Discussion

The use of an appropriate methodology that takes into account the GRADE tool, provides high-reliability recommendations and increases the chance of positive assessment using guideline evaluation tools. [32]. For this reason, organisations such as WHO and RCPCH in their new standards [7] both recommend the GRADE methodology for guideline development. Unfortunately, many authors do not conduct a systematic approach to the process of creating guidelines and the quality of including data remains often unsatisfactory. [4, 5] Using non-systematic methods compromises the validity and reliability of recommendations, leading to potentially untrustworthy results.

WHO actively incorporates the GRADE methodology into its guideline development process. The GRADE methodology serves as a systematic and transparent approach used in the WHO handbook to assess the quality of evidence. When creating guidelines, WHO applies the GRADE methodology to varying extents, depending on factors such as the nature of the guideline and the available evidence. [33, 34]

During the development of guidelines, the WHO handbook recommends a comprehensive assessment of each relevant research. This assessment includes evaluating the study design, examining the potential risks of bias, ensuring consistency of findings across multiple studies, assessing the precision of the reported results, and considering the possibility of publication bias. In this process, WHO conducts systematic reviews of available studies that investigate various treatment approaches. The design of each study is critically evaluated to determine its reliability and potential sources of bias. This evaluation process allows WHO to ensure the use of high-quality evidence and minimizes the risk of drawing incorrect conclusions. Based on the accumulated evidence, WHO recommends assigning a GRADE rating to each body of evidence. This rating indicates the level of confidence in the estimated effect derived from the analysed evidence. The GRADE rating system classifies the evidence as high, moderate, low, or very low, providing transparency about the strength of the recommendations. The incorporation of the GRADE methodology helps to thoughtfully examine both the benefits and potential limitations of interventions. By considering all of these factors of guideline development, WHO aims to publish guidelines that are of high quality, evidence-based, and clinically useful. [2]

Setting Standards for the Development of Clinical Guidelines in Paediatrics and Child Health provides the newest summary of the RCPCH standards for guideline development within the United Kingdom. RCPCH aims to improve and diminish inequalities in clinical practice in paediatrics by ensuring that guidelines are based on the proper evidence. [7]

RCPCH incorporates National Institute for Health and Care Excellence (NICE) methodology [3] into its standards. When creating guidelines, the NICE key principles are followed: 1. ensuring that guidance is based on the best evidence of effectiveness and cost, 2. involving independent committees of experts, 3. including at least two lay members, 4. conducting consultations to allow stakeholders to comment on the recommendations, 5. reviewing and updating published guidelines if necessary, 6. ensuring the processes, methods and policies necessary for guideline development remain up‑to‑date.

RCPCH Guideline Development Group (GDG) collaborate with stakeholders to ensure the usefulness of guidelines in daily clinical practice. RCPCH conducts an assessment of collected data and each relevant publication is evaluated with respect to its methodology and reliability. Since 2013 the GRADE approach has been recommended to assess the quality of evidence, replacing the earlier system used in the SIGN methodology. [7] The previous was based on grades of recommendations (A-D, Good Practice Point), the assignment of which depended on the strength of the evidence and the possibility of extrapolating the results to the target population. Good Practice Points grades were based on the clinical experience and consensus of the GDG. [8]

Incorporation of GRADE methodology enables the comparison of collected data on many levels, including internal validity, inconsistency, indirectness, imprecision, or publication bias. RCPCH emphasises the significance of GRADE methodology due to its comprehensiveness and transparency. However, this approach may be more demanding and pose difficulties for small organisations, which collaborate with RCPCH. For this reason, RCPCH also considers utilising a non-GRADE approach. [7]

Although GRADE tool is an excellent standard for guideline development, only three [12, 18, 30] from twenty-three guidelines in this review used GRADE. This review indicates significant variations in the strategies used to collect and present data on ROP across different countries. While some authors rely on rigorous literature reviews, others base their guidelines on national or international data without any standardised methodology. Understanding the reasons behind these differences and identifying country-specific limitations is crucial for harmonising global guideline development processes.

Conclusions

Determining the quality of the evidence and the strength of the recommendations is essential to present evidence-based data transparently, enabling their easy use in clinical practice. Our analysis revealed the need for significant improvement in the process of creating guidelines for retinopathy of prematurity in most countries. We hope that raising awareness about the tools available to support authors will help spread their use as a standard practice.

Conflict of interest

The authors declared no potential conflict of interest.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.