Quality assessment of Clinical Practice Guidelines (CPG) for the diagnosis and treatment of Inflammatory Bowel Disease using the AGREE II instrument: A Systematic Review.

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Renato Zambrano-Sánchez, Paulina Alvarez-Mena, Diego Hidalgo, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1754875/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: The incidence and diagnosis of inflammatory bowel disease (IBD) has increased considerably in recent years. Many clinical practice guidelines (CPG) have been developed for the management of this disease across different clinical contexts, however, little evidence exists on their methodological quality. Therefore, we aimed to systematically evaluate the quality of CPGs for the diagnosis and treatment of IBD using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Methods: We identified CPGs by searching databases (MEDLINE - PubMed, EMBASE, CINAHL, LILACS) and other sources of gray literature on January 2022. We included guidelines with specific recommendations for the diagnosis and treatment of IBD and evaluated them with the AGREE II instrument to assess their methodological quality. Six independent reviewers assessed the quality of the guidelines and resolved conflicts by consensus. We assessed the degree of agreement using the intraclass correlation coefficient (ICC) and change in quality over time was appraised in two periods: from 2012 to 2017 and from 2018 to 2022. Results: We analyzed and evaluated 26 CPGs that met the inclusion criteria. The overall agreement among reviewers was moderate (ICC: 0.74; 95% CI 0.36 - 0.89). The mean scores of the AGREE II domains were: "Scope and purpose" 84.51%, "Stakeholder involvement" 60.90%, "Rigor of development" 69.95%, "Clarity of presentation" 85.58%, "Applicability" 26.60%, and "Editorial independence" 62.02%. No changes in quality were found over time. Conclusions: The quality of the CPGs evaluated was generally good, with a large majority of the assessed guidelines being "recommended" and "recommended with modifications"; despite this, there is still room for improvement, especially in terms of stakeholder involvement and applicability. Efforts to develop high quality CPGs for IBD need to be further optimized. Inflammatory bowel disease Crohn disease Ulcerative colitis Clinical practice guidelines Systematic review. Figures Figure 1 Figure 2 Figure 3 1. Introduction Ulcerative colitis and Crohn's disease are the main forms of inflammatory bowel disease (IBD). Both pathologies involve chronic inflammation of the gastrointestinal tract and show heterogeneity in terms of symptoms, which mainly include abdominal pain and diarrhea associated with malabsorption, weight loss and fever. ( 1 ) IBD involves periods of relapse and remission. ( 2 ) Although its etiology is unknown, it has been considered a multifactorial disease due to its association to genetic factors ( 3 ) , immune mediators ( 4 ) , changes in the intestinal microbiome ( 5 ) and exposure to various environmental agents. ( 6 ) The onset of IBD generally occurs around the third decade of life, but 25% of cases begin during childhood and adolescence. ( 7 ) The peak age of onset for Crohn's disease is generally between 20 and 30 years of age, while Ulcerative Colitis usually begins at around 30 and 40 years of age. ( 8 ) The incidence and prevalence of IBD vary according to the geographic location, environment and ethnicity. ( 9 ) The latest reported data on the incidence of Ulcerative Colitis in North America and Europe ranged from 0 to 19.2 per 100,000 and 0.6 to 24.3 per 100,000, respectively ( 10 ) ; whereas the prevalence of Ulcerative Colitis was 37.5 to 248.6 per 100,000 in North America and 4.9 to 505 per 100,000 in Europe. ( 11 ) For Crohn's disease, the incidence varied from 0 to 20.2 per 100,000 in North America and from 0.3 to 12.7 per 100,000 in Europe. ( 10 ) In Latin America these data have considerable differences, however, in the last decades there has been a progressive increase with a prevalence of 0.99 to 44.3 per 100,000 inhabitants for Ulcerative Colitis and 0.24 to 16.7 per 100,000 inhabitants for Crohn's disease. ( 12 , 13 ) Epidemiological data suggest that the global incidence of IBD presents a marked increase, implying that the health systems of developing countries do not have the resources, health staff and infrastructure necessary for the diagnosis and treatment of the pathology. Considering the increasing prevalence of IBD and its impacts in terms of health, society and economy (direct and indirect costs for the health systems and out-of-pocket expenses) ( 13 ) , it is important to ensure high quality tools that facilitate its systematized treatment. For this reason, in the last decade, there have been important advances in terms of therapies for the management of IBD through pharmacological, non-pharmacological and surgical interventions ( 14 , 15 ) , these advances have been translated into several Clinical Practice Guidelines (CPG), which quality has not yet been assessed. CPGs are systematically developed statements intended to help physicians and patients to make decisions about appropriate medical care in specific circumstances based on high-quality scientific evidence. ( 16 ) Their recommendations are intended to improve the quality of patient care by encouraging interventions of proven benefit and discouraging ineffective or potentially harmful interventions. ( 16 ) Several tools currently exist to assess the quality of a CPG and its implementation ( 17 ) ; the AGREE (Appraisal of Guidelines, Research, and Evaluation) collaboration developed the AGREE II tool which is the most validated and widely used tool. ( 18 , 19 ) This tool is helpful to assess the transparency in guidelines development and their quality, it provides a methodological strategy for guidelines development, and establishes a scheme for their reporting. ( 20 ) The AGREE II tool can be applied in Clinical Practice Guidelines (CPG) for diagnosis and medical interventions as well as for the evaluation of guidelines on health promotion, public health, among others. ( 20 ) Therefore, the main objective of this study is to systematically evaluate CPG for the diagnosis and treatment of IBD using the AGREE II tool, to provide evidence on their methodological quality and to assess changes in guideline quality over time. 2. Methods 2.1 Data Search A systematic search was performed up to January 2022 to look for CPG on the diagnosis and treatment of IBD. CPGs were searched on databases (MEDLINE - PubMed, EMBASE, CINAHL, LILACS), professional societies (CAG, British Society of Gastroenterology, AGA, Brazilian Society of Gastroenterology), registries and guideline developers´ websites (NICE, SIGN). The full search strategy is detailed in Additional file 1. 2.2 Inclusion and exclusion criteria We included: 1.- CPGs with specific recommendations for the diagnosis and treatment of IBD, both for Crohn's disease (CD) and ulcerative colitis (UC); 2. CPGs on IBD that included pediatric, young, adult, and elderly populations; 3. - CPGs that conducted their search strategy in at least one database; 4.- CPGs that mentioned how they reached recommendations; and 5.- CPGs published without date restriction until January 2022. The following documents were excluded: 1.- secondary publications such as systematic reviews and meta-analyses for IBD and 2.- abstracts developed from CPG for IBD. 2.3 Data Collection Five reviewers working in pairs (DH, CMG, PA, RZ, RV) independently peer-screened the guidelines by title and abstract following the above inclusion and exclusion criteria. If the inclusion criteria were met, the full-text article were retrieved and screened by pairs for eligibility. All the screening process was performed using Rayyan (Rayyan Systems Inc) ( 21 ) . Two reviewers independently extracted the following data for each CPG: title, year of publication, submitting organization, type of funding, method used to collect evidence, number of sources documented, methods used to assess the quality and validity of the evidence, methods used to formulate the recommendations, country, and language. In case of disagreement, a third reviewer (VA, DSR) was involved. 2.4 Quality assessment The AGREE II instrument ( 18 – 20 , 22 ) was used to evaluate the quality of the included CPGs. This instrument provides criteria for assessing the quality of the clinical practice guidelines through 23 items or questions, divided into 6 domains or categories; including: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Each item or question is classified on a 7-point Likert-type scale, 7 being the maximum score corresponding to "strongly agree" and 1 the minimum score corresponding to "strongly disagree". For the global guideline evaluation, we used a 3-point scale: 1 "not recommended", 2 "recommended with modifications" and 3 "recommended". Six reviewers (DH, CMG, PA, RZ, JAF, RV), with clinical and methodological expertise, independently peer-scored each of the 23 items of the 6 domains of the AGREE II instrument for each CPG that was included. In case of disagreements with the assessment, a consensus was reached with the support of a third reviewer (AV, DSR). 2.5 Statistical analysis A descriptive analysis of the CPGs was performed using the general characteristics of each CPG from the extracted data. To calculate the score for each domain of the AGREE II tool, all item scores were summed up and the total value was standardized as a percentage of the maximum possible score for that domain, using the following formula: With this method, the standardized score for each domain ranged from 0 to 100%. The result of the standardized score for each domain for all the guidelines is presented through the mean, median, first quartile (Q1), third quartile (Q3), interquartile range (IQR) and a boxplot. The degree of agreement between reviewers was assessed through the intraclass correlation coefficient (ICC) with a 95% confidence interval (CI). For the analysis of quality change over time, Student's t-test was used to compare the means and categorize the CPGs into two periods: 2012 to 2017 and 2018 to 2022. Data analysis was performed in the statistical software RStudio v.1.4 ( 23 ) using the libraries ggplot2 ( 24 ) , irr ( 25 ) , tidyverse ( 26 ) and table1 ( 27 ) . 3. Results 3.1 Guideline characteristics 8723 records were retrieved from the search strategy and 8165 remained after deduplication. 