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An appraisal of clinical practice guidelines for constipation: a right attitude towards to guidelines

  • Hongliang Tian1,
  • Chao Ding1,
  • Jianfeng Gong1Email author,
  • Xiaolong Ge1,
  • Lynne V. McFarland2,
  • Lili Gu1,
  • Qiyi Chen1,
  • Chunlian Ma1,
  • Weiming Zhu1,
  • Jieshou Li1 and
  • Ning Li1Email author
Contributed equally
BMC GastroenterologyBMC series – open, inclusive and trusted201616:52

https://doi.org/10.1186/s12876-016-0466-8

Received: 10 August 2015

Accepted: 25 April 2016

Published: 4 May 2016

Abstract

Background

Clinical practice guidelines (CPGs) are formally developed statements that assist users to provide proper health care for a kind of disease and play a significant contribution in healthcare system. This study report the methodological quality of CPGs on constipation.

Methods

The “Appraisal of Guidelines and Research and Evaluation” (AGREEII) instrument was developed to determine the quality of CPGs. A comprehensive search was developed using five databases and three guideline websites until/up to December, 2015. Four independent authors evaluated the methodological issues of the CPGs by the AGREEII instrument.

Results

We identified 22 relevant guidelines on constipation from 1234 citations. The overall agreement among evaluators was 0.84 using the intra-class correlation coefficient. The mean AGREEII scores for the domains “scope and purpose” (51.77) and “rigor of development” (56.73) were moderate; afterward, three domains “stakeholder involvement” (32.23), “editorial independence” (29.59) and “applicability” (29.14) were low scores. The “clarity and presentation” (23.73) had the lowest scores.

Conclusion

Although existing constipation guidelines may accurately reflect current clinical practices, many guidelines’ methodological quality is low. Therefore, more emphasis and attentions should be taken to the development of high-quality guidelines.

Keywords

Constipation Clinical practice guideline AGREEII

Background

Constipation is a disorder defined by incomplete defecation, and/or infrequent bowel movements which associated with persistent difficult and/or painful defecation, fecal incontinence, and abdominal pain [1]. It is a common clinical functional diseases. The worldwide constipation surveys show a wide range of prevalence rates between 1 % and >20 % in western populations, although, a recent epidemiological reports found 16 % general adult populations were constipation [2]. Constipation may be found for up to 20 % of community-dwelling elderly individuals. Moreover the incidence of functional constipation in childhood estimated 3 % [3].

Because of its high disease burden, the treatment of constipation has become an important issue for clinicians and patients. During the last two decade there were more than 20 developed clinical practice guidelines (CPGs) to manage the constipation. The main role of the CPGs is to give clear recommendations to help clinicians make appropriate clinical decision for specific clinical circumstance [4, 5].

However, not all guidelines are developed with the same methodologically rigorous approaches, there is no research for evaluating the quality of CPGs on constipation so far. With the above in mind, the objectives of the present study was to systematically review guidelines using the appraisal of guidelines for research and evaluation (AGREEII) instrument related to constipation [6].

Methods

Literature search

An electronic literature search using multiple databases (PubMed, EMBASE, The China Journal Full-text Database, Chinese Biomedical Literature Database, Chinese Scientific Journals Full-text Database), and guideline website or databases—including the Guidelines International Network (GIN) Database, the National Guideline Clearinghouse (NGC), National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), National Comprehensive Cancer Network (NCCN) was conducted limited to Chinese and English from the inception to May 2015. MeSH terms and text words “guideline, consensus, recommendation, criteria, statement, constipation” for constipation and guidelines were used within the MEDLINE database. The same search strategy was made applicable for the other databases or websites.

Guideline selection and data extraction

Four reviewers (THL,DC,LN,GJF) independently extracted the guidelines which met the characteristics (for example, a clear guideline definition as proposed by the institute of Medicine [4], focused exclusively on constipation disease). We constructed a standard form table to extract the data of guidelines. Four reviewers extracted data separately, disagreements were discussed or by a fifth reviewer (GXL) if no consensus was reached.

