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\begin{document}

\title{Methodological assessment of Mexican Clinical Practice Guidelines:
Critical appraisal and GRADE framework adherence.}



\author[1]{Luis Colunga-Lozano}%
\author[2]{Vilma  Gerardo-Morales}%
\author[2]{Giordano Pérez-Gaxiola}%
\author[3]{Alan Omar Vázquez-Alvarez}%
\author[3]{Francisco Javier González-Torres }%
\author[3]{Leonardo Perales-Guerrero }%
\author[3]{Ekatherina Yanowsky-Ortega }%
\author[3]{Ulises I. Martínez-Tolentino}%
\author[3]{Sergio J. Sánchez-Villaseca}%
\author[3]{Luz Angélica García-Macías}%
\author[4]{Robby Nieuwlaat}%
\author[4]{Gordon Guyatt}%
\author[5]{Ivan D. Florez}%
\affil[1]{Hospital Civil de Guadalajara Dr Juan I Menchaca}%
\affil[2]{Hospital Pediatrico de Sinaloa}%
\affil[3]{Universidad de Guadalajara Centro Universitario de Ciencias de la Salud}%
\affil[4]{McMaster University}%
\affil[5]{Universidad de Antioquia}%


\vspace{-1em}



  
  \date{May 26, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background and Objective Clinical Practice Guidelines (CPGs) provide
evidence-based recommendations to healthcare professionals, policy
makers, patients and other stakeholders. Mexico is the biggest producer
of CPGs in Latin America and Caribbean countries. The National
Healthcare Technology Excellence Center (acronym in Spanish: CENETEC) is
responsible for the CPG development, adaptation and update. The aim of
this study was to assess the Mexican CPG quality and adherence to the
GRADE framework. Study design We conducted a descriptive cross-sectional
study of 86 CPGs representing all the CPGs produced by CENETEC between
2015 and 2017 and published in an online database called ``Catalogo
Maestro''. We performed quality assessment with the online AGREE II tool
and assessed the reporting on the GRADE framework. Results Of the 86
CPGs, 34 were published in 2015, 21 in 2016 and 31 in 2017. The overall
quality by AGREE II proved a median of 16.6\% (Min 16.6\%, Max 50\%). Of
the 86 CPGs, 25 (29\%) used the GRADE framework; adherence to GRADE
standards was, however, inconsistent and generally poor. Conclusion CPGs
produced by CENETEC during this period had a low score by AGREE II
standards and low adherence to the GRADE framework. A concerted
initiative could rapidly improve CENETEC guidelines.%
\end{abstract}%



\sloppy




\textbf{Abbreviation list}

AGREE = Appraisal of Guidelines for Research and Evaluation.

CENETEC = National Healthcare Technology Excellence Center (acronym in
Spanish: CENETEC)

CPGs = Clinical Practice Guidelines.

EtD = Evidence to Decision

EBM = Evidence-based Medicine.

GRADE = Grading of Recommendations, Assessment, Development and
Evaluation

NICE = National Institute for Health and Care Excellence.

OCEBM = Oxford Centre for Evidence-Based Medicine.

RS = Systematic Review.

SIGN = Scottish Intercollegiate Guidelines Network.

SoF = Summary of Findings.

\textbf{Introduction}

Clinical Practice Guidelines (CPGs) are health-related documents created
to provide evidence-based recommendations to healthcare professionals,
policy makers, patients and other stakeholders.\textsuperscript{(1)} In
Mexico, CPGs are developed by the National Healthcare Technology
Excellence Center (acronym in Spanish: CENETEC). CENETEC was founded in
2004 and includes the Mexican Healthcare institutions. To date, CENETEC
has produced more than 760 CPGs, focusing on four categories: diseases,
nursing, medical procedures and healthcare process.\textsuperscript{(2)}

CPGs methodology has improved over time, from non-standardized ``Good
Old Boys Sitting Around a Table'' (GOBSAT) approaches to standardized
methods.\textsuperscript{(3)} Different resources and methodologies have
contributed to this improvement. Two of them particularly have been key
in the guidelines methodology enterprise; The development of the
Appraisal of Guidelines for Research and Evaluation (AGREE II) tool -
which is the most widely used tool to assess the quality of CPGs - and
the Grading of Recommendations, Assessment, Development and Evaluation
(GRADE) framework, which has become the reference methodological
standard for the development of guidelines. \textsuperscript{(4-10)}

CENETEC's massive CPGs production may be impressive and admirable but
raises the issue of the rigor with which its guidelines are produced,
their applicability and usefulness. To date, few studies had appraised
CENETEC guidelines with the AGREE tool,\textsuperscript{(11)} however,
there is no systematic assessment of the quality of the guidelines
produced by the CENETEC aiming to include their entire production. The
aim of the current study was to assess the quality of Mexican CPGs and
to evaluate their adherence to the GRADE framework.