203 records were subsequently screened by full-text, of which 26 CPGs were included for data extraction after meeting the inclusion criteria (Fig. 1). Details on the characteristics of the included CPGs are shown in Table 1. ( 28 – 53 ) Of the 26 included CPGs, four were from the United States (15.38%) and four were developed by an international collaboration (15.38%); three were from the United Kingdom, three from Canada and three from Japan (11.53% each), two were from Brazil and two from Mexico (7.69% each); one was from Germany, Israel, South Korea, the Netherlands and Poland (3.84% each). Included guidelines were published between 2012 and 2021 (see Table 1). Three of the 26 guidelines focused exclusively on the pediatric population while the others were mainly focused on adults. ( 29 , 33 , 51 ) In terms of the scope of the CPGs, 22 dealt with diagnosis and clinical management ( 28 – 30 , 32 – 41 , 43 – 45 , 47 – 49 , 51 – 53 ) , two with the use of biologic drugs only ( 42 , 46 ) , one with surgical management in the emergency setting ( 50 ) and one with the surgical management of ulcerative colitis. ( 31 ) All guidelines were considered evidence-based according to our a priori criteria. Eighteen guidelines (69.23%) used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to assess the quality of evidence and grade the strength of recommendations. Seven guidelines (26.92%) used the Oxford Centre for Evidence-Based Medicine criteria, and one guideline (3.84%) used a self-grading system to assess the quality of evidence (Table 1). Table 1. General characteristics of the CPGs. Guideline Country Organization Year Method used to asses quality and strength of evidence AGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis (28) USA American Gastroenterological Association (AGA) 2019 GRADE* ESPGHAN Revised Porto Criteria for the Diagnosis of Inflammatory Bowel Disease in Children and Adolescents (29) UK European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) 2013 Oxford Centre for Evidence-Based Medicine ACG Clinical Guideline: Management of Crohn’s Disease in Adults (30) USA American College of Gastroenterology 2018 GRADE European evidence based consensus on surgery for ulcerative colitis (31) Multinational European Crohn’s and Colitis Organization (ECCO) 2014 Oxford Center for Evidence-Based Medicine Updated German Clinical Practice Guideline on “Diagnosis and treatment of Crohn's disease” 2014 (32) Germany German Society for gastroenterology, digestive and metabolic diseases (DGVS) with the participation of Deutsche Gesellschaft for General and Visceral Surgery (DGAV), German Society of Surgery (DGCh), German Society for Internal Medicine (DGIM), German Society for Coloproctology (DGK), German Morbus Crohn's / ulcerative colitis association (DCCV), Society for pediatric gastroenterology and nutrition (GPGE), Competence Network for Inflammatory Bowel Diseases. 2014 Oxford Center for Evidence-Based Medicine Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease (33) Multinational European Crohn's and Colitis Organization (ECCO / ESPGHAN) 2014 Oxford Center for Evidence-Based Medicine Management of paediatric ulcerative colitis, Part 1: ambulatory care- an evidence-based guideline from ECCO and ESPGHAN (34) Israel Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel. 2018 Oxford Centre for Evidence-Based Medicine Evidence-based clinical practice guidelines for Crohn’s disease, integrated with formal consensus of experts in Japan (35) Japan Japanese Society of Gastroenterology and the Research group of Intractable Bowel Disease subsidized by the Ministry of the Health, Labour and Welfare of Japan 2013 Self-grading scheme used to assess the quality of the evidence Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation (36) Mexico Pan American Crohn's and Colitis Organization 2016 Oxford Center for Evidence-Based Medicine Mexican consensus for the diagnosis and treatment of idiopathic chronic ulcerative colitis (37) Mexico Mexican Association of Gastroenterology 2017 GRADE Crohn's disease Management in adults, children and young people (38) UK NICE National institute for health care and excellence 2012 GRADE Second Korean guidelines for the management of ulcerative colitis (39) Korea Korean Association for the Study of Intestinal Diseases (KASID) 2017 GRADE AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis (40) USA AGA American Gastroenterological Association 2020 GRADE Evidence-based clinical practice guidelines for inflammatory bowel disease (41) Japan The Japanese Society of Gastroenterology (JSGE) 2018 GRADE Ulcerative colitis - treatment with biologicals (42) Brazil Brazilian Study Group on Inflammatory Bowel Disease, Brazilian Medical Association 2018 GRADE British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults (43) UK British Society of Gastroenterology and others 2019 GRADE Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn’s Disease (44) Canada Canadian Association of Gastroenterology (CAG) 2019 GRADE Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn’s Disease: The Toronto Consensus (45) Canada Canadian Association of Gastroenterology (CAG) 2018 GRADE Crohn’s disease - treatment with biological medication (46) Brazil Brazilian Study Group on Inflammatory Bowel Disease, Brazilian Gastroenterology Federation, Brazilian Coloproctology Society, Brazilian Medical Association 2018 GRADE Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn’s Disease (47) Canada Canadian Association of Gastroenterology (CAG) 2019 GRADE Evidence-based clinical practice guidelines for inflammatory bowel disease 2020 (48) Japan The Japanese Society of Gastroenterology (JSGE) 2021 GRADE AGA Clinical Practice Guidelines on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn’s Disease (49) USA AGA American Gastroenterological Association 2021 GRADE WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting (50) Netherlands The World Society of Emergency Surgery WSES 2021 GRADE The Medical Management of Paediatric Crohn’s Disease: an ECCO-ESPGHAN Guideline Update (51) Multinational European Crohn’s and Colitis Organization [ECCO] and the Paediatric IBD Porto group of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition [ESPGHAN] 2021 Oxford Center for Evidence-Based Medicine Guidelines for the management of patients with Crohn’s disease. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology (52) Poland The Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology 2021 GRADE ECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment (53) Multinational The European Crohn’s and Colitis Organization [ECCO] 2020 GRADE *GRADE = Grading of Recommendations, Assessment, Development and Evaluation 3.2 Quality assessment The agreement between the 6 reviewers was moderate with an ICC of 0.74 (95% CI: 0.36–0.89, p-value = 6.83e -4 ). A summary of the ICCs achieved by each pair of reviewers is shown in Table 2. Table 2. Intraclass correlation coefficients (ICC) by peer reviewers. Pair of reviewers ICC 95% CI *P-value **ICC interpretation RZ + PA 0.69 0.02 - 0.90 0.020 Moderate CM + JF 0.74 -0.07 - 0.97 0.065 Moderate DH + RV 0.03 -0.03 - 0.74 0.292 Poor DH + JF 0.69 -0.15 - 0.99 0.093 moderate Global 0.74 0.36 - 0.89 6.83e -4 moderate *Significance level <0.05 **ICC interpretation following Ko and Li 2016 (53) Figure 2 shows a boxplot summarizing the statistical analysis of the standardized scores for each domain assessed with the AGREE II tool. In addition, Table 3 shows the standardized scores for all domain assessed in each clinical practice guideline. 3.2.1 Domain 1: Scope and purpose This domain evaluates the general objective of the CPG, specific health aspects and the target population. ( 19 ) The mean score was 84.51% (median: 90.27%, Q1: 78.47%, Q3: 94.44% and IQR = 15.97%; Fig. 2). Twenty-four CPGs (92.30%) scored above 60% in this domain. ( 28 , 29 , 31 – 36 , 38 – 53 ) See Table 3 for details on domain 1. 3.2.2 Domain 2: Stakeholder involvement This domain refers to the degree to which the guideline has been developed by the appropriate stakeholders and represents the views of intended users. ( 19 ) The mean score was 60.90% (median: 66.67%, Q1: 36.11%, Q3: 83.33% and IQR = 47.22%; Fig. 2). Fourteen CPGs (53.84%) scored above 60% in this domain. ( 32 , 38 , 40 , 41 , 43 – 45 , 47 – 53 ) See Table 3 for details on domain 2. 3.2.3 Domain 3: Rigor of development This domain refers to the process used to gather and synthesize evidence, the methods used to formulate and update recommendations. ( 19 ) The mean score was 69.95% (median: 69.79%, Q1: 58.07%, Q3: 100.00% and IQR = 28.12%; Fig. 2). Nineteen CPGs (73.07%) scored above 60% in this domain. (28,32–34,36,38–41,43-45,47−53) See Table 3 for details on domain 3. 3.2.4 Domain 4: Clarity of presentation This domain focuses on the language, structure and format of the guideline. ( 19 ) The mean score was 85.58% (median: 91.67%, Q1: 75.00%, Q3: 100.00% and IQR = 25%; Fig. 2). Twenty-four CPGs (92.30%) scored above 60% in this domain. (28–41,43-45,47−53) See Table 3 for details on domain 4. 3.2.5 Domain 5: Applicability This domain refers to barriers and facilitators to CPG implementation, strategies for its adoption and resource considerations. ( 19 ) The median score was 26.60% (median: 20.83%, Q1: 12.50%, Q3: 39.06% and IQR = 26.56%; Fig. 2). Only one CPG (3.84%) scored above 60% in this domain. ( 38 ) See Table 3 for details on domain 5. Table 3. Standardized scores by domains of AGREE II. Guideline Scope and Purpose Stakeholder Involvement Rigour of Development Clarity of Presentation Applicability Editorial Independence Overall Recommendation AGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis (28) 94.44 30.56 60.42 83.33 25.00 75.00 Recommended, with modifications ESPGHAN Revised Porto Criteria for the Diagnosis of Inflammatory Bowel Disease in Children and Adolescents (29) 75.00 36.11 57.29 86.11 18.75 33.33 Recommended, with modifications ACG Clinical Guideline: Management of Crohn’s Disease in Adults (30) 44.44 5.56 35.42 72.22 4.17 29.17 Not recommended European evidence based consensus on surgery for ulcerative colitis (31) 75.00 36.11 50.00 66.67 6.25 29.17 Recommended, with modifications Updated German Clinical Practice Guideline on “Diagnosis and treatment of Crohn's disease” 2014 (32) 91.67 86.11 83.33 61.11 12.50 91.67 Recommended, with modifications Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease (33) 72.22 52.78 61.46 83.33 12.50 12.50 Recommended, with modifications Management of paediatric ulcerative colitis, Part 1: ambulatory care- an evidence-based guideline from ECCO and ESPGHAN (34) 83.33 27.78 67.71 83.33 6.25 66.67 Recommended, with modifications Evidence-based clinical practice guidelines for Crohn’s disease, integrated with formal consensus of experts in Japan (35) 91.67 52.78 56.25 94.44 16.67 79.17 Recommended, with modifications Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation (36) 75.00 30.56 60.42 69.44 12.50 50.00 Recommended, with modifications Mexican consensus for the diagnosis and treatment of idiopathic chronic ulcerative colitis (37) 36.11 19.44 50.00 63.89 6.25 62.50 Not recommended Crohn's disease Management in adults, children and young people (38) 94.44 83.33 94.79 100.00 83.33 75.00 Recommended Second Korean guidelines for the management of ulcerative colitis (39) 80.55 58.33 71.88 100.00 22.92 29.17 Recommended, with modifications AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis (40) 100.00 80.56 91.67 100.00 56.25 83.33 Recommended Evidence-based clinical practice guidelines for inflammatory bowel disease (41) 91.66 75.00 82.29 88.89 58.33 83.33 Recommended, with modifications Ulcerative colitis - treatment with biologicals (42) 88.88 33.33 45.83 55.56 6.25 0.00 Not recommended British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults (43) 100.00 100.00 91.67 100.00 45.83 100.00 Recommended Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn’s Disease (44) 100.00 94.44 85.42 100.00 25.00 95.83 Recommended Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn’s Disease: The Toronto Consensus (45) 86.11 91.67 79.17 100.00 14.58 95.83 Recommended, with modifications Crohn’s disease - treatment with biological medication (46) 80.55 44.44 34.38 44.44 4.17 0.00 Not recommended Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn’s Disease (47) 100.00 91.67 90.63 100.00 37.50 91.67 Recommended Evidence-based clinical practice guidelines for inflammatory bowel disease 2020 (48) 77.78 66.67 66.67 91.67 18.75 87.50 Recommended, with modifications AGA Clinical Practice Guidelines on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn’s Disease (49) 94.44 83.33 87.50 100.00 52.08 91.67 Recommended WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting (50) 86.11 69.44 63.54 91.67 25.00 50.00 Recommended, with modifications The Medical Management of Paediatric Crohn’s Disease: an ECCO-ESPGHAN Guideline Update (51) 91.67 66.67 86.46 100.00 39.58 100.00 Recommended, with modifications Guidelines for the management of patients with Crohn’s disease. