spearman’s correlation (ρ) of every item
Items CriteriaNumber of ‘yes’ %
Spearman’s correlation (ρ)
Basic information
1 Title/subtitle 12 100 0.90
2 Executive summary 12 100 0.90
3 Abbreviations and acronyms
12 100 0.87
4 Corresponding developer
10 83.3 0.84
Background
5 Brief description of the health problem(s)
10 83.3 0.86
6 Aim(s) of the guideline and specific objectives
10 83.3 0.84
7 Target population(s) 9 75 0.81
8 End users and settings 3 25 0.81
9 Guideline development groups
5 41.7 0.78
Evidence
10 Healthcare questions 0 0 0.82
11 Systematic reviews 11 91.6 0.73
12 Assessment of the certainty of the body of evidence
6 50 0.71
Recommendations
13 Recommendations 6 50 0.76
14 Rationale/explanation for recommendations
0 0 0.77
15 Evidence to decision processes
2 16.7 0.72
Review and quality assurance
16 External review 6 50 0.88
17 Quality assurance 1 8.3 0.97
Funding and declaration and management of interests
18 Funding source(s) and role(s) of the funder
2 16.7 0.91
19 Declaration and management of interests
4 33.3 0.82
Other information
20 Access 10 83.3 0.87
21 Suggestions for further research
4 33.3 0.82
22 Limitations of the guideline
1 8.3 0.93
two estimators is shown in table 2, and the ρ of each item was >0.7, indicating the robustness of this study results.
Quality of reporting evaluation by rIGhtThe quality of guideline reporting was evaluated using the RIGHT tool; notably, most included guidelines did not show high reporting quality (table 3). We assessed each
item in strict accordance with the standard and calculated the percentage of fully reported items. The best reporting quality achieved a score of 77.1%,18 whereas the worst achieved a score of 37.1%.21 Overall evaluation results showed that 16.7% of included guidelines were of high quality, 75% were of medium quality and 8.3% were of low quality (figure 2).
basic informationIn general, all included guidelines showed sufficient reporting of basic information. Only two12 14 did not report any corresponding developers or authors, whereas others fully reported the title, executive summary, abbre-viations and corresponding information.
backgroundBackground was not adequately reported in any of the included guidelines; notably, two16 22 did not describe the epidemiology of epilepsy, two19 22 did not clearly describe the aim of the guidelines, three12 18 21 had no subgroups, one19 did not explicitly describe the intended primary and potential users, two13 21 did not describe the specific roles of authors who contributed to guideline develop-ment, and four12 15 16 21 did not list the identity informa-tion of authors. Furthermore, only two12 13 guidelines were intended to focus on low- income regions.
evidenceReporting of evidence was inadequate. Although most included guidelines stated that they were developed based on randomised controlled trials or meta- analyses, none included regular reporting of population, intervention, comparator and outcome. Four guidelines13 14 21 23 did not indicate the manner in which outcomes were selected, and it was unclear whether those guidelines were the first version or an updated version.21 Five16–19 22 included guidelines assessed evidence in accordance with the Grading of Recommendations Assessment, Development and Evaluation approach.
recommendationClear and actionable recommendations were provided in all guidelines; however, four12 19–21 did not clearly indi-cate the strength of each recommendation, only one22 considered feedback from children with epilepsy and their parents (ie, through follow- up and online survey), two16 22 emphasised that guideline development groups had made decisions through repeated discussions, and only two guidelines18 23 included equity when formulating its recommendations.
review and quality assuranceSix guidelines12 14 18–20 22 had been peer- reviewed, and only one16 had undergone quality assurance process.
