Investigation and Evaluation of Chinese Clinical Practice Guidelines Published in Medical Journals in 2019:the Quality of Evidence and Strength of Recommendations

To investigate the methodological issues related to the quality of evidence and strength of recommendations of 2019 Chinese clinical practice guidelines (hereafter referred to as "guidelines") published in journals, so as to provide reference for standardization of recommendations.

We searched and analyzed information on Chinese guidelines published in 2019, evaluated the quality of evidence, and graded the strength of recommendations. Information on grading methods, grading descriptions, phrases for the quality of evidence, and the strength of recommendation was extracted.

A total of 226 Chinese clinical practice guidelines were published in journals in 2019, of which 106 guidelines (87 Chinese guidelines, 19 English guidelines) were included in this study. There were 18 grading methods adopted, with the GRADE(Grading of Recommendations Assessment, Development and Evaluation) system being the most used(35.8%, 38/106). A total of 6 grading descriptions were used; the most frequently used symbol for grading the quality of evidence was letters (39.6%, 42/106); the most frequently used symbol for grading the strength of recommendations was text (34.9%, 37/106). The most common word used in the guidelines to describe the recommended strength was "may". Among the 38 guidelines that used the GRADE system, only 15 followed the presentation recommended by the GRADE working group. There were 250 clearly graded recommendations included, with 60.4% (151/250) being strong recommendations and 44.8% (112/250) citing low or very low-quality evidence. There were 96 recommendations(38.4%, 96/250) that were supported by systematic reviews.

Chinese guidelines published in journals in 2019 that used the grading system accounts for a small proportion compared with those that did not use. And the quality of evidence and strength of recommendations used in guidelines remains incomplete, inconsistent and irregular. The GRADE system is underused. Very few guidelines present grading criteria and details in accordance with the requirements of the GRADE Working Group.We recommend the use of the GRADE system to promote the rigorous, transparent and rational development of guideline recommendations.