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology (52) 94.44 72.22 71.88 91.67 33.33 0.00 Recommended, with modifications ECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment (53) 91.67 94.44 92.71 97.22 47.92 100.00 Recommended Mean Score 84.51 60.90 69.95 85.58 26.60 62.02 Median 90.27 66.67 69.79 91.67 20.83 75.00 3.2.6 Domain 6: Editorial Independence This domain is about the formulation of recommendations, understand whether they are biased by conflicts of interest. ( 19 ) The median score was 62.02% (median: 75.00%, Q1: 30.21%, Q3: 91.67% and IQR = 61.45%; Fig. 2). Sixteen CPGs (61.53%) scored above 60% in this domain. ( 28 , 32 , 34 , 35 , 37 , 38 , 40 , 41 , 43 – 45 , 47 – 49 , 51 , 53 ) See Table 3 for details on domain 6. 3.2.7 Overall assessment Seven out of the 26 evaluated CPGs (26.9%) were "recommended" by the independent reviewers. ( 38 , 40 , 43 , 44 , 47 , 49 , 53 ) Most of the CPGs, 15 guidelines (57.7%), were "recommended with modifications". (28,29,31–36,39,41,45,48,50−52) Finally, 4 CPGs (15.4%) were "not recommended" (see Table 3). ( 30 , 37 , 42 , 46 ) 3.2.8 Combined assessment Finally, to visualize and compare the mean AGREE II scores obtained by the 26 CPGs assessed in this study, we generated a hexagonal radar graph where each domain is represented on a radial axis centered at 0 and the maximum score of each domain corresponds to each vertex of the hexagon (Fig. 3). The domains "scope and purpose", "stakeholder involvement", "rigor of development", "clarity of presentation" and "editorial independence" show similar areas in the scores achieved; however, the domain "applicability" is notoriously deficient in all the evaluated guidelines. 3.3 Quality assessment over time With respect to quality change over time, no statistically significant differences were found for the means of the standardized scores for each AGREE II domain between the guidelines published during the 2012–2017 period and those published between 2018 and 2022 (Table 4). Table 4. Quality changes over time. Domain Guidelines from 2012-2017 Guidelines from 2018-2022 **P-value Scope and purpose 81.9 (9.15) 85.6 (17.9) 0.5868 Stakeholder involvement 54.5 (21.0) 63.7 (29.4) 0.4336 Rigour of development 66.9 (15.3) 71.3 (19.6) 0.5817 Clarity of presentation 82.6 (15.3) 86.9 (17.0) 0.5521 Applicability 23.2 (24.8) 28.1 (19.0) 0.5815 Editorial independence 50.0 (28.7) 67.4 (36.3) 0.2444 *Data given as mean +/- (SD) of standardized scores. **Significance level <0.05, p-value with Student's t method for the difference of two means. 4 Discussion 4.1 What do the findings of this study mean? This review showed that the evaluated IBD CPGs had an acceptable quality based on the AGREE II instrument since 7 out of the 26 evaluated guidelines were “recommended”, 15 were “recommended with modifications” and only 4 were “not recommended”. The domains with the highest scores were “clarity of presentation” and “scope and purpose”, which reached values over 60%, indicating that most of the assessed guidelines had well-defined general and specific objectives, the population to which the guideline was intended to apply was well defined, and the recommendations were clearly described and identifiable. Rigor of development was the domain that received the third best score with 69.95%; this domain could be argued to have the greatest effect on the quality of a clinical practice guideline, since it has to do with the entire process used to formulate and construct the recommendations and it is the one that comprises the most items within AGREE II for its evaluation ( 55 ) . We consider that a score over 60% is more than acceptable for “rigor of development”, which achieved this score due to most guidelines were partly penalized for being unclear with the description of external experts’ assessment and for not having an explicit updating statement. The domains "stakeholder involvement" and "editorial independence" obtained scores slightly over 60% (60.90% and 62.02%, respectively; Fig. 3), which indicates that the views and preferences of patients still need to be considered when the CPG is drafted and that an expert methodologist/epidemiologist should be included in the guideline drafting group. In addition, both domains achieved low scores due to the limited information most guidelines provided in terms of funding and its influence on the guidelines’ content, as well as the lack of detail they included regarding conflicts of interest and how these conflicts were dealt. Considering these limitations on the development of CPGs could contribute to their improvement. The “applicability” domain was the worst scored domain in this review with an average score of 26.60% (Fig. 3), well below the 60% cut-off point for this domain. The main reason for this is that most guideline developers do not fully consider guideline’s implementation in terms of facilitators and barriers for guidelines’ applicability or they do not fully consider the resources and tools that are available in a specific context. We also noted that most of the guidelines did not consider the economic impact of their recommendations on resources and health budgets, for example, most guidelines did not include health economists in the guideline development group or did not perform cost-benefit analysis. The limitations and omissions that have been observed in the included guidelines restraint the translation of these documents into clinical practice, thus hindering its operability. Regarding quality change over time, this study failed to demonstrate statistically significant differences between guidelines published during the 2012–2017 period versus guidelines published between 2018 and 2022 (see Table 4) for any domain covered by AGREE II. This finding may be due to the small sample size in this study, which is associated to the specific inclusion criteria applied in the selection of CPGs as well as the large variety of CPGs for IBD (clinical, surgical, preventive, etc.) we encountered when screening. In addition, the time ranges we compared were too short since guidelines’ development in terms of IBD and our study’s criteria has been an early activity. However, one point to highlight is the implementation and dissemination of the GRADE methodology in the development of guidelines, especially in those produced in the last 4 years; our study found that 17 out of the 26 included CPGs had used this methodology as a framework for grading the evidence and formulating their recommendations. 4.2 The context of this review with other literature While this review is not the first to evaluate clinical practice guidelines on inflammatory bowel disease, it is the first to evaluate a large sample of CPGs as there was no date restriction in its search, which gave us a much broader picture of what has been produced in the past and current time. Thus, in line with other reviews of CPG for IBD conducted by other investigators, and addressing different contexts of inflammatory bowel disease, the domains with the highest scores were “clarity of presentation” and “scope and purpose” and the domains with the lowest scores were “stakeholder involvement” and “applicability”. ( 56 , 57 , 58 ) These results are also similar to previous CPG evaluations for other clinical-surgical areas such as interventional radiology, pediatrics or dermatology. ( 59 , 60 , 61 ) In addition, other studies that investigated quality changes over time for clinical practice guidelines in other specialties did not find evidence of significant changes in quality in the different evaluated periods of time. ( 62 , 63 , 64 ) These results are consistent with the findings of this study. However, studies by Bhatt et al. ( 65 ) for pediatric type II diabetes CPG and Acuña-Izcaray et al. ( 66 ) for asthma CPG, found statistically significant differences in quality over time for the selected periods for each individual domain, while a statistical significance has not been found for all domains at the same time. 4.3 Strengths and limitations Although a strength of our systematic review was the broad and exhaustive approach of our search – carried out in databases, compiling entities and guideline developers, with a sensitive strategy designed for this purpose – it is possible that our review may have missed some CPGs that were not adequately indexed or that dealt with other contexts related to inflammatory bowel disease. Likewise, our study only included CPGs published in English or Spanish, factors that could have contributed to a potential selection bias. Likewise, having chosen CPGs with well-defined inclusion criteria, it is likely that our results have overestimated the score obtained by selecting guidelines that would score higher than the entire possible universe of CPGs for IBD. Therefore, our conclusions acquire more relevance when evaluating this type of guidelines. On the other hand, although the degree of agreement reached by the reviewers was moderate (ICC = 0.74), this may be due to the fact that the AGREE II instrument weights each item with a 7-point Likert-type scale, where only the extreme values of this scale are well defined, but it is prone to subjectivity for intermediate values 3, 4 and 5 on the scale. As our research had a large number of reviewers (six), reaching a higher value for the intraclass correlation coefficient (ICC) to improve reliability was difficult. However, we consider that the value achieved does provide adequate reliability. In addition, since the implementation of the AGREE II tool in 2010, it has become the most widely used and popular resource for assessing the quality of CPGs, choosing a cut-off point above which a guideline can be defined as having good quality is subjective and this selection will depend on the context in which the review is being performed. As Brouwers et al. ( 67 ) noted, “there is no evidence that if a guideline exceeds a certain score, the recommendations are eas“er to adopt, or improve processes of care, or lead to better patient outcomes than guidelines that do not achieve that score”. (67, p.195) That is, the validity of the overall assessment may be limited, as there are no clear rules yet on how to weigh the different domain scores to make a decision on whether or not to recommend guidelines. 