Funding and declaration and management of interestsThree guidelines12 14 21 did not describe the funding sources, whereas two15 16 precisely declared that the stakeholder did not participate in the development of
on October 1, 2020 by guest. P
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MJ O
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ecember 2019. D
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7Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
Open access
Tab
le 3
Q
ualit
y of
rep
ortin
g ev
alua
tion
by
RIG
HT
(eac
h ite
m)
Sec
tio
n/to
pic
Num
ber
Item
Ass
essm
ent
1213
1415
1617
1819
2021
2223
Bas
ic in
form
atio
n
Title
/sub
title
1aId
entif
y th
e re
por
t as
a g
uid
elin
e,
that
is, w
ith ‘g
uid
elin
e(s)
’ or
‘rec
omm
end
atio
n(s)
’ in
the
title
.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1bD
escr
ibe
the
year
of p
ublic
atio
n of
th
e gu
idel
ine.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1cD
escr
ibe
the
focu
s of
the
gu
idel
ine,
suc
h as
scr
eeni
ng,
dia
gnos
is, t
reat
men
t m
anag
emen
t,
pre
vent
ion
or o
ther
s.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Exe
cutiv
e su
mm
ary
2P
rovi
de
a su
mm
ary
of t
he
reco
mm
end
atio
ns c
onta
ined
in t
he
guid
elin
e.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Ab
bre
viat
ions
and
ac
rony
ms
3D
efine
new
or
key
term
s, a
nd
pro
vid
e a
list
of a
bb
revi
atio
ns a
nd
acro
nym
s if
app
licab
le.
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Cor
resp
ond
ing
dev
elop
er4
Iden
tify
at le
ast
one
corr
esp
ond
ing
dev
elop
er o
r au
thor
who
can
be
cont
acte
d a
bou
t th
e gu
idel
ine.
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Bac
kgro
und
Brie
f des
crip
tion
of t
he h
ealth
p
rob
lem
(s)
5D
escr
ibe
the
bas
ic e
pid
emio
logy
of
the
pro
ble
m, s
uch
as t
he
pre
vale
nce/
inci
den
ce, m
orb
idity
, m
orta
lity
and
bur
den
(inc
lud
ing
finan
cial
) res
ultin
g fr
om t
he
pro
ble
m.
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Aim
(s) o
f the
gu
idel
ine
and
sp
ecifi
c ob
ject
ives
6D
escr
ibe
the
aim
(s) o
f the
gu
idel
ine
and
sp
ecifi
c ob
ject
ives
, su
ch a
s im
pro
vem
ents
in h
ealth
in
dic
ator
s (e
g, m
orta
lity
and
d
isea
se p
reva
lenc
e), q
ualit
y of
life
or
cos
t sa
ving
.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Targ
et p
opul
atio
n(s)
7aD
escr
ibe
the
prim
ary
pop
ulat
ion(
s) t
hat
is a
ffect
ed b
y th
e re
com
men
dat
ion(
s) in
the
gu
idel
ine.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
7bD
escr
ibe
any
sub
grou
ps
that
are
gi
ven
spec
ial c
onsi
der
atio
n in
the
gu
idel
ine.
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Con
tinue
d
on October 1, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2019-029589 on 3 D
ecember 2019. D
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http://bmjopen.bmj.com/
8 Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
Open access
Sec
tio
n/to
pic
Num
ber
Item
Ass
essm
ent
1213
1415
1617
1819
2021
2223
End
use
rs a
nd
sett
ings
8aD
escr
ibe
the
inte
nded
prim
ary
user
s of
the
gui
del
ine
(suc
h as
prim
ary
care
pro
vid
ers,
cl
inic
al s
pec
ialis
ts, p
ublic
hea
lth
pra
ctiti
oner
s, p
rogr
amm
e m
anag
ers
and
pol
icym
aker
s)
and
oth
er p
oten
tial u
sers
of t
he
guid
elin
e.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
8bD
escr
ibe
the
sett
ing(
s) fo
r w
hich
th
e gu
idel
ine
is in
tend
ed, s
uch
as p
rimar
y ca
re, l
ow- i
ncom
e an
d m
idd
le- i
ncom
e co
untr
ies,
or
inp
atie
nt fa
cilit
ies.
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Gui
del
ine
dev
elop
men
t gr
oup
s
9aD
escr
ibe
how
all
cont
ribut
ors
to t
he g
uid
elin
e d
evel
opm
ent
wer
e se
lect
ed a
nd t
heir
role
s an
d r
esp
onsi
bili
ties
(eg,
ste
erin
g gr
oup
, gui
del
ine
pan
el, e
xter
nal
revi
ewer
s, s
yste
mat
ic r
evie
w t
eam
an
d m
etho
dol
ogis
ts).