\textbf{METHODS}

\textbf{Study design}

We conducted a descriptive cross-sectional study of Mexican CPGs
produced by the CENETEC.

\textbf{Selection criteria and sample size calculation}

Our population of interest was all the CPGs, regardless of their scope,
produced by CENETEC and published on their online database called
``\selectlanguage{ngerman}\emph{Catálogo Maestro -- Master Database} '' between 2015 and 2017.
(Website citation) The total population of CPGs at the time of this
study design were 224 CPGs (Accessed on el
20/11/2017\emph{http://cenetec-difusion.com/gpc-sns/?cat=52}).

We considered the GRADE framework as the reference standard to frame the
question, judge the quality of evidence, and move from evidence to
recommendations. \textsuperscript{(9)}Leyva de Los Rios et al. reported
the frequency of the GRADE framework use in the CPGs from CENETEC as
10\%.\textsuperscript{(12)} Therefore, considering an alpha error of
0.05, and a 95\% confidence interval, we determined that we needed to
assess 86 CPGs. We chose a random sample from the total population of
224 CPGs using the software Epidat, version 4.2. \textsuperscript{(13)}
The CPGs were allocated randomly among the assessors (GMV, VAA, PGL,
YOE, MTU, SVS, GML, GTF, LEC). The list of the included CPGs is reported
in Table 1S.

\textbf{CPG selection and collected variables}

Two team members (LEC, GTF) extracted in duplicate the CPGs
characteristics, disagreements were solved by discussion. Recorded
variables were: Year of publication, type of CPG (Full Update/Partial
Update), librarian involvement, number of questions, adaptation
strategy, type of studies included (International Guideline,
Non-Cochrane and Cochrane Systematic Reviews), quality assessment for
GCPs and Systematic Reviews, number of articles obtained by the search
strategy, the use of GRADE approach, adherence to the GRADE framework,
recommendations systems, type of recommendations, number of
recommendations and good clinical practice statements.

\textbf{AGREE II tool ~}

We used the AGREE II tool to assess the quality of the CPGs development.
(6) AGREE II is a validated instrument composed of 23 items grouped
under 6 domains and one final item to evaluate the overall quality of
the CPG. The domains are: Scope and Purpose (3 items), Stakeholder
Involvement (3 items), Rigor of Development (8 items), Clarity of
Presentation (3 items), Applicability (4 items), and Editorial
Independence (4 items). For each item, each appraiser is asked to score
based on the statement, using a Likert scale from 1 ((Strongly disagree)
to 7 (Strongly agree). A score between 2 and 6 is assigned when the
reporting of the AGREE II item does not meet the full criteria or
considerations depending on the completeness and quality of reporting.
Scores increase as more criteria are met and considerations
addressed.\textsuperscript{(5, 14, 15)}

Following the recommendations by the AGREE collaboration, each CPG was
evaluated independently by three assessors. With the aim of reducing the
variability among the assessors we performed an intensive training in
the tool led by one of the investigators (IDF), expert in the use of
AGREE II. After initial training, the assessors were calibrated by
independently assessing two CPGs (one low quality and one high quality),
followed by feedback from the trainer (IDF), and by a group discussion
to solve any issues that arose.

We performed two rounds of assessment and feedback. We considered
disagreement between the assessors when the differences among the scores
were of 3 or more points, and they were resolved by discussion. If
agreement was not achieved after the discussion, two reviewers (IDF,
LEC) made the final assessment and decision. Final scores per domain
were calculated by summing up scores from the 3 assessors per individual
item in a domain and by scaling the total as a percentage of the maximum
possible score for that domain. Therefore, each domain was scored in a
range from 0 to 100\%.