Quality appraisal and recommendation

We evaluated the twenty-two included CPGs quality by AGREEII instrument [6]. The instrument includes a 23-item tool comprising six quality domains. The four authors read the entire AGREEII handbook and then independently rated all included guidelines using formula as follows:
$$ \frac{\mathrm{Obtained}\ \mathrm{score}\ \hbox{-}\ \mathrm{Minimum}\ \mathrm{possible}\ \mathrm{score}}{\mathrm{Maximum}\ \mathrm{possible}\ \mathrm{socre}\ \hbox{-}\ \mathrm{Minimum}\ \mathrm{possible}\ \mathrm{score}}\times 100\% $$

According to the handbook for use of the AGREEII instrument, the six domain scores were considered independently. Finally, a guideline is labelled as “strongly recommended” if most domain scores are greater than 60 %. Guideline is “recommended” when most scores are between 30 % and 60 %. A guideline is labelled as “not recommended” when most domain scores are less than 30 % [7].

Statistical analysis

A descriptive study of item frequency was carried out and the AGREEII domain scores calculated as means. Intra-class correlation coefficients (ICCs) is a measure of the reliability of measurements or ratings within each domain [8]. Statistically significant was considered if p value less than 0.05.

Results and discussion

Literature search

Figure 1 shows how we screened the guidelines, we preliminary search found 1234 citations, 35 were excluded because they were duplicate citations. By screening their titles and abstracts and 1,146 citations were ineligible as they didn’t meet the characteristics of constipation CPGs, 31 articles were excluded from the left 53 studies as following: eight were duplicates, seven were not in English or Chinese, 14 were guidelines not related to constipation, and 2 guidelines were the old version. Finally, a total of 22 guidelines were included [931].
Fig. 1

Flow of information through the different phases of the literature search

Guideline characteristics

The summary of CPGs baseline data were shown in Table 1. The twenty-two CPGs published between 2000 and 2014. Of the 22 selected CPGs, half of were from north America (America and Canada), six from European (UK, Ireland, Italy, Sweden) and the remaining five were from Asia (two from China, one from Korea, one from Indonesia and one multi-national),respectively. The scope of the CPRs varied: one guideline topic covered prevention, diagnosis and treatment of constipation [31]; two focused only on prevention and treatment [14, 16]; 16 covered diagnosis and treatment [9, 12, 13, 15, 1719, 2129]; three only focused on treatment [10, 20, 30] and one focused on prevention [11]. CPGs cited a range of number of references (range: 0–364, mean: 78) and were of varying length (mean number of pages = 25, range: 5–255). Each of the domains being evaluated using the AGREEII appraisal (Table 2). The ICCs score was moderate among raters (0.84; 95 % CI, 0.56–0.86).
Table 1

Characteristics of clinical practice guidelines for constipation

Title

Year

Country

Organization

Type of constipation

Topics covered

Update

No. of reference

Guideline page

Publication types

Systematic search

Evidence-based

Financial

American Gastroenterological Association Medical Position Statement: Guidelines on Constipation [9]

2000

USA

AGA

Slow-Transit Constipation, Pelvic Floor Dysfunction, Combination Syndromes

Diagnosis,treatment

Not reported

1

6

Journal

Not reported

Not reported

Not reported

Practice Guidelines for the Management of Constipation in adults [10]

2002

USA

Not reported

Constipation in adults

Treatment

Not reported

203

51

Special website (http://www.arna.com.au/)

Not reported

Not reported

Not reported

Prevention of constipation in the older adult population [11]

2005

Canada

RNAOPA

Older adult populations

Prevention

Yes

226

16

Special website (http://rnao.ca/bpg/guidelines/prevention-constipation-older-adult-population)

Not reported

Yes

Not reported

Management of chronic constipation: recommendations from a consensus panel [12]

2005

USA

None

Chronic constipation

Diagnosis,treatment

Not reported

55

8

Journal

Yes

Not reported

Yes,Pharmaceuticals Cor.