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
9bLi
st a
ll in
div
idua
ls in
volv
ed in
d
evel
opin
g th
e gu
idel
ine,
incl
udin
g th
eir
title
, rol
e(s)
and
inst
itutio
nal
affil
iatio
n(s)
.
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
Yes
No
Evi
den
ce
Hea
lthca
re
que
stio
ns10
aS
tate
the
key
que
stio
ns t
hat
wer
e th
e b
asis
for
the
reco
mm
end
atio
ns
in P
ICO
(pop
ulat
ion,
inte
rven
tion,
co
mp
arat
or a
nd o
utco
me)
or
othe
r fo
rmat
as
app
rop
riate
.
No
No
No
No
No
No
No
No
No
No
No
No
10b
Ind
icat
e ho
w t
he o
utco
mes
wer
e se
lect
ed a
nd s
orte
d.
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Tab
le 3
C
ontin
ued
Con
tinue
d
on October 1, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2019-029589 on 3 D
ecember 2019. D
ownloaded from
http://bmjopen.bmj.com/
9Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
Open access
Sec
tio
n/to
pic
Num
ber
Item
Ass
essm
ent
1213
1415
1617
1819
2021
2223
Sys
tem
atic
rev
iew
s11
aIn
dic
ate
whe
ther
the
gui
del
ine
is
bas
ed o
n ne
w s
yste
mat
ic r
evie
ws
don
e sp
ecifi
cally
for
this
gui
del
ine
or w
heth
er e
xist
ing
syst
emat
ic
revi
ews
wer
e us
ed.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
11b
If th
e gu
idel
ine
dev
elop
ers
used
ex
istin
g sy
stem
atic
rev
iew
s,
refe
renc
e th
ese
and
des
crib
e ho
w
thos
e re
view
s w
ere
iden
tified
and
as
sess
ed (p
rovi
de
the
sear
ch
stra
tegi
es a
nd t
he s
elec
tion
crite
ria, a
nd d
escr
ibe
how
the
ris
k of
bia
s w
as e
valu
ated
) and
w
heth
er t
hey
wer
e up
dat
ed.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Ass
essm
ent
of t
he
cert
aint
y of
the
b
ody
of e
vid
ence
12D
escr
ibe
the
app
roac
h us
ed t
o as
sess
the
cer
tain
ty o
f the
bod
y of
ev
iden
ce.
No
No
No
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Rec
omm
end
atio
ns
Rec
omm
end
atio
ns13
aP
rovi
de
clea
r, p
reci
se a
nd
actio
nab
le r
ecom
men
dat
ions
.Ye
sYe
sYe
sYe
sYe
sYe
sYe
sYe
sYe
sYe
sYe
sYe
s
13b
Pre
sent
sep
arat
e re
com
men
dat
ions
for
imp
orta
nt
sub
grou
ps
if th
e ev
iden
ce
sugg
ests
tha
t th
ere
are
imp
orta
nt
diff
eren
ces
in fa
ctor
s in
fluen
cing
re
com
men
dat
ions
, par
ticul
arly
the
b
alan
ce o
f ben
efits
and
har
ms
acro
ss s
ubgr
oup
s.
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
13c
Ind
icat
e th
e st
reng
th o
f re
com
men
dat
ions
and
the
ce
rtai
nty
of t
he s
upp
ortin
g ev
iden
ce.
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Tab
le 3
C
ontin
ued
Con
tinue
d
on October 1, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2019-029589 on 3 D
ecember 2019. D
ownloaded from
http://bmjopen.bmj.com/
10 Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
Open access
Sec
tio
n/to
pic
Num
ber
Item
Ass
essm
ent
1213
1415
1617
1819
2021
2223
Rat
iona
le/
exp
lana
tion
for
reco
mm
end
atio
ns
14a
Des
crib
e w
heth
er v
alue
s an
d p
refe
renc
es o
f the
tar
get
pop
ulat
ion(
s) w
ere
cons
ider
ed
in t
he fo
rmul
atio
n of
eac
h re
com
men
dat
ion.