The AGREE collaboration does not define minimum domain scores or
patterns of scores across domains to differentiate between high quality
and poor-quality guidelines. \textsuperscript{(20)} ~Instead, the
recommendation for users is to use the scores to compare CPG among them
and determine specific thresholds based on the context in which the
guidelines are to be used. All the assessment were performed using the
My AGREE-PLUS online tool provided by the AGREE collaboration
(\emph{http://www.agreetrust.org/resource-centre/agree-plus/}).

\textbf{GRADE framework adherence}

We describe the use of the GRADE framework in the included CPGs. GRADE
can be used to define the CPG questions, develop SR, identify the
importance of the outcomes, prepare evidence profile, summary of
findings (SoF), assess the overall quality of the evidence and decide on
the direction and strength of the recommendation. Currently, there is
not a validated tool to assess adherence to GRADE. We defined an
appropriate use of GRADE framework if the CPGs reported the following
items: \textsuperscript{(7-10)}

\begin{itemize}
\tightlist
\item
  Questions with explicit statement for each PICO element.
\item
  SoF with the following characteristics: Number of studies, number of
  participants, risk of bias domains, relative effect, absolute effect
  and certainty of the evidence.
\item
  Explicit reference to all GRADE domains:
\item
  \textbf{Rating down criteria} : Risk of bias, imprecision,
  indirectness, inconsistency and publication bias.
\item
  \textbf{Rating up criteria} : Large magnitude of an effect,
  Dose-response gradient and effect of plausible residual confounding.
\end{itemize}

\textbf{Statistical Analysis}

We calculated descriptive statistics to summarize our results. We
explored the normal distribution of the continuous variables with the
Shapiro-Wilk test. The results were express with mean and standard
deviation (SD) if we fail to reject a normal distribution. The results
were express with median and interquartile range (IQR) if normal
distribution was rejected. We calculated proportions and frequencies for
categorical variables. All the analyses were performed using the
software SPSS (IBM SPSS Statistics for Windows, Version 22.0. Armonk,
NY: IBM Corp). A Venn diagram was created with Eulerr web platform/site
to display the combination of the grading systems
(http://eulerr.co/).\textsuperscript{(16)}

\textbf{RESULTS}

\textbf{General description}

We included 86 CPGs in our analysis. Table 1 summarizes the guideline
characteristics. Thirty-four (39.5\%) were published in 2015, 54
(62.8\%) de novo guidelines, 79 (91.9\%) provided therapeutic
recommendations and 45 (52.3\%) focus on specific diseases.

Table 2 summarizes the guideline development process. Librarian
involvement was present in 32 CPGs (37.2\%), international guidelines
were included in 66 CPGs (76.7\%), Cochrane SR in 36 CPGs (41.9\%) and
non-Cochrane SR in 59 CPGs (68.6\%); no critical appraisal was reported.
Several of the guidelines used more than one evidence grading system in
the same document to provide their recommendations (48.8\%). The systems
implemented were the approaches by the National Institute of Health and
Care Excellence (NICE) (42, 48.8\%), Shekelle (27, 31.4\%), GRADE (25,
29.1\%), the Scottish International Guideline Network (SIGN) (19,
22.1\%) and by the Oxford Centre for Evidence Based Medicine (OCEBM)
(18, 20.9\%) (figure 1). The authors used the NICE and SIGN approaches
that had no adopted the GRADE framework.

\textbf{AGREE II critical appraisal.}

The overall quality assessment obtained a median score of 16.6\% (IQR
0.0) (Figure 2). Table 3 summarizes the details per domain by percentage
of the AGREE II tool. Scope and Purpose and Clarity of presentation
domains showed the highest scores (27.7\% IQR 16.6 and 27.7\% IQR 11.1,
respectively). Individual domains are reported in table 4. The following
items were not reported in any of the included CPGs: The views and
preferences of the target population (patients, public, etc.) and the
methods for formulating the recommendations.

\textbf{GRADE framework}

Twenty-five (29.1\%) of the CPGs reported using the GRADE framework for
the quality of evidence assessment. However, most of the CPGs combined
GRADE with others grading systems; only five GPGs used the GRADE
framework exclusively. Regarding the GRADE adherence: None of the
included CPGs reported the explicit statement of each PICO element, only
one (4\%) reported SoF tables and none reported the explicit reference
to all GRADE domains.