4.4 What is new and conclusion Overall, this study determined that the quality of clinical practice guidelines for the diagnosis and treatment of inflammatory bowel disease is acceptable and that there is still room for improvement, especially in terms of stakeholder participation (inclusion of patients, expert methodologists/epidemiologists) and applicability (enablers, barriers, optimization of resources, external review). It is desirable that guideline developers consider these shortcomings in the future for the overall improvement of guidelines’ quality to reduce clinical practice heterogeneity in IBD. Abbreviations CPG (Clinical practice guideline) AGREE (Appraisal of Guidelines, Research, and Evaluation) GRADE (Grading of Recommendations, Assessment, Development and Evaluation) PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) IBD (Inflammatory bowel disease) CD (Crohn's disease) UC (Ulcerative colitis) ICC (Intraclass correlation coefficient) IQR (Interquartile range) SD (Standard deviation) Qi (Quartile) CI (Confidence interval) Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This research study has not received any funding from the public or private sector or from any non-profit entity. Authors' contributions DH, AV-G and CM-G conceived the idea for this research and designed the study. RZ-S, PA-M, CM-G and CME-L searched the literature. DH, CM-G, RZ-S, PA-M and RV screened and selected the guidelines according to the inclusion criteria. DH, CM-G, RZ-S, PA-M, JAF and RV rated and evaluated the guidelines with the AGREE II tool. RZ-S and PA-M conducted the statistical analysis and interpreted the results. RZ-S, PA-M and CM-G wrote the first draft of the report. CM-G, JAF, DS-R, CME-L, RV, AV-G contributed to the review and approved the final manuscript. Acknowledgements We thank the University UTE and the Center for Research in Public Health and Epidemiology (CISPEC) for their support, collaboration and work in the editorial process of this publication. References Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults.2019-31;68(3):1–106. 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Facultad de Ciencias de la Salud Eugenio Espejo. Universidad UTE","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Simancas-Racines","suffix":""},{"id":126061333,"identity":"ebef0eab-24be-4408-80a6-5f54ab0d3d2a","order_by":7,"name":"Andrés Viteri-García","email":"","orcid":"","institution":"Centro de Investigación en Epidemiología Clínica y Salud Pública (CISPEC). Facultad de Ciencias de la Salud Eugenio Espejo. Universidad UTE","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Andrés","middleName":"","lastName":"Viteri-García","suffix":""},{"id":126061334,"identity":"b53c2000-8e36-4f87-8182-89dc9a927357","order_by":8,"name":"Camila Montesinos-Guevara","email":"data:image/png;base64,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","orcid":"","institution":"Centro de Investigación en Epidemiología Clínica y Salud Pública (CISPEC). Facultad de Ciencias de la Salud Eugenio Espejo. Universidad UTE","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Camila","middleName":"","lastName":"Montesinos-Guevara","suffix":""}],"badges":[],"createdAt":"2022-06-13 21:14:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1754875/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1754875/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":24799786,"identity":"58b2db5b-5c3d-4354-9bb2-a7713636584c","added_by":"auto","created_at":"2022-08-04 18:13:02","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":157725,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram showing the flow of records that were obtained and reviewed throughout the different phases of the quality assessment.\u003c/p\u003e","description":"","filename":"Figure1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1754875/v1/839ac894d04d1681eb800034.jpeg"},{"id":24799699,"identity":"2f05243c-6aba-4693-9e1a-49e30890fdc2","added_by":"auto","created_at":"2022-08-04 18:08:02","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":73954,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of standardized scores by domain for the 26 CPGs.\u003c/p\u003e","description":"","filename":"Figure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1754875/v1/24f01abef986dd448d4a1431.jpeg"},{"id":24799697,"identity":"725997d6-3e81-4033-8140-b227447191b0","added_by":"auto","created_at":"2022-08-04 18:08:02","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":91482,"visible":true,"origin":"","legend":"\u003cp\u003eRadar chart of the mean standardized scores by domains of the 26 IBD CPGs assessed.\u003c/p\u003e","description":"","filename":"Figure3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1754875/v1/53aec7cc24646dc86ecc8d5d.jpeg"},{"id":24799787,"identity":"f66948dc-9e66-45b4-a204-b7b2d0ffdc26","added_by":"auto","created_at":"2022-08-04 18:13:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":813843,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1754875/v1/94d0ea2d-9c0d-4ff5-8c61-b83c25bcba4b.pdf"},{"id":24799700,"identity":"99062227-606f-4870-8171-04c5423c82fe","added_by":"auto","created_at":"2022-08-04 18:08:03","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":18656,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-1754875/v1/fa293b0ae07f517df281e41e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Quality assessment of Clinical Practice Guidelines (CPG) for the diagnosis and treatment of Inflammatory Bowel Disease using the AGREE II instrument: A Systematic Review.","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eUlcerative colitis and Crohn's disease are the main forms of inflammatory bowel disease (IBD). Both pathologies involve chronic inflammation of the gastrointestinal tract and show heterogeneity in terms of symptoms, which mainly include abdominal pain and diarrhea associated with malabsorption, weight loss and fever.\u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e IBD involves periods of relapse and remission.\u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e Although its etiology is unknown, it has been considered a multifactorial disease due to its association to genetic factors\u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e, immune mediators\u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e, changes in the intestinal microbiome\u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e and exposure to various environmental agents.\u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe onset of IBD generally occurs around the third decade of life, but 25% of cases begin during childhood and adolescence. \u003csup\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e The peak age of onset for Crohn's disease is generally between 20 and 30 years of age, while Ulcerative Colitis usually begins at around 30 and 40 years of age. \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe incidence and prevalence of IBD vary according to the geographic location, environment and ethnicity.\u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e The latest reported data on the incidence of Ulcerative Colitis in North America and Europe ranged from 0 to 19.2 per 100,000 and 0.6 to 24.3 per 100,000, respectively \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e; whereas the prevalence of Ulcerative Colitis was 37.5 to 248.6 per 100,000 in North America and 4.9 to 505 per 100,000 in Europe.\u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e For Crohn's disease, the incidence varied from 0 to 20.2 per 100,000 in North America and from 0.3 to 12.7 per 100,000 in Europe. \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e In Latin America these data have considerable differences, however, in the last decades there has been a progressive increase with a prevalence of 0.99 to 44.3 per 100,000 inhabitants for Ulcerative Colitis and 0.24 to 16.7 per 100,000 inhabitants for Crohn's disease.\u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e Epidemiological data suggest that the global incidence of IBD presents a marked increase, implying that the health systems of developing countries do not have the resources, health staff and infrastructure necessary for the diagnosis and treatment of the pathology.\u003c/p\u003e \u003cp\u003eConsidering the increasing prevalence of IBD and its impacts in terms of health, society and economy (direct and indirect costs for the health systems and out-of-pocket expenses) \u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e, it is important to ensure high quality tools that facilitate its systematized treatment. For this reason, in the last decade, there have been important advances in terms of therapies for the management of IBD through pharmacological, non-pharmacological and surgical interventions \u003csup\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e, these advances have been translated into several Clinical Practice Guidelines (CPG), which quality has not yet been assessed.\u003c/p\u003e \u003cp\u003eCPGs are systematically developed statements intended to help physicians and patients to make decisions about appropriate medical care in specific circumstances based on high-quality scientific evidence.\u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e Their recommendations are intended to improve the quality of patient care by encouraging interventions of proven benefit and discouraging ineffective or potentially harmful interventions.\u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e Several tools currently exist to assess the quality of a CPG and its implementation\u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e; the AGREE (Appraisal of Guidelines, Research, and Evaluation) collaboration developed the AGREE II tool which is the most validated and widely used tool.\u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e This tool is helpful to assess the transparency in guidelines development and their quality, it provides a methodological strategy for guidelines development, and establishes a scheme for their reporting.\u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e The AGREE II tool can be applied in Clinical Practice Guidelines (CPG) for diagnosis and medical interventions as well as for the evaluation of guidelines on health promotion, public health, among others.