Evaluation and Treatment of Constipation in Infants and Children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition [13]

2006

USA

NASPGHAN Constipation Guideline Committee

Infants and Children constipation

Diagnosis,treatment

Yes

96

13

Journal

Not reported

Yes

Not reported

Putting evidence into practice:evidence-based inventions for the prevention and management of constipation in patients with cancer [14]

2008

USA

ONS

constipation in patients with cancer

Prevention,treatment

Not reported

72

21

Journal

Not reported

Yes

Not reported

The management of constipation in palliative care: clinical practice recommendations [15]

2008

Ireland

The European Consensus Group on Constipation in Palliative Care

Constipation

Diagnosis,treatment

Not reported

43

13

Journal

Not reported

Yes

Yes,Pharmaceuticals Cor.

Management of constipation [16]

2009

UK

NICE

Older adults

Prevention,treatment

Not reported

34

10

Special website (AHRQ)

Yes

Yes

Not reported

National Consensus on The Management of Constipation in Indonesia 2010 [17]

2010

Indonesia

ISG

Constipation

Diagnosis,treatment

Not reported

18

8

Journal

Not reported

No

Not reported

Constipation in Children and Young People: Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care [18]

2010

UK

NCC-WCH

Constipation in children and young people

Diagnosis,treatment

Not reported

140

255

Special website (NICE)

Yes

Yes

Not reported

Consensus Recommendations for the Management of Constipation in Patients with Advanced, Progressive Illness [19]

2010

Canada

The Canadian Consensus Development Group

Patients with Advanced, Progressive Illness

Diagnosis,treatment

Not reported

20

13

Journal

Not reported

Yes

Yes (edu cational grant from Wyeth)

Prucalopride for the treatment of chronic constipation in women [20]

2010

UK

NICE

Chronic constipation in women

Treatment

Not reported

11

38

Special website (Cancer Care Ontario Website)

Not reported

Yes

Not reported

Common views on diagnosis and treatment of chronic constipation with Chinese medicine [21]

2011

China

CACM

Chronic constipation

Diagnosis,treatment

Yes

24

5

Journal

Not reported

No

Not reported

World Gastroenterology Organisation Global Guideline Constipation-A Global Perspective [22]

2011

Sweden

WGO

Adult patients

Diagnosis,treatment

Not reported

0

5

Journal

Not reported

Yes

None

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation [23, 24]

2012

Italy

AIGO/SICCR

Chronic constipation and obstructed defecation

Diagnosis Treatment

Not Reported

364

30

Journal

Not reported

Yes

Associazione Italiana Gastroenterologi and Endoscopisti Digestivi Ospedalieri

Practical Treatments for Constipation in Korea [25]

2012

Korea

KSNM

Constipation

Diagnosis,,treatment

Not reported

63

9

Journal

Not reported

Not reported

Not reported

Diagnosis and Treatment Guideline of Chronic Constipation in China [26]

2013

China

CMAG/CMAS

Chronic constipation

Diagnosis,treatment

Not reported

63

8

Journal

Not reported

Not reported

Not reported

Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN [27]

2013

USA

ESPGHAN and NASPGHAN

Functional Constipation in Infants and Children

Diagnosis, treatment

Yes

111

17

Journal

Yes

Yes

NASPGHAN and ESPGHAN

Primary Care Management of Chronic Constipation in Asia: The ANMA Chronic Constipation Too l [28]

2013

Asia

ANMA

Chronic Constipation

Diagnosis,,treatment

Not reported

124

12

Journal

Not reported

No

educational grant was receive d from Janssen Pharmaceuticals and Boehringer Ingelheim

American Gastroenterological Association Medical Position Statement on Constipation [29]

2013

USA

AGA

Chronic Constipation

Diagnosis,treatment

Yes

1

7

Journal

Not reported

Yes

Not reported

Lubiprostone for treating chronic idiopathic constipation [30]

2014

UK

NICE

Chronic idiopathic constipation

Treatment

Not reported

0

9

Special website (NICE)

Yes

Yes

NICE

Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid-induced constipation [31]