\textbf{DISCUSSION}

Our study found that CENETEC guideline production had a low score by the
AGREE II tool. Using this instrument, we identified the following
pitfalls in eligible guidelines i) Most of the health related questions
were not created using the explicit elements of the PICO format ii) The
target audience was excessively broad \emph{-- aiming to reach nurses,
doctors and other healthcare professional, across the different levels
of health care --} iii) The views and preferences of the target
population were not included iv) The systematic review methods were
inconsistent across the guidelines v) The CPGs mixed different grading
systems, vi) no formal external peer review was conducted vi) The
transition from the evidence to the recommendations was not transparent
and clear vii) and the recommendations were sometimes were unclear and
ambiguous viii)

We also found that guideline adherence to the GRADE framework was very
low. Only one of the approximately 30\% of the guidelines that purported
to use GRADE included SoF tables, nor did they transparently address the
GRADE domains related to reasons rating the quality of the evidence down
or up.

The strengths of this study include the intensive training in the AGREE
II tool provided to the reviewers, the experience of the team in used of
the GRADE framework, and the relatively large number of CPGs included.
Our study is limited by the following: although we did provide intensive
training before the CPGs assessment, most of the reviewers were not
experts in guideline development, and so possibilities of incomplete
understanding remain. A standardized and valid tool to assess adherence
to the GRADE framework is unavailable. To address this issue, we created
an ad hoc instrument, the reliability and validity of which remains
untested.

In 2019 Cabrera et al. reviewed the guideline development process with
respect to the GRADE framework in guidelines developed in Latin America
and Caribbean countries.\textsuperscript{(17)} The CPGs were developed
by Colombia (68\%), Peru (13\%), Chile (9\%), Argentina, Costa Rica,
Brazil, Honduras and Dominican Republic. The authors focused their
analysis in detecting the methods for grading the quality of evidence
and topic prioritization without formally assessing the adherence to the
GRADE framework. The authors conducted a literature search on MEDLINE,
SciELO and Embase, also, they search within guideline repositories and
other governmental websites. They did not, however, include the
``Catalogo maestro'', and thus excluded all the CENETEC CPGs. Of the
1,370 CPGs the authors assessed, only 98 (8.9\%) followed the GRADE
framework. In our findings we identify more CPGs using the GRADE
approach (29.1\%), but found very poor adherence to GRADE, an issue
unaddressed in this previous work.

In general, our findings shown that despite the impressive and admirable
production of CPGs by CENETEC, they in general have a number of
methodological limitations.

\textbf{CONCLUSION}

CPGs produced by CENETEC during this period had a low score by AGREE II
standards and low adherence to the GRADE framework. Improving the
training of methodologists in the GRADE methodology and addressing the
specific pitfalls in the guidelines development process that we have
highlighted should be a priority for CENETEC guidelines process.
Enhancing the developer's capacity and the guidelines quality will
result in better and more trustworthy guideline to be used in Mexico

\textbf{CONFLICT OF INTEREST:} The authors declared that they do not
have financial conflicts of interest. Also, none of the authors are part
of CENETEC organization. RN, IDF and GG are members of the GRADE working
group. IDF is part of the AGREE collaboration.

\textbf{AUTHORS CONTRIBUTIONS}

\textbf{LECL:} Refining the research idea, creating the research design,
selecting an Instrument, selection of statistical tests, performing
statistical analyses, interpretation of statistical analyses, performing
the CPGs assessment, writing the manuscript and managing submission
process.

\textbf{GPG:} Conceptualizing the research idea, creating the research
design, selecting an instrument, interpretation of statistical analyses
and manuscript feedback.

\textbf{GMV:} Conceptualizing the research idea, creating the research
design, selecting an Instrument, performing the CPGs assessment,
manuscript feedback.

\textbf{VAAO:} Performing the CPGs assessment and manuscript feedback.

\textbf{GTFJ} : Performing the CPGs assessment and manuscript feedback.

\textbf{PGL:} Performing the CPGs assessment and manuscript feedback.

\textbf{YOE:} Performing the CPGs assessment and manuscript feedback.

\textbf{MTUI:} Performing the CPGs assessment and manuscript feedback.