If y
es, d
escr
ibe
the
app
roac
hes
and
met
hod
s us
ed
to e
licit
or id
entif
y th
ese
valu
es
and
pre
fere
nces
. If v
alue
s an
d
pre
fere
nces
wer
e no
t co
nsid
ered
, p
rovi
de
an e
xpla
natio
n.
No
No
No
No
No
No
No
No
No
No
Yes
Yes
14b
Des
crib
e w
heth
er c
ost
and
re
sour
ce im
plic
atio
ns w
ere
cons
ider
ed in
the
form
ulat
ion
of r
ecom
men
dat
ions
. If y
es,
des
crib
e th
e sp
ecifi
c ap
pro
ache
s an
d m
etho
ds
used
(suc
h as
co
st- e
ffect
iven
ess
anal
ysis
) and
su
mm
aris
e th
e re
sults
. If r
esou
rce
issu
es w
ere
not
cons
ider
ed,
pro
vid
e an
exp
lana
tion.
No
No
No
No
No
No
No
No
No
No
Yes
No
14c
Des
crib
e ot
her
fact
ors
take
n in
to
cons
ider
atio
n w
hen
form
ulat
ing
the
reco
mm
end
atio
ns, s
uch
as
equi
ty, f
easi
bili
ty a
nd a
ccep
tab
ility
.
No
No
No
No
No
No
Yes
No
No
No
No
Yes
Evi
den
ce t
o d
ecis
ion
pro
cess
es15
Des
crib
e th
e p
roce
sses
and
ap
pro
ache
s us
ed b
y th
e gu
idel
ine
dev
elop
men
t gr
oup
to
mak
e d
ecis
ions
, par
ticul
arly
the
fo
rmul
atio
n of
rec
omm
end
atio
ns
(suc
h as
how
con
sens
us w
as
defi
ned
and
ach
ieve
d a
nd w
heth
er
votin
g w
as u
sed
).
No
No
No
No
Yes
No
No
No
No
No
Yes
No
Rev
iew
and
qua
lity
assu
ranc
e
Ext
erna
l rev
iew
16In
dic
ate
whe
ther
the
dra
ft
guid
elin
e un
der
wen
t in
dep
end
ent
revi
ew a
nd, i
f so,
how
thi
s w
as
exec
uted
and
the
com
men
ts
cons
ider
ed a
nd a
dd
ress
ed.
Yes
No
Yes
No
No
No
Yes
Yes
Yes
No
Yes
No
Qua
lity
assu
ranc
e17
Ind
icat
e w
heth
er t
he g
uid
elin
e w
as
sub
ject
ed t
o a
qua
lity
assu
ranc
e p
roce
ss.
No
No
No
No
Yes
No
No
No
No
No
No
No
Fund
ing
and
dec
lara
tion
and
man
agem
ent
of in
tere
sts
Tab
le 3
C
ontin
ued
Con
tinue
d
on October 1, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2019-029589 on 3 D
ecember 2019. D
ownloaded from
http://bmjopen.bmj.com/
11Wang Z, et al. BMJ Open 2019;9:e029589. doi:10.1136/bmjopen-2019-029589
Open access
Sec
tio
n/to
pic
Num
ber
Item
Ass
essm
ent
1213
1415
1617
1819
2021
2223
Fund
ing
sour
ce(s
) an
d r
ole(
s) o
f the
fu
nder
18a
Des
crib
e th
e sp
ecifi
c so
urce
s of
fu
ndin
g fo
r al
l sta
ges
of g
uid
elin
e d
evel
opm
ent.
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
18b
Des
crib
e th
e ro
le o
f fun
der
(s) i
n th
e d
iffer
ent
stag
es o
f gui
del
ine
dev
elop
men
t an
d in
the
d
isse
min
atio
n an
d im
ple
men
tatio
n of
the
rec
omm
end
atio
ns.