2014

USA

None

Opioid-induced constipation

Prevention,diagnosis,treatment

Not reported

61

10

Journal

Not reported

Not reported

AstraZeneca

Footnotes: NICE National Institute for Health and Care Excellence, ESMO European Society for Medical Oncology, ESDO European Society of Digestive Oncology, NCCN National Comprehensive Cancer Network, SEOM Spanish Society of Medical Oncology, GIN Guidelines International Network, NASPGHAN North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, AIGO Italian Association of Hospital Gastroenterologists, SICCR Italian Society of Colo-Rectal Surgery, NCC-WCH National Collaborating Centre for Women‘s and Children‘s Health, KSNM Constipation Study Group in the Korean Society of Neurogastroenterology and Motility, NASPGHAN the North American Society for Pediatric Gastroenterology Hepatology and Nutrition, ESPGHAN: the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition, ANMA the Asian Neurogastroenterology and Motility Association, AGA American Gastroenterological Association, RNAOPA Registered Nurses Assocation of Ontario-Professional Association, ONS the Oncology Nursing Society, ISG The Indonesian Society of Gastroenterology, CACM China Association of Chinese Medicine, WGO World Gastroenterology Organization, CMAG/CMAS Chinese Medical Association of Gastroenterology Branch, Chinese Medical Association of Surgery Branch

Table 2

Guideline score according to score on each of the domains assessed by the AGREEII instrument

Title

Scope and Purpose

Stakeholder

Rigour

Clarity

Applicability

Editorial Independence

Recommendation

American Gastroenterological Association Medical Position Statement: Guidelines on Constipation [9]

31 %

11 %

7 %

44 %

15 %

0 %

Not recommended

Practice Guidelines for the Management of Constipation in adults [10]

44 %

22 %

36 %

44 %

25 %

0 %

Not recommended

Prevention of constipation in the older adult population [11]

81 %

39 %

58 %

72 %

54 %

54 %

Strongly recommended

Management of chronic constipation: recommendations from a consensus panel [12]

39 %

14 %

9 %

53 %

17 %

33 %

Not recommended

Evaluation and Treatment of Constipation in Infants and Children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition [13]

56 %

31 %

46 %

58 %

31 %

0 %

Recommended

Putting evidence into practice:evidence-based inventions for the prevention and management of constipation in patients with cancer [14]

64 %

28 %

45 %

47 %

33 %

0 %

Recommended

The management of constipation in palliative care: clinical practice recommendations [15]

56 %

17 %

41 %

67 %

23 %

21 %

Not recommended

Management of constipation [16]

75 %

31 %

63 %

67 %

44 %

29 %

Recommended

National Consensus on The Management of Constipation in Indonesia 2010 [17]

56 %

8 %

3 %

69 %

10 %

0 %

Not recommended

Constipation in Children and Young People: Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care [18]

78 %

61 %

50 %

75 %

54 %

71 %

Strongly recommended

Consensus Recommendations for the Management of Constipation in Patients with Advanced, Progressive Illness [19]

50 %

19 %

40 %

64 %

21 %

50 %

Recommended

Prucalopride for the treatment of chronic constipation in women [20]

56 %

39 %

33 %

72 %

58 %

50 %

Recommended

Common views on diagnosis and treatment of chronic constipation with Chinese medicine [21]

17 %

8 %

11 %

56 %

23 %

0 %

Not recommended

World Gastroenterology Organisation Global Guideline Constipation-A Global Perspective [22]

36 %

14 %

14 %

47 %

21 %

83 %

Not recommended

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation [23, 24]

50 %

19 %

48 %

50 %

21 %

17 %

Not recommended

Practical Treatments for Constipation in Korea [25]

44 %

11 %

16 %

39 %

21 %

33 %

Not recommended

Diagnosis and Treatment Guideline of Chronic Constipation in China [26]

25 %

11 %

15 %

47 %

19 %

0 %

Not recommended

Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN [27]

81 %

25 %

66 %

83 %

23 %

38 %

Recommended

Primary Care Management of Chronic Constipation in Asia: The ANMA Chronic Constipation Tool [28]

50 %

36 %

22 %

53 %

23 %

38 %

Recommended

American Gastroenterological Association Medical Position Statement on Constipation [29]

