Methodological and reporting quality of comprehensive hypertension guidelines published between 2017 and 2022.

Hypertension, also known as high blood pressure, is a serious medical condition that may cause severe health problems, such as heart attack and stroke. According to the World Health Organization (WHO),[1] an estimated 1.28 billion adults worldwide aged 30–79 years had hypertension in 2021, two-third of whom were living in low- and middle-income countries. Many national and international clinical practice guidelines (CPGs) on the diagnosis, evaluation, and treatment of hypertension have been published to promote its control. Among these, comprehensive hypertension guidelines provide broader direction to more target users, especially primary healthcare practitioners, than "narrow" types of guidelines. The credibility of hypertension guidelines is of great concern to stakeholders. Many researchers have used the Appraisal of Guidelines for REsearch & Evaluation (AGREE) instrument and the Reporting Items for practice Guidelines in HealThcare (RIGHT) checklist to evaluate the quality of hypertension guidelines. However, due to the development of guideline methodology and the continuous publication of new evidence on hypertension, the earlier results may no longer reflect the present status of hypertension guidelines. The purpose of this study was to assess the methodological and reporting quality of comprehensive hypertension guidelines published in the past 6 years, find the main problems, and, based on the present situation, specifically address the situation in China to evaluate the need for new guidelines for hypertension. We systematically searched 6 databases, 10 guideline websites, and Google. We limited the search to comprehensive hypertension guidelines published between January 1, 2017, and April 19, 2023 in English or Chinese. The details of the search strategy are presented in Supplementary File, https://links.lww.com/CM9/B596. We included comprehensive hypertension guidelines that focused at least on adults. Comprehensive hypertension guidelines were defined as guidelines that address at least the diagnosis, evaluation, and treatment of hypertension. The following types of articles were excluded: (1) guidelines restricted to specific types on hypertension or specific population groups (e.g., secondary hypertension, gestational hypertension, hypertension among the elderly); (2) earlier versions of guidelines, for which an updated version is available; (3) executive summaries of guidelines; (4) guidelines published in languages other than Chinese and English; and (5) duplicates. Four investigators (Zijun Wang, Yunlan Liu, Junxian Zhao, and Yajia Sun) were divided into two groups to select guidelines and extract data. Disagreements were resolved by discussion, or consulting a third investigator (Yaolong Chen). The AGREE II tool and the RIGHT checklist were used to appraise the methodological and reporting quality of the included guidelines, respectively. This project was registered with the Open Science Framework (OSF, https://osf.io/), registration DOI: 10.17605/OSF.IO/RBZ7K. Twenty-five guidelines were included in this study. The selection process, list of included guidelines, and characteristics of the comprehensive guidelines are presented in Supplementary File, https://links.lww.com/CM9/B596. The intraclass correlation coefficient (ICC) values for methodological quality assessments of the two investigator groups were 0.94 and 0.98, respectively, indicating high reliability and consistency in the scores between investigators in the same group. The mean overall score (OS) of the AGREE II quality assessment over all included guidelines was 34.1%. "Clarity and presentation" had the highest mean domain score (61.1%), and "Rigor of development" had the lowest mean domain score (25.7%). Only ten guidelines had an OS above 75.0%. The mean overall reporting rates (ORR) of the RIGHT quality assessment over all guidelines was 39.9%. "Basic information" had the highest mean domain reporting rate (67.3%), and "Review and quality assurance" the lowest mean domain reporting rate (22.0%). Twenty-six guidelines (14.9%) had an ORR higher than 75.0%. The AGREE II OS and the RIGHT ORR were highest in guidelines published in 2018, updated, published in website only, and developed by national institutions or councils. Guidelines published in the United States (AGREE II: 58.0%, RIGHT: 72.6%), United Kingdom (AGREE II: 57.9%, RIGHT: 77.4%), and Malaysia (AGREE II: 55.1%, RIGHT: 69.3%) got the top three highest mean OS of AGREE II and mean ORR of RIGHT. The quality of Chinese guidelines was in the middle with a mean AGREE II OS of 31.3% and mean RIGHT ORR of 34.7%. Rating the quality of evidence and/or strength of recommendations, reporting funding, and reporting information about conflicts of interest were associated with higher mean AGREE II OS and RIGHT ORR. These subgroups also had a higher mean domain score and domain reporting rate in all domains of AGREE II and RIGHT, respectively. To our knowledge, few studies of comprehensive hypertension guidelines have been performed prior to ours. We could, however, indirectly compare the AGREE II assessment results from our study to those from prevention and treatment guidelines for hypertension, i.e., the comprehensive hypertension guidelines included were not restricted to those published from 1998 to 2017.