\textbf{SVSJ:} Performing the CPGs assessment and manuscript feedback.

\textbf{GMLA:} Performing the CPGs assessment and manuscript feedback.

\textbf{RN:} Interpretation of statistical analyses and manuscript
feedback.\textbf{GG:} Interpretation of statistical analyses and
manuscript feedback.

\textbf{IDF:} Selecting an Instrument, selection of statistical tests,
interpretation of statistical analyses and manuscript feedback.

\textbf{References}

1. World, Health, Organization. WHO Handbook for guideline development.
2nd ed. Switzerland (Geneva)2014.

2. CENETEC. CENETEC difusión 2018. Available from:
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3. Wollersheim H. Beyond the evidence of guidelines. The Netherlands
journal of medicine. 2009;67(2):39-40.

4. Agree., Collaboration. Development and validation of an international
appraisal instrument for assessing the quality of clinical practice
guidelines: the AGREE project. Quality \& safety in health care.
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5. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et
al. AGREE II: advancing guideline development, reporting, and evaluation
in health care. Preventive medicine. 2010;51(5):421-4.

6. Dans AL, Dans LF. Appraising a tool for guideline appraisal (the
AGREE II instrument). Journal of clinical epidemiology.
2010;63(12):1281-2.

7. GRADE, Working, Group. The Grading of Recommendations Assessment,
Development and Evaluation (GRADE) 2004 - 2018 {[}01/21/2019{]}.
Available from: http://www.gradeworkinggroup.org/.

8. Group TGW. GRADE handbook for grading quality of evidence and
strength of recommendations. Schünemann H BJ, Guyatt G, Oxman A,
editor2013 (Updated October).

9. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE
guidelines: 1. Introduction-GRADE evidence profiles and summary of
findings tables. Journal of clinical epidemiology. 2011;64(4):383-94.

10. Zhang Y, Akl EA, Schünemann HJ. Using systematic reviews in
guideline development: The GRADE approach. Research Synthesis Methods
{[}Internet{]}. 2018. Available from:
https://onlinelibrary.wiley.com/doi/abs/10.1002/jrsm.1313.

11. Poblano-Verastegui O, Vieyra-Romero WI, Galvan-Garcia AF,
Fernandez-Elorriaga M, Rodriguez-Martinez AI, Saturno-Hernandez PJ.
{[}Quality and compliance with Clinical Practice Guidelines of Chronic
Noncommunicable Diseases in primary care{]}. Salud publica de Mexico.
2017;59(2):165-75.

12. Leyva De Los Ríos CD P-GG, Izabal Delgado DE, Coronado Araujo J,
Rodríguez Páez IV, Rodríguez Lizárraga JD. Use of Cochrane Evidence in
Mexican clinical practice guidelines Gloval Evidence Summit Using
Evidence Improving lives; Cope Town, South Afríca2017.

13. Epidat. programa para análisis epidemiológico de datos. Versión 4.2.
Consellería de Sanidade, Xunta de Galicia, España; Organización
Panamericana de la Salud (OPS-OMS); Universidad CES, Colombia. 2016.

14. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et
al. Development of the AGREE II, part 1: performance, usefulness and
areas for improvement. CMAJ : Canadian Medical Association journal =
journal de l'Association medicale canadienne. 2010;182(10):1045-52.

15. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et
al. Development of the AGREE II, part 2: assessment of validity of items
and tools to support application. CMAJ : Canadian Medical Association
journal = journal de l'Association medicale canadienne.
2010;182(10):E472-8.

16. J L. eulerr: Area-Proportional Euler and Venn Diagrams with
Ellipses. R package version 5.1.0,. 2019.

17. Cabrera PA, Pardo R. Review of evidence based clinical practice
guidelines developed in Latin America and Caribbean during the last
decade: an analysis of the methods for grading quality of evidence and
topic prioritization. Globalization and health. 2019;15(1):14.