33 %

17 %

25 %

61 %

42 %

25 %

Not recommended

Lubiprostone for treating chronic idiopathic constipation [30]

75 %

39 %

46 %

44 %

38 %

67 %

Recommended

Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid-induced constipation [31]

42 %

22 %

15 %

36 %

25 %

42 %

Not recommended

Total (\( \overline{X} \)±SD)

51.77 ± 18.24

23.73 ± 13.16

32.23 ± 19.24

56.73 ± 12.91

29.14 ± 13.55

29.59 ± 25.91

-

Appraisal of guidelines

Domain 1

Scope and purpose is concerned with the overall aim of the guideline, the specific health questions, and the target population (items 1–3) [32]. This domain’s mean score was 51.77 %, and nine of the guidelines (47.62 %) scored below 50 % [9, 10, 12, 21, 22, 25, 26, 29, 31].

Domain 2

Stakeholder involvement focuses on the extent to which the guideline was developed by the appropriate stakeholders and represents the views of its intended users (items 4–6) [32]. Of all AGREEII domains, this domain received the lowest scores (23.73 %) with only one CPG scoring over 50 %. Eighteen CPGs had been developed by a multi-disciplinary organization (81.82 %) [9, 11, 1330].

Domain 3

Rigor of development criteria relates to the process used to gather and synthesize the evidence, the methods to formulate the recommendations, and to update those (items 7–14) [32]. Overall, the mean score for this domain was only 32.23 % (range, 3 % to 66 %), with 18 CPGs scoring < 50 %. Meanwhile, only five CPGs reported systematic evidence searching [12, 16, 18, 27, 30], and Just 40.90 %(9/22) guidelines provided the methods for formulating the recommendations [1116, 26, 27, 29]. Moreover, an explicit link between the recommendations and the evidence were explicit in 20/22 of the guidelines and only five guidelines described a procedure about updating [11, 13, 21, 27, 29].

Domain 4

Clarity of presentation deals with the language, structure, and format of the guideline (items 15–17) [32]. The mean score for this domain was 56.73 % (range, 36 % to 83 %). Most CPGs provided a concrete and precise description of key recommendations with only eight guidelines scoring less than 50 % [9, 10, 14, 22, 25, 26, 30, 31].

Domain 5

Applicability pertains to the likely barriers and facilitators to implementation, strategies to improve uptake, and resource implications of applying the guideline (items 18–21) [32]. This domain’s score was 29.14 % (range, 10 % to 58 %) and only three CPGs scored > 50 % [11, 18, 20]. A total of 10 CPGs discussed barriers to implementing the guideline’s recommendations [11, 13, 14, 16, 18, 20, 21, 2931] and 7 guideline provides advice and/or tools on how the recommendations can be put into practice [11, 16, 18, 20, 2931]. Resource implications were not explicitly discussed, only five CPGs offered cost implications [11, 18, 20, 29, 30].

Domain 6

Editorial independence is concerned with the formulation of recommendations not being unduly biased with competing interests (items 22–23) [32]. The mean score for this domain was 29.59 %. Fifteen guidelines scored below 50 %. Most (63.64 %) guidelines did not provide the information whether they received funding or not [911, 13, 14, 1618, 2022, 25, 26, 29].

Overall assessment

Guidelines were graded by the overall assessment. Only two CPGs can be strongly recommended [11, 18]. Eight can be recommended with provisions or alterations because of the most domains scoring between 30 % and 60 % [13, 14, 16, 19, 20, 27, 28, 30]. The remaining 12 CPGs were labelled as ‘not recommended’ due to the poor domain scores [9, 10, 12, 15, 17, 2126, 31] (Table 2).

