Quality of clinical practice guidelines for management of limb amputations : A systematic review

Background
The quality of clinical practice guidelines (CPGs) is important to ensure guideline adoption by clinicians.

Purpose
The aim of this review was to identify CPGs for the management of limb amputations, appraise the quality of CPGs, and synthesize recommendations from comprehensive CPGs of high quality.

Data Sources
MEDLINE, EMBASE, CINAHL, PEDro, guideline-specific websites, websites for associations or networks for people with amputations, and Google Scholar were searched from April 2007 to April 2017.

Study Selection
Publications were included if they were CPGs or consensus statements/standards endorsed by a certified organization, covered the management of limb amputations, were freely accessible, and were written in English.

Data Extraction
Two reviewers independently screened titles and abstracts for eligible CPGs and rated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE-II) instrument.

Data Synthesis
Of the 15 included CPGs, 11 were of low to moderate quality and 4 were of high quality. Mean (or median) domain scores on AGREE-II were as follows: 83% for domain 1 (scope and purpose), 61% for domain 2 (stakeholder involvement), 7% for domain 3 (rigor of development), 65% for domain 4 (clarity and presentation), 24% for domain 5 (applicability), and 21% for domain 6 (editorial independence). Strong recommendations from comprehensive and high-quality CPGs were few and focused on the development of individualized treatment plans, exercises for improving physical function and the ability to perform activities of daily living, and the assessment of physical function and prognostic factors.

Limitations
CPGs that were not written in English were excluded. Final recommendations from CPGs might differ if different criteria were used. Low domain scores on the AGREE-II might be due to poor reporting rather than poor methodology in the CPG development process.

Conclusions
Few CPGs for the management of limb amputations were of high quality, and few recommendations were strong. To improve the quality of future CPGs, guideline developers should report funding and competing interests of members, provide information to aid in the practical application of CPGs, and use a systematic approach to search for evidence and derive strength of recommendations.