[2] The average methodological quality of the comprehensive hypertension guidelines in the past 6 years was lower than before 2017 (47.7% vs. 34.1%), which was also consistent across all domains except "Clarity and presentation." The methodological quality of comprehensive hypertension guidelines was also low compared with guidelines on other types of hypertension. We were unable to find any reviews assessing the reporting quality of guidelines on hypertension. The methodological quality in the domains "Stakeholder involvement", "Rigor of development", and "Applicability" was particularly low (below 30.0%). "Stakeholder involvement", which addresses whether the guideline group is formed in a standardized manner and whether experts from a variety of fields, patients, or the public are involved in the development of the guidelines. Comprehensive hypertension guidelines cover a wide range of topics, and the participation of experts with different backgrounds can enhance the credibility and scope of the guidelines, which is particularly important for comprehensive guidelines. At the same time, the number of hypertensive patients is high, and many of them may choose to take treatment at home instead of hospitalization; and so, giving full consideration to the will of patients when forming recommendations is the key to promote the implementation of guidelines and improve patient compliance. Therefore, more attention needs to be paid to the composition of the working group of comprehensive hypertension guidelines in the future. The RIGHT reporting rate across the domains "Evidence", "Review and quality assurance", and "Funding, declaration of interest" was also below 30.0%. The low reporting rate of "Evidence" and "Review and quality assurance" also reflects the poor quality in the "Rigor of development" in AGREE II. This suggests that comprehensive hypertension guidelines should be developed in accordance with rigorous methodological procedures, with attention to clear reporting of key methodological steps such as clinical questions, evidence retrieval and screening, and review processes. The low reporting rate in the domain "Funding, declaration of interest" also suggests that the comprehensive hypertension guidelines should enhance the reporting and management of conflict of interest in a standardized way, to improve the reliability of the guidelines. The methodological[3] and reporting quality[4] of the comprehensive hypertension guidelines was lower than in guidelines worldwide on average. An analysis of 421 CPGs for the management of common non-communicable diseases in primary care found that the methodological quality of guidelines developed at governmental institutions (odds ratio, 10.38; 95% CI, 2.72–39.60), and reporting funding (odds ratio, 10.34; 95% CI, 4.77–22.39) were above average,[3] which is in line with our findings. For reporting quality, previous studies have shown that WHO guidelines using the GRADE approach are of highest quality.[4] In our study, only one guideline used the GRADE method as an evidence quality evaluation tool, but guidelines that graded evidence quality and/or recommendation strength with any method reported higher quality than those that did not use any evidence or strength grading method (48.2% vs. 27.3%). Therefore, although the average quality of comprehensive hypertension guidelines is lower than guidelines in general, the existing problems are similar. In addition, this study ranked the methodological and reporting quality of guidelines developed in various countries, and the results showed that guidelines developed in China were of medium quality, close to the overall mean levels of methodological and reporting quality of the comprehensive hypertension guidelines in the past 6 years. Comparing the quality of the five Chinese comprehensive hypertension guidelines we included with Chinese clinical practice guidelines on any topics published in medical journals in 2019,[5] the average overall scores of methodological and reporting quality were similar (AGREE II 25.3% vs. 31.3%; RIGHT 33.9% vs. 34.7%). In conclusion, the quality of Chinese comprehensive hypertension guidelines is at an average level both in the same field of international guidelines and in China as a whole. But it still needs to improve by developing new high-quality comprehensive hypertension guidelines. This study has several strengths. First, we included the comprehensive hypertension guidelines in past 6 years, which should cover most of the newly published guidelines in this field. Second, we assessed both methodological and reporting quality, while most of the existing studies on hypertension guidelines evaluation were restricted to the methodological quality without evaluating the reporting quality. Third, we conducted subgroup analyses according to the key information of the guidelines to evaluate the factors affecting the methodological and reporting quality from multiple perspectives. Fourth, we ranked the methodological and reporting quality of guidelines published in different countries, so that our results can provide additional reference value for policy makers. Limitations of our study include that we did not include an analysis of recommendations and only included guidelines published in Chinese and English. In conclusion, the methodological and reporting quality of comprehensive hypertension guidelines published in the past 6 years is low. Perfect methodological process is an important factor to improve the quality of guidelines. Authors of future comprehensive hypertension guidelines should strictly follow the AGREE II tool and RIGHT checklist to standardize the formulation process and writing of the guidelines. Second, considering the high burden of disease associated with hypertension globally and the low methodological and reporting quality of current guidelines, there is an urgent need for high-quality, comprehensive guidelines on hypertension. Third, the quality advantage of the long and well-developed guidelines suggests that comprehensive hypertension guidelines should be provided with sufficient layout or online attachment links to ensure the integrity of the guidelines. Conflicts of interest None.