Stratification of CPG quality

In order to examine which factors may have impacted quality scores in the six domains, we stratified the data on the following variables (guideline area, AGREEII publication date, publication type, working group, comprehensive search or not, fund support or not, and evidence-based or not) in Table 3. We didn’t find the difference in six domains quality related to publication year of AGREEII (before or after 2010). Meanwhile, guidelines published in guideline databases were significantly have a higher scores than that in journals. The scores from CPGs developed by medical societies were higher when compared with individuals for the following items: Scope &Purpose, Stakeholders, Rigour, and Applicability. If CPGs were evidence-based, those three domains (Rigour, Applicability and Editorial independence) would have a higher scores. Apart from above, we found no differences in the rest of the comparisons.
Table 3

Mean (±SD) AGREEII scores by subgroups

Subgroups

Scope & Purpose

Stakeholders

Rigour

Clarity

Applicability

Editorial Independence

Year of publication

      

  ≤ 2010 (n = 12)

57.17 ± 15.41

26.67 ± 14.93

35.92 ± 19.77

61.00 ± 11.4

32.08 ± 16.62

25.67 ± 25.98

  > 2010 (n = 10)

45.30 ± 20.18

20.20 ± 10.53

27.80 ± 18.80

51.60 ± 13.34

25.67 ± 25.98

34.30 ± 26.39

P values

0.146

0.249

0.337

0.096

0.247

0.451

Publication Type

      

 Journal (n = 16)

44.72 ± 15.14

18.33 ± 7.88

25.72 ± 17.65

53.94 ± 12.35

24.17 ± 8.30

24.83 ± 22.83

 Database (n = 6)

68.17 + 14.74

38.5 + 12.93

47.67 + 11.84

62.33 + 14.43

45.5 + 12.49

45.17 + 26.63

P values

0.003

0.01

0.004

0.239

0.007

0.134

Type of development group

      

 Individual (n = 4)

50.00 ± 16.79

22.25 ± 6.95

30.75 ± 24.42

50.00 ± 13.29

27.75 ± 11.47

26.00 ± 18.17

 Medical society (n = 18)

52.17 ± 19.07

24.06 ± 14.39

32.59 ± 18.85

58.22 ± 12.74

29.44 ± 14.17

30.39 ± 27.70

P values

0.829

0.718

0.896

0.318

0.808

0.707

Systematic search

      

 No (n = 14)

47.57 ± 16.55

19.79 ± 10.70

29.50 ± 17.86

55.43 ± 11.51

26.79 ± 113.64

22.00 ± 27.5

 Yes (n = 8)

59.13 + 20.01

30.63 + 15.07

37.00 + 22.5

59.00 + 15.70

33.25 + 13.02

42.88 + 17.03

P values

0.190

0.1

0.428

0.585

0.288

0.04

Financial

      

 No (n = 14)

46.08 ± 15.97

19.23 ± 9.74

25.31 ± 18.73

52.31 ± 10.78

23.77 ± 8.63

15.08 ± 17.59

 Yes (n = 8)

60.00 ± 19.21

30.22 ± 15.39

42.22 ± 16.22

63.11 ± 13.68

36.89 ± 15.85

50.56 ± 21.48

P values

0.46

0.97

0.51

0.91

0.10

0.18

Evidence-based

      

 No (n = 13)

46.08 ± 15.97

19.23 ± 9.74

25.31 ± 18.73

52.31 ± 10.78

23.77 ± 8.63

15.08 ± 17.59

 Yes (n = 9)

60.00 ± 19.20

30.22 ± 15.39

42.22 ± 16.22

63.11 ± 13.68

36.89 ± 15.85

50.56 ± 21.48

P values

0.09

0.08

0.04

0.07

0.04

0.00

Discussion

We conducted a comprehensive assessment of the quality of CPGs for constipation. In general, these guidelines existed many deficits. Most of the guidelines had a low score in the following (domain 2, domain 3, domain 5 and domain 6). Table 4 showed that the scores results when compared with international CPGs level [33].
Table 4

A comparison of domain scores between these 22 CPGs and international level (%)

Domain

Scope and purpose

Stakeholder involvement

Rigor of development

Clarity of presentation

Applicability

Editorial independence

Constipation mean scores

52

24

32

57

29

30

International mean scores

64

35

43

60

22

30

According to the results, the mean score of domain 3 received only 32.23 %. Methods of the search and the criteria for choose evidence must be clearly described. Meanwhile, the contents of health benefits and risks, externally reviewed by experts should be provided. In order to improve the score of domain 3, particular attention should be paid in above shortcomings.