\u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTherefore, the main objective of this study is to systematically evaluate CPG for the diagnosis and treatment of IBD using the AGREE II tool, to provide evidence on their methodological quality and to assess changes in guideline quality over time.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Data Search\u003c/h2\u003e \u003cp\u003eA systematic search was performed up to January 2022 to look for CPG on the diagnosis and treatment of IBD. CPGs were searched on databases (MEDLINE - PubMed, EMBASE, CINAHL, LILACS), professional societies (CAG, British Society of Gastroenterology, AGA, Brazilian Society of Gastroenterology), registries and guideline developers\u0026acute; websites (NICE, SIGN). The full search strategy is detailed in \u003cem\u003eAdditional file 1.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Inclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eWe included: 1.- CPGs with specific recommendations for the diagnosis and treatment of IBD, both for Crohn's disease (CD) and ulcerative colitis (UC); 2. CPGs on IBD that included pediatric, young, adult, and elderly populations; 3. - CPGs that conducted their search strategy in at least one database; 4.- CPGs that mentioned how they reached recommendations; and 5.- CPGs published without date restriction until January 2022. The following documents were excluded: 1.- secondary publications such as systematic reviews and meta-analyses for IBD and 2.- abstracts developed from CPG for IBD.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Collection\u003c/h2\u003e \u003cp\u003eFive reviewers working in pairs (DH, CMG, PA, RZ, RV) independently peer-screened the guidelines by title and abstract following the above inclusion and exclusion criteria. If the inclusion criteria were met, the full-text article were retrieved and screened by pairs for eligibility. All the screening process was performed using Rayyan (Rayyan Systems Inc) \u003csup\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/sup\u003e. Two reviewers independently extracted the following data for each CPG: title, year of publication, submitting organization, type of funding, method used to collect evidence, number of sources documented, methods used to assess the quality and validity of the evidence, methods used to formulate the recommendations, country, and language. In case of disagreement, a third reviewer (VA, DSR) was involved.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Quality assessment\u003c/h2\u003e \u003cp\u003eThe AGREE II instrument \u003csup\u003e(\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e was used to evaluate the quality of the included CPGs. This instrument provides criteria for assessing the quality of the clinical practice guidelines through 23 items or questions, divided into 6 domains or categories; including: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Each item or question is classified on a 7-point Likert-type scale, 7 being the maximum score corresponding to \"strongly agree\" and 1 the minimum score corresponding to \"strongly disagree\". For the global guideline evaluation, we used a 3-point scale: 1 \"not recommended\", 2 \"recommended with modifications\" and 3 \"recommended\". Six reviewers (DH, CMG, PA, RZ, JAF, RV), with clinical and methodological expertise, independently peer-scored each of the 23 items of the 6 domains of the AGREE II instrument for each CPG that was included. In case of disagreements with the assessment, a consensus was reached with the support of a third reviewer (AV, DSR).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e \u003cp\u003eA descriptive analysis of the CPGs was performed using the general characteristics of each CPG from the extracted data. To calculate the score for each domain of the AGREE II tool, all item scores were summed up and the total value was standardized as a percentage of the maximum possible score for that domain, using the following formula:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWith this method, the standardized score for each domain ranged from 0 to 100%. The result of the standardized score for each domain for all the guidelines is presented through the mean, median, first quartile (Q1), third quartile (Q3), interquartile range (IQR) and a boxplot. The degree of agreement between reviewers was assessed through the intraclass correlation coefficient (ICC) with a 95% confidence interval (CI). For the analysis of quality change over time, Student's t-test was used to compare the means and categorize the CPGs into two periods: 2012 to 2017 and 2018 to 2022. Data analysis was performed in the statistical software RStudio v.1.4\u003csup\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/sup\u003e using the libraries ggplot2\u003csup\u003e(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/sup\u003e, irr\u003csup\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/sup\u003e, tidyverse\u003csup\u003e(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/sup\u003e and table1\u003csup\u003e(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003e3.1 Guideline characteristics\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e8723 records were retrieved from the search strategy and 8165 remained after deduplication. 203 records were subsequently screened by full-text, of which 26 CPGs were included for data extraction after meeting the inclusion criteria (Fig.\u0026nbsp;1). Details on the characteristics of the included CPGs are shown in Table\u0026nbsp;1. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eOf the 26 included CPGs, four were from the United States (15.38%) and four were developed by an international collaboration (15.38%); three were from the United Kingdom, three from Canada and three from Japan (11.53% each), two were from Brazil and two from Mexico (7.69% each); one was from Germany, Israel, South Korea, the Netherlands and Poland (3.84% each). Included guidelines were published between 2012 and 2021 (see Table\u0026nbsp;1).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThree of the 26 guidelines focused exclusively on the pediatric population while the others were mainly focused on adults.\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/sup\u003e In terms of the scope of the CPGs, 22 dealt with diagnosis and clinical management \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/sup\u003e, two with the use of biologic drugs only \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/sup\u003e, one with surgical management in the emergency setting \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/sup\u003e and one with the surgical management of ulcerative colitis.\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/sup\u003e All guidelines were considered evidence-based according to our a priori criteria.\u003c/p\u003e\n\u003cp\u003eEighteen guidelines (69.23%) used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to assess the quality of evidence and grade the strength of recommendations. Seven guidelines (26.92%) used the Oxford Centre for Evidence-Based Medicine criteria, and one guideline (3.84%) used a self-grading system to assess the quality of evidence (Table\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;1.\u003c/strong\u003e General characteristics of the CPGs.\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003e\u003cstrong\u003eGuideline\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003e\u003cstrong\u003eOrganization\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e\u003cstrong\u003eMethod used to asses quality and strength of evidence\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eAGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis \u003csup\u003e(28)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eUSA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eAmerican Gastroenterological Association (AGA)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eESPGHAN Revised Porto Criteria for the Diagnosis of Inflammatory Bowel Disease in Children and Adolescents \u003csup\u003e(29)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eUK\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eEuropean Society of Pediatric\u0026nbsp;\u0026nbsp; Gastroenterology, Hepatology and Nutrition (ESPGHAN)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2013\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eOxford Centre for Evidence-Based Medicine\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eACG Clinical Guideline: Management of Crohn\u0026rsquo;s\u003cbr /\u003e Disease in Adults \u003csup\u003e(30)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eUSA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eAmerican College of Gastroenterology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eEuropean evidence based consensus on\u003cbr /\u003e surgery for ulcerative colitis \u003csup\u003e(31)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eMultinational\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eEuropean Crohn\u0026rsquo;s and Colitis Organization (ECCO)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2014\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eOxford Center for Evidence-Based Medicine\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eUpdated German Clinical Practice Guideline on \u0026ldquo;Diagnosis and treatment of Crohn's disease\u0026rdquo; 2014 \u003csup\u003e(32)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eGermany\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eGerman Society for gastroenterology, digestive and metabolic diseases (DGVS) with the participation of Deutsche Gesellschaft\u003cbr /\u003e for General and Visceral Surgery (DGAV), German Society of Surgery (DGCh), German Society for Internal Medicine (DGIM), German Society for Coloproctology (DGK), German Morbus Crohn's / ulcerative colitis association (DCCV), Society for pediatric gastroenterology and nutrition (GPGE), Competence Network for Inflammatory Bowel Diseases.