No
No
No
Yes
Yes
No
No
No
No
No
No
No
Dec
lara
tion
and
m
anag
emen
t of
in
tere
sts
19a
Des
crib
e w
hat
typ
es o
f con
flict
s (fi
nanc
ial a
nd n
on- fi
nanc
ial)
wer
e re
leva
nt t
o gu
idel
ine
dev
elop
men
t.
No
No
No
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
19b
Des
crib
e ho
w c
onfli
cts
of in
tere
st
wer
e ev
alua
ted
and
man
aged
and
ho
w u
sers
of t
he g
uid
elin
e ca
n ac
cess
the
dec
lara
tions
.
No
No
No
Yes
No
No
Yes
No
Yes
No
Yes
No
Oth
er in
form
atio
n
Acc
ess
20D
escr
ibe
whe
re t
he g
uid
elin
e,
its a
pp
end
ices
and
oth
er r
elat
ed
doc
umen
ts c
an b
e ac
cess
ed.
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Sug
gest
ions
for
furt
her
rese
arch
21D
escr
ibe
the
gap
s in
the
evi
den
ce
and
/or
pro
vid
e su
gges
tions
for
futu
re r
esea
rch.
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
Lim
itatio
ns o
f the
gu
idel
ine
22D
escr
ibe
any
limita
tions
in t
he
guid
elin
e d
evel
opm
ent
pro
cess
(s
uch
as t
he d
evel
opm
ent
grou
ps
wer
e no
t m
ultid
isci
plin
ary
or
pat
ient
s’ v
alue
s an
d p
refe
renc
es
wer
e no
t so
ught
), an
d in
dic
ate
how
the
se li
mita
tions
mig
ht
have
affe
cted
the
val
idity
of t
he
reco
mm
end
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Figure 2 Quality of reporting evaluation by RIGHT. (A) Reporting quality for each guideline. (B) Overall evaluation of reporting quality.
the guidelines at any stage. Four15 18 20 22 had detailed a description of the conflict of interest of the authors.
Other informationMost guidelines provided accession websites for the full guidelines and their appendices but two.12 13 Four guide-lines15–18 provided suggestions for further research; one17 presented some limitations of its use and suggested future guideline developers to avoid such limitations.
dIsCussIOnThis study identified 12 guidelines on epilepsy published in the past 5 years, including both Western medicine and TCM. Appraisal of these guidelines with the RIGHT tool revealed that the quality of reporting varied among guidelines. Some of the included guide-lines showed relatively higher quality and favourable overall recommendations; these could be used by healthcare providers and patients as the basis for discus-sion on management of epilepsy. However, considering individual differences among patients, each recom-mendation should be used with caution. Moreover, some items in these guidelines were of low quality (eg, healthcare- related questions, rationale/explanation for recommendations, quality assurance, funding source(s) and role(s) of the funder, and limitations of the guide-line); thus, these aspects should receive greater atten-tion in future guideline reporting.
Notable strengths of this study include its use of comprehensive systematic review to identify eligible clinical guidelines and its assessment of quality using the RIGHT tool, which is published by the WHO and is an internationally accepted standard for appraisal of guidelines. This study found that CPGs for epilepsy are wide- ranging and have been published in many regions in the past 5 years.