There were only 2 CPGs included guideline developing experts in the panel [11, 18]. What’s more, no patients was invited to participate in the development term. The domain 5 “applicability” have an important role in the CPGs promotion, it should provide advice and/or tools on how the recommendations can be put into practice. These low scores reflect that CPG producers remain have much work to be done to improve guideline applicability.

Lastly, the scores in the domain 6 were less than 30 %. Many guidelines are developed with external funding, the name of the funding body and a statement that the funding body did not influence the content of the guideline should be explicit consideration [34]. What’s more, there should be a clearly declaration that competing interests of guideline development group members have been recorded and addressed. Therefore, conflict of interests need to be clearly stated.

There are two guidelines which we want to recommend strongly due to their high overall quality developed by Registered Nurses Association of Ontario-Professional Association (RNAOPA) [11] and an Italian guideline by the National Collaborating Centre for Women‘s and Children‘s Health (NCC-WCH) [18]. The detailed recommendations were listed in Table 5. Eight of twenty-two guidelines can be reported with provisos and alterations [13, 14, 16, 19, 20, 27, 28, 30], while the remaining 12 CPGs could not be recommended because most domain scores below 30 % [9, 10, 12, 15, 17, 2126, 2931].
Table 5

The detail recommendations information of 2 highly guidelines

Title

Items

Recommendations

Prevention of constipation in the older adult population [11]

Practice Recommendations

Assess client history (dietary fibre, medications), Physical activity, Evaluate client response for ongoing interventions

Education Recommendation

Comprehensive education programs

Organization & Policy Recommendations

Establish an interdisciplinary team

Constipation in Children and Young People: Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care [18]

History-taking

Stool patterns, Symptoms associated with defecation, History, Timing of onset of constipation and potential precipitating factors, Passage of meconium, Growth and general wellbeing, Symptoms in legs/locomotor development, Abdomen, Diet and fluid intake

Physical examination

Inspection of perianal area: appearance, position, patency, etc.; Abdominal examination; Spine/lumbosacral region/gluteal examination; Lower limb neuromuscular examination including tone and strength, reflexes

Laxatives

Macrogols (Polyethylene glycol3350 + electrolytes), Osmotic laxatives (Lactulose); Stimulant laxatives (Sodium picosulfate, Bisacodyl, Senna)

Diet and lifestyle

Infant formula, weaning, insufficient fluid intake; Adequate fluid intake; Adequate fibre

Clinical investigations

Endoscopy, Test for coeliac disease and hypothyroidism, Test for coeliac disease and hypothyroidism, plain abdominal radiograph, Transit studies, Rectal biopsy, Ultrasound; biofeedback; Antegrade colonic enema procedure

However, our evaluation has several limitations. First, AGREEII rarely suggest how guidelines should select topics. To be useful, guidelines should address the challenges that clinicians face in practice, but developers may exclude clinically important topics when available evidence does not meet minimum standards. Second, inclusion criteria have a language restriction (English and Chinese), language search bias might happen. Third, we used only the AGREEII instrument evaluated the CPGs other than instruments may bring some selection bias [35]. AGREEII instrument have been introduced from 2010, frankly speaking, guidelines published before 2010 did not have access to AGREEII to comply with it. Unfortunately, there is no difference when we compare the six domains quality before and after 2010. We can find even if methodological requirements for CPGs are reported comply with these remains unsatisfactory. What’s more, how to spread the CPGs preferable is essential for clinical practice [36]. Through above specific methodological quality analysis, which can effectively promote the development of future constipation CPGs.

Conclusions

The results find that the quality of CPGs for constipation is poor. Guideline quality may be improved if we comply with the AGREEII instrument.

Notes

Declarations

Acknowledgment

This work was funded by National Natural Science Foundation of China (81270006) and 12th Five-Year Major Program of Army Research (AWS12J001). We would like to thank Nadeem Anjum from Nanjing University for the language modifications.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of General Surgery, Jinling Hospital, Medical School of Nanjing University
(2)
Department of Medicinal Chemistry, University of Washington

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Copyright

© Tian et al. 2016

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