How Equity Is Addressed in Clinical Practice Guidelines: A Content Analysis

Shi C, Tian J, Wang Q, Petkovic J, Ren D, Yang K, Yang Y
Source: BMJ Open
Publication Year: 2014
Population Focus: Vulnerable/disadvantaged
Intervention Type: Best practices
Study Design: Review
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/25479795
Abstract

OBJECTIVES:
Considering equity into guidelines presents methodological challenges. This study aims to qualitatively synthesize the methods for incorporating equity in clinical practice guidelines (CPGs).

SETTING:
Content analysis of methodological publications.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES:
Methodological publications were included if they provided checklists/frameworks on when, how and to what extent equity should be incorporated in CPGs.

DATA SOURCES:
We electronically searched MEDLINE, retrieved references, and browsed guideline development organization websites from inception to January 2013. After study selection by two authors, general characteristics and checklists items/framework components from included studies were extracted. Based on the questions or items from checklists/frameworks (unit of analysis), content analysis was conducted to identify themes and questions/items were grouped into these themes.

PRIMARY OUTCOMES:
The primary outcomes were methodological themes and processes on how to address equity issues in guideline development.

RESULTS:
8 studies with 10 publications were included from 3405 citations. In total, a list of 87 questions/items was generated from 17 checklists/frameworks. After content analysis, questions were grouped into eight themes (‘scoping questions’, ‘searching relevant evidence’, ‘appraising evidence and recommendations’, ‘formulating recommendations’, ‘monitoring implementation’, ‘providing a flow chart to include equity in CPGs’, and ‘others: reporting of guidelines and comments from stakeholders’ for CPG developers and ‘assessing the quality of CPGs’ for CPG users). Four included studies covered more than five of these themes. We also summarized the process of guideline development based on the themes mentioned above.

CONCLUSIONS:
For disadvantaged population-specific CPGs, eight important methodological issues identified in this review should be considered when including equity in CPGs under the guidance of a scientific guideline development manual.

Insights Results

Overview of article

  • This article assesses the current landscape of health inequity of clinical guidelines through a literature review, evaluating methods for including equity considerations in clinical practice guidelines (CPGs)
    Methods
  • Researchers electronically searched MEDLINE, retrieved references, and browsed guideline development organization websites from inception to January 2013. After study selection, general characteristics and checklists items/framework components from included studies were extracted. Based on the questions or items from checklists/frameworks, content analysis was conducted to identify themes and questions/items were grouped into these themes

Results

  • Through the literature review, researchers found and reviewed 87 questions/items. From this review, 8 important methodological issues emerged (7 for developers; 1 for users) that should be considered when including equity in clinical practice guidances: 1) Scoping questions; 2) Searching relevant evidence; 3) Appraising evidence and recommendations; 4) Formulation recommendations; 5) Monitoring implementation; 6) Providing a flow chart to include equity in CPGs; 7) Reporting of guidelines and comments from stakeholders; 8) [for users] Assessing the quality of CPGs
  • All of the articles reported the “scoping questions” theme
  • There are few studies (8) and publications (10) that focus on how to address health equity issues in guidelines. Few also provided methodological guidance to help CPG users identify information on equity and few described how to assess the quality of CPGs which considered equity issues in their recommendations, process for developing CPGs or how to report equity concerns
  • Most of the identified studies provided CPG developers with open-ended questions in checklists/frameworks rather than a tool to assess why, what, when and how equity issues should be addressed

Key takeaways/implications

  • The paper suggests using a guideline development handbook (e.g., WHO’s handbook for guideline development, NICE’s guidelines manual 2012) as the integration of health equity into guidelines would be more effective when used in combination with a handbook
  • Among existing checklists, Keuken et al’s article, and the National Health and Medical Research Council (NHMRC) covered most of the themes and have the greatest potential to be used as a tool for guiding equity considerations in guidelines
  • Limitations of the study include the content analysis a potential likelihood of replicability
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