However, according to the appraisal of each item based on the RIGHT tool, all included guidelines were desig-nated as ‘recommended with provisions or modifications’ due to inadequate reporting quality. A previous research drew a conclusion of a heterogeneity in methodological quality and great gaps in topics of epilepsy guidelines as assessed by AGREE II tool.24 Although different tools were used to assess epilepsy guidelines, and both assess-ment tools as mentioned above focus on different aspects, similar findings were concluded in this study, showing that the included epilepsy guidelines are of poor reporting quality. The findings in the present study are consistent with the assessments of guidelines in multiple regions, as well as patients and clinical medicine interventions: the included guidelines did not adhere to established reporting quality standards, and further improvement in guideline development is needed. Although there were limitations in the included guidelines according to assessment via the RIGHT tool, only four of the included guidelines provided suggestions for future guideline developers to avoid such limitations in future work. The greatest limitation in the included guidelines was a lack of consideration of the requirements and recommenda-tions for patients and their relatives with regard to psycho-logical or economic burden. An ideal clinical guideline should enable improvement for patients and their disor-ders, thereby guiding clinical doctors and better serving the patients. Furthermore, few or the included guide-lines reported how stakeholders influenced the develop-ment of the guidelines, which suggests that the guidelines may exhibit low credibility, especially those targeting a specific treatment recommendation. Only one guideline focused on TCM interventions for epilepsy; reporting of this guideline was not of high quality and solely targeted children with epilepsy. It is well known that antiepileptic drugs perform irreversible harm to the liver and kidneys; epilepsy in 25.3% of adult patients and 13.4% of paediatric patients was reported to have led to intractable epilepsy due to antiepileptic resistance and long- term treatment.25 Thus, to reduce the adverse effects of antiepileptic drugs, TCM or other complementary alternative therapies should be recommended for use in clinical applications according to a systematic review. The findings of this study may serve as an alert for epilepsy guidelines development and reporting in the future as poor reporting quality of CPGs could mislead clinical care for patients with epilepsy.
LimitationsThere were some limitations to this study. The main limitation was that only papers published in English
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and Chinese were searched for this study, leading to some guidelines published in Japanese, Russian, French, Spanish, German, Italian or other languages being missed. Second, the inclusion of six regions limited the findings to those regions; however, the regions were chosen because they were expected to be representative. We consider epilepsy interventions and other healthcare practices to have a particular impact in the USA, Europe, UK and China, where higher morbidity is reported. Third, a robust series of eligibility criteria were formu-lated and tested before these guidelines were identified; however, some guidelines might be missed by computer-ised searches. Finally, the RIGHT tool has a broad range of assessment of individual guideline components for specialists across medical specialties and levels of seniority, which might have led to subjective estimation during the decision- making process. However, the correlation between the estimators suggested that the RIGHT tool overcomes this potential bias.
In future updates, guidelines that achieved higher quality of reporting and overall recommendations could be improved based on the RIGHT tool specifications, as well as with insight from a large number of resources that are available to support guideline development and implementation.26 27 Future research should iden-tify patients with epilepsy and interventions other than those reviewed here in a manner supported by sufficient evidence to facilitate guideline development.
COnCLusIOnsAppraisal of these guidelines using the RIGHT tool revealed that the quality of reporting varied among guide-lines. Items that exhibited low quality in most included guidelines were healthcare questions, rationale/expla-nation for recommendations, quality assurance, funding source(s) and role(s) of the funder, and limitations of the guideline. Thus, these aspects should receive greater attention in future guideline reporting.
Author affiliations1Medical College of Acupuncture and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China2Primary Care, Population Sciences, and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK3Oncology Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China4Geriatric Ward, The Second Hospital Affiliated of Heilongjiang University of Chinese Medicine (Southern Branch), Harbin, China
Contributors ZW and YZ contributed equally to this work. This review was drafted by ZW and YZ, and revised by XG and LL. The search strategy was addressed by XMH and WG, and updated by ZW. ZW and XMH screened potential trials, extracted the data and completed the data synthesis independently. XG and LL arbitrated in cases of disagreement and ensured the absence of errors. All authors gave final approval for the version to be published. We confirm that we have read the journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.
Funding This study is supported by the International Program for Postgraduates, Guangzhou University of Chinese Medicine, and Construction of High Level University, Guangzhou University of Chinese Medicine.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
data availability statement All data relevant to the study are included in the article.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
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Reporting specifications regarding epilepsy practice guidelines based on the RIGHT reporting checklist: an analysisAbstractIntroductionMethodsStudy designReview protocolEligibility criteriaTypes of guidelinesTypes of participants and public involvementTypes of interventions
Literature searchData extractionAssessment of the quality of reportingData analysis and investigation of heterogeneity
ResultsGuideline characteristicsQuality of reporting evaluation by RIGHTBasic informationBackgroundEvidenceRecommendationReview and quality assuranceFunding and declaration and management of interestsOther information
DiscussionLimitations
ConclusionsReferences