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2014\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eOxford Center for Evidence-Based Medicine\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eConsensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease \u003csup\u003e(33)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eMultinational\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eEuropean Crohn's and Colitis Organization (ECCO / ESPGHAN)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2014\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eOxford Center for Evidence-Based Medicine\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eManagement of paediatric ulcerative colitis, Part 1: ambulatory care- an evidence-based\u003cbr /\u003e guideline from ECCO and ESPGHAN \u003csup\u003e(34)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eIsrael\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eShaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eOxford Centre for Evidence-Based Medicine\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eEvidence-based clinical practice guidelines for Crohn\u0026rsquo;s disease, integrated with formal consensus of experts in Japan\u003csup\u003e (35)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eJapan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eJapanese Society of Gastroenterology and the Research group of Intractable Bowel Disease subsidized by the Ministry of the Health, Labour and Welfare of Japan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2013\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e\u003cbr /\u003e Self-grading scheme used to assess the quality of the evidence\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eDiagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation \u003csup\u003e(36)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eMexico\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003ePan American Crohn's and Colitis Organization\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eOxford Center for Evidence-Based Medicine\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eMexican consensus for the diagnosis and treatment of idiopathic chronic ulcerative colitis \u003csup\u003e(37)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eMexico\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eMexican Association of Gastroenterology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2017\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e\u0026nbsp;GRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eCrohn's disease Management in adults, children and young people \u003csup\u003e(38)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eUK\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eNICE National institute for health care and excellence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2012\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eSecond Korean guidelines for the management of ulcerative colitis \u003csup\u003e(39)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eKorea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eKorean Association for the Study of Intestinal Diseases (KASID)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2017\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eAGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis\u003csup\u003e (40)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eUSA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eAGA American Gastroenterological\u003cbr /\u003e Association\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2020\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eEvidence-based clinical practice guidelines for inflammatory bowel disease \u003csup\u003e(41)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eJapan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eThe Japanese Society of Gastroenterology (JSGE)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eUlcerative colitis - treatment with biologicals \u003csup\u003e(42)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eBrazil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eBrazilian Study Group on Inflammatory Bowel Disease, Brazilian Medical Association\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eBritish Society of Gastroenterology consensus\u003cbr /\u003e guidelines on the management of inflammatory bowel disease in adults\u003csup\u003e (43)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eUK\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eBritish Society of Gastroenterology and others\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eCanadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn\u0026rsquo;s Disease \u003csup\u003e(44)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eCanada\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eCanadian Association of Gastroenterology (CAG)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eClinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn\u0026rsquo;s Disease: The Toronto Consensus \u003csup\u003e(45)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eCanada\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eCanadian Association of Gastroenterology (CAG)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eCrohn\u0026rsquo;s disease - treatment with biological\u003cbr /\u003e medication \u003csup\u003e(46)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eBrazil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eBrazilian Study Group on Inflammatory Bowel Disease, Brazilian Gastroenterology Federation, Brazilian Coloproctology Society, Brazilian Medical Association\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eCanadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn\u0026rsquo;s Disease \u003csup\u003e(47)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eCanada\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eCanadian Association of Gastroenterology (CAG)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eEvidence-based clinical practice guidelines for inflammatory bowel disease 2020 \u003csup\u003e(48)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eJapan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eThe Japanese Society of Gastroenterology (JSGE)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2021\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eAGA Clinical Practice Guidelines on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn\u0026rsquo;s Disease\u003csup\u003e (49)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eUSA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eAGA American Gastroenterological Association\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2021\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eWSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting \u003csup\u003e(50)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eNetherlands\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eThe World Society of Emergency Surgery WSES\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2021\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eThe Medical Management of Paediatric Crohn\u0026rsquo;s Disease: an ECCO-ESPGHAN Guideline Update \u003csup\u003e(51)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eMultinational\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eEuropean Crohn\u0026rsquo;s and Colitis Organization [ECCO] and the\u003cbr /\u003e Paediatric IBD Porto group of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition [ESPGHAN]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2021\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eOxford Center for Evidence-Based Medicine\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eGuidelines for the management of patients with Crohn\u0026rsquo;s disease. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology \u003csup\u003e(52)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003ePoland\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eThe Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2021\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"271\"\u003e\n\u003cp\u003eECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment \u003csup\u003e(53)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"188\"\u003e\n\u003cp\u003eMultinational\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eThe European Crohn\u0026rsquo;s and Colitis Organization [ECCO]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e2020\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eGRADE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n*GRADE = Grading of Recommendations, Assessment, Development and Evaluation\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003e3.2 Quality assessment\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eThe agreement between the 6 reviewers was moderate with an ICC of 0.74 (95% CI: 0.36\u0026ndash;0.89, p-value\u0026thinsp;=\u0026thinsp;6.83e\u003csup\u003e-4\u003c/sup\u003e). A summary of the ICCs achieved by each pair of reviewers is shown in Table\u0026nbsp;2.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;2.\u003c/strong\u003e Intraclass correlation coefficients (ICC) by peer reviewers.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cstrong\u003ePair of reviewers\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e\u003cstrong\u003eICC\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e\u003cstrong\u003e*P-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003e**ICC interpretation\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003eRZ + PA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e0.02 - 0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e0.020\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eModerate\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003eCM + JF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e-0.07 - 0.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e0.065\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eModerate\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003eDH + RV\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e-0.03 - 0.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e0.292\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003ePoor\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003eDH + JF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e-0.15 - 0.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e0.093\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003emoderate\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003eGlobal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e0.36 - 0.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e6.83e\u003csup\u003e-4\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003emoderate\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Significance level \u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e**ICC interpretation following Ko and Li 2016\u003csup\u003e(53)\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 2 shows a boxplot summarizing the statistical analysis of the standardized scores for each domain assessed with the AGREE II tool. In addition, Table\u0026nbsp;3 shows the standardized scores for all domain assessed in each clinical practice guideline.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\n\u003ch2\u003e3.2.1 Domain 1: Scope and purpose\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eThis domain evaluates the general objective of the CPG, specific health aspects and the target population. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e The mean score was 84.51% (median: 90.27%, Q1: 78.47%, Q3: 94.44% and IQR\u0026thinsp;=\u0026thinsp;15.97%; Fig.\u0026nbsp;2). Twenty-four CPGs (92.30%) scored above 60% in this domain. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/sup\u003e See Table\u0026nbsp;3 for details on domain 1.