Tables\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Table 3. AGREE II Critical appraisal overall domains (\%), N =
86} & \textbf{Table 3. AGREE II Critical appraisal overall domains (\%),
N = 86}\tabularnewline
\midrule
\endhead
Variables & Estimates\tabularnewline
Scope and Purpose, median (IQR) & 27.7 (16.6)\tabularnewline
Stakeholder Involvement, median (IQR) & 22.2 (5.5)\tabularnewline
Rigor of Development, median (IQR) & 17 (6.9)\tabularnewline
Clarity of Presentation, median (IQR) & 27.7 (11.1)\tabularnewline
Applicability, median (IQR) & 16.6 (8.3)\tabularnewline
Editorial Independence, median (IQR) & 16.6 (0.0)
\textsuperscript{\textbackslash{}euro}\tabularnewline
Overall Assessment, median (IQR) & 16.6 (0.0)
\selectlanguage{ngerman}\textsuperscript{£}\tabularnewline
\textbackslash{}euro. Minimal value 16.6, maximal value 33.3, £ Minimal
value 16.6, maximal value 50 & \textbackslash{}euro. Minimal value 16.6,
maximal value 33.3, \selectlanguage{ngerman}£ Minimal value 16.6, maximal value
50\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Table 4. AGREE II Critical appraisal - individual domains. N =
86} & \textbf{Table 4. AGREE II Critical appraisal - individual domains.
N = 86}\tabularnewline
\midrule
\endhead
Variables & Scores\tabularnewline
Scope and Purpose, median (min -- max) &\tabularnewline
1. ~~~~~~The overall objective(s) of the guideline is (are) specifically
described. & 3 (2 -- 5)\tabularnewline
2. ~~~~~~The health question(s) covered by the guideline is (are)
specifically described. & 2 (2 -- 5)\tabularnewline
3. ~~~~~~The population (patients, public, etc.) to whom the guideline
is meant to apply is specifically described. & 2 (2 -- 6)\tabularnewline
Stakeholder involvement, median (min -- max) &\tabularnewline
4. ~~~~~~The guideline development group includes individuals from all
relevant professional groups. & 3 (2 -- 5)\tabularnewline
5. ~~~~~~The views and preferences of the target population (patients,
public, etc.) have been sought. & 1\tabularnewline
6. ~~~~~~The target users of the guideline are clearly defined. & 3 (2
-- 6)\tabularnewline
Rigor of development, median (min -- max) &\tabularnewline
7. ~~~~~~Systematic methods were used to search for evidence. & 2 (2 --
4)\tabularnewline
8. ~~~~~~The criteria for selecting the evidence are clearly described.
& 2 (2 - 3)\tabularnewline
9. ~~~~~~The strengths and limitations of the body of evidence are
clearly described. & 2 (2 -- 3)\tabularnewline
10. ~~The methods for formulating the recommendations are clearly
described. & 1\tabularnewline
11. ~~The health benefits, side effects, and risks have been considered
in formulating the recommendations. & 2 (1 -- 4)\tabularnewline
12. ~~There is an explicit link between the recommendations and the
supporting evidence. & 3 (2 -- 4)\tabularnewline
13. ~~The guideline has been externally reviewed by experts prior to its
publication. & 2 (1 -- 3)\tabularnewline
14. ~~A procedure for updating the guideline is provided. & 2 (2 --
5)\tabularnewline
Clarity of presentation, median (min -- max) &\tabularnewline
15. ~~The recommendations are specific and unambiguous. & 3 (2 --
5)\tabularnewline
16. ~~The different options for management of the condition or health
issue are clearly presented. & 2 (2 -- 5)\tabularnewline
17. ~~Key recommendations are easily identifiable. & 3 (2 --
7)\tabularnewline
Applicability, median (min -- max) &\tabularnewline
18. ~~The guideline describes facilitators and barriers to its
application. & 2 (1 -- 4)\tabularnewline
19. ~~The guideline provides advice and/or tools on how the
recommendations can be put into practice. & 3 (2 -- 4)\tabularnewline
20. ~~The potential resource implications of applying the
recommendations have been considered. & 2 (2 -- 3)\tabularnewline
21. ~~The guideline presents monitoring and/or auditing criteria. & 2 (1
-- 5)\tabularnewline
Editorial independence, median (min -- max) &\tabularnewline
22. ~~The views of the funding body have not influenced the content of
the guideline. & 2 (2 -- 4)\tabularnewline
23. ~~Competing interests of guideline development group members have
been recorded and addressed. & 2 (2 - 4)\tabularnewline
Overall Assessment, median (min -- max) & 2 (2 -- 4)\tabularnewline
\bottomrule
\end{longtable}

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