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\n\u003ch2\u003e3.2.2 Domain 2: Stakeholder involvement\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eThis domain refers to the degree to which the guideline has been developed by the appropriate stakeholders and represents the views of intended users. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e The mean score was 60.90% (median: 66.67%, Q1: 36.11%, Q3: 83.33% and IQR\u0026thinsp;=\u0026thinsp;47.22%; Fig.\u0026nbsp;2). Fourteen CPGs (53.84%) scored above 60% in this domain. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/sup\u003e See Table\u0026nbsp;3 for details on domain 2.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\n\u003ch2\u003e3.2.3 Domain 3: Rigor of development\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eThis domain refers to the process used to gather and synthesize evidence, the methods used to formulate and update recommendations. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e The mean score was 69.95% (median: 69.79%, Q1: 58.07%, Q3: 100.00% and IQR\u0026thinsp;=\u0026thinsp;28.12%; Fig.\u0026nbsp;2). Nineteen CPGs (73.07%) scored above 60% in this domain. \u003csup\u003e(28,32\u0026ndash;34,36,38\u0026ndash;41,43-45,47\u0026minus;53)\u003c/sup\u003e See Table\u0026nbsp;3 for details on domain 3.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n\u003ch2\u003e3.2.4 Domain 4: Clarity of presentation\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eThis domain focuses on the language, structure and format of the guideline. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e The mean score was 85.58% (median: 91.67%, Q1: 75.00%, Q3: 100.00% and IQR\u0026thinsp;=\u0026thinsp;25%; Fig.\u0026nbsp;2). Twenty-four CPGs (92.30%) scored above 60% in this domain. \u003csup\u003e(28\u0026ndash;41,43-45,47\u0026minus;53)\u003c/sup\u003e See Table\u0026nbsp;3 for details on domain 4.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\n\u003ch2\u003e3.2.5 Domain 5: Applicability\u003c/h2\u003e\n\u003cp\u003eThis domain refers to barriers and facilitators to CPG implementation, strategies for its adoption and resource considerations. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e The median score was 26.60% (median: 20.83%, Q1: 12.50%, Q3: 39.06% and IQR\u0026thinsp;=\u0026thinsp;26.56%; Fig.\u0026nbsp;2). Only one CPG (3.84%) scored above 60% in this domain. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/sup\u003e See Table\u0026nbsp;3 for details on domain 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;3.\u003c/strong\u003e Standardized scores by domains of AGREE II.\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003e\u003cstrong\u003eGuideline\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e\u003cstrong\u003eScope and Purpose\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e\u003cstrong\u003eStakeholder Involvement\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e\u003cstrong\u003eRigour of Development\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e\u003cstrong\u003eClarity of Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e\u003cstrong\u003eApplicability\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e\u003cstrong\u003eEditorial Independence\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003e\u003cstrong\u003eOverall Recommendation\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eAGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis \u003csup\u003e(28)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e94.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e30.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e60.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e83.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e25.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e75.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eESPGHAN Revised Porto Criteria for the Diagnosis of Inflammatory Bowel Disease in Children and Adolescents \u003csup\u003e(29)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e75.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e36.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e57.29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e86.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e18.75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e33.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eACG Clinical Guideline: Management of Crohn\u0026rsquo;s\u003cbr /\u003e Disease in Adults \u003csup\u003e(30)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e44.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e5.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e35.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e72.22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e4.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e29.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eNot recommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eEuropean evidence based consensus on\u003cbr /\u003e surgery for ulcerative colitis \u003csup\u003e(31)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e75.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e36.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e50.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e66.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e6.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e29.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eUpdated German Clinical Practice Guideline on \u0026ldquo;Diagnosis and treatment of Crohn's disease\u0026rdquo; 2014 \u003csup\u003e(32)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e86.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e83.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e61.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e12.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eConsensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease \u003csup\u003e(33)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e72.22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e52.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e61.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e83.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e12.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e12.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eManagement of paediatric ulcerative colitis, Part 1: ambulatory care- an evidence-based\u003cbr /\u003e guideline from ECCO and ESPGHAN \u003csup\u003e(34)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e83.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e27.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e67.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e83.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e6.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e66.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eEvidence-based clinical practice guidelines for Crohn\u0026rsquo;s disease, integrated with formal consensus of experts in Japan\u003csup\u003e (35)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e52.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e56.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e94.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e16.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e79.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eDiagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation \u003csup\u003e(36)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e75.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e30.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e60.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e69.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e12.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e50.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eMexican consensus for the diagnosis and treatment of idiopathic chronic ulcerative colitis \u003csup\u003e(37)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e36.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e19.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e50.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e63.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e6.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e62.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eNot recommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eCrohn's disease Management in adults, children and young people \u003csup\u003e(38)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e94.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e83.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e94.79\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e83.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e75.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eSecond Korean guidelines for the management of ulcerative colitis \u003csup\u003e(39)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e80.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e58.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e71.88\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e22.92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e29.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eAGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis\u003csup\u003e (40)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e80.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e56.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e83.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eEvidence-based clinical practice guidelines for inflammatory bowel disease \u003csup\u003e(41)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e91.66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e75.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e82.29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e88.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e58.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e83.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eUlcerative colitis - treatment with biologicals \u003csup\u003e(42)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e88.88\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e33.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e45.83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e55.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e6.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eNot recommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eBritish Society of Gastroenterology consensus\u003cbr /\u003e guidelines on the management of inflammatory bowel disease in adults\u003csup\u003e (43)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e45.83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eCanadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn\u0026rsquo;s Disease \u003csup\u003e(44)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e94.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e85.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e25.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e95.83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eClinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn\u0026rsquo;s Disease: The Toronto Consensus \u003csup\u003e(45)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e86.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e79.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e14.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e95.83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eCrohn\u0026rsquo;s disease - treatment with biological\u003cbr /\u003e medication \u003csup\u003e(46)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e80.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e44.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e34.38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e44.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e4.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eNot recommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eCanadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn\u0026rsquo;s Disease \u003csup\u003e(47)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e90.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e37.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eEvidence-based clinical practice guidelines for inflammatory bowel disease 2020 \u003csup\u003e(48)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e77.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e66.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e66.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e18.75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e87.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eAGA Clinical Practice Guidelines on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn\u0026rsquo;s Disease\u003csup\u003e (49)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e94.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e83.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e87.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e52.08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eWSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting \u003csup\u003e(50)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e86.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e69.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e63.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e25.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e50.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eThe Medical Management of Paediatric Crohn\u0026rsquo;s Disease: an ECCO-ESPGHAN Guideline Update \u003csup\u003e(51)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e66.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e86.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e39.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eGuidelines for the management of patients with Crohn\u0026rsquo;s disease. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology \u003csup\u003e(52)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e94.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e72.22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e71.88\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e33.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended, with modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003eECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment \u003csup\u003e(53)\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e94.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e92.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e97.22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e47.92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003eRecommended\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003e\u003cstrong\u003eMean Score \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e84.51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e60.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e69.95\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e85.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e26.60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e62.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"172\"\u003e\n\u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e90.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e66.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e69.79\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e91.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e20.83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e75.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"147\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n\u003ch2\u003e3.2.6 Domain 6: Editorial Independence\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eThis domain is about the formulation of recommendations, understand whether they are biased by conflicts of interest. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e The median score was 62.02% (median: 75.00%, Q1: 30.21%, Q3: 91.67% and IQR\u0026thinsp;=\u0026thinsp;61.45%; Fig.\u0026nbsp;2). Sixteen CPGs (61.53%) scored above 60% in this domain. \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/sup\u003e See Table\u0026nbsp;3 for details on domain 6.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\n\u003ch2\u003e3.2.7 Overall assessment\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eSeven out of the 26 evaluated CPGs (26.9%) were \"recommended\" by the independent reviewers.\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/sup\u003e Most of the CPGs, 15 guidelines (57.7%), were \"recommended with modifications\".\u003csup\u003e(28,29,31\u0026ndash;36,39,41,45,48,50\u0026minus;52)\u003c/sup\u003e Finally, 4 CPGs (15.4%) were \"not recommended\" (see Table\u0026nbsp;3).\u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\n\u003ch2\u003e3.2.8 Combined assessment\u003c/h2\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eFinally, to visualize and compare the mean AGREE II scores obtained by the 26 CPGs assessed in this study, we generated a hexagonal radar graph where each domain is represented on a radial axis centered at 0 and the maximum score of each domain corresponds to each vertex of the hexagon (Fig.\u0026nbsp;3). The domains \"scope and purpose\", \"stakeholder involvement\", \"rigor of development\", \"clarity of presentation\" and \"editorial independence\" show similar areas in the scores achieved; however, the domain \"applicability\" is notoriously deficient in all the evaluated guidelines.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n\u003ch2\u003e3.3 Quality assessment over time\u003c/h2\u003e\n\u003cp\u003eWith respect to quality change over time, no statistically significant differences were found for the means of the standardized scores for each AGREE II domain between the guidelines published during the 2012\u0026ndash;2017 period and those published between 2018 and 2022 (Table\u0026nbsp;4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;4.\u003c/strong\u003e Quality changes over time.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"135\"\u003e\n\u003cp\u003e\u003cstrong\u003eGuidelines from 2012-2017\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"141\"\u003e\n\u003cp\u003e\u003cstrong\u003eGuidelines from 2018-2022\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"136\"\u003e\n\u003cp\u003e\u003cstrong\u003e**P-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eScope and purpose\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"135\"\u003e\n\u003cp\u003e81.9 (9.15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"141\"\u003e\n\u003cp\u003e85.6 (17.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"136\"\u003e\n\u003cp\u003e0.5868\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eStakeholder involvement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"135\"\u003e\n\u003cp\u003e54.5 (21.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"141\"\u003e\n\u003cp\u003e63.7 (29.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"136\"\u003e\n\u003cp\u003e0.4336\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eRigour of development\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"135\"\u003e\n\u003cp\u003e66.9 (15.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"141\"\u003e\n\u003cp\u003e71.3 (19.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"136\"\u003e\n\u003cp\u003e0.5817\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eClarity of presentation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"135\"\u003e\n\u003cp\u003e82.6 (15.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"141\"\u003e\n\u003cp\u003e86.9 (17.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"136\"\u003e\n\u003cp\u003e0.5521\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eApplicability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"135\"\u003e\n\u003cp\u003e23.2 (24.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"141\"\u003e\n\u003cp\u003e28.1 (19.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"136\"\u003e\n\u003cp\u003e0.5815\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eEditorial independence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"135\"\u003e\n\u003cp\u003e50.0 (28.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"141\"\u003e\n\u003cp\u003e67.4 (36.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"136\"\u003e\n\u003cp\u003e0.2444\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*Data given as mean +/- (SD) of standardized scores.\u003c/p\u003e\n\u003cp\u003e**Significance level \u0026lt;0.05, p-value with Student's t method for the difference of two means.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.1 What do the findings of this study mean?\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis review showed that the evaluated IBD CPGs had an acceptable quality based on the AGREE II instrument since 7 out of the 26 evaluated guidelines were \u0026ldquo;recommended\u0026rdquo;, 15 were \u0026ldquo;recommended with modifications\u0026rdquo; and only 4 were \u0026ldquo;not recommended\u0026rdquo;. The domains with the highest scores were \u0026ldquo;clarity of presentation\u0026rdquo; and \u0026ldquo;scope and purpose\u0026rdquo;, which reached values over 60%, indicating that most of the assessed guidelines had well-defined general and specific objectives, the population to which the guideline was intended to apply was well defined, and the recommendations were clearly described and identifiable. Rigor of development was the domain that received the third best score with 69.95%; this domain could be argued to have the greatest effect on the quality of a clinical practice guideline, since it has to do with the entire process used to formulate and construct the recommendations and it is the one that comprises the most items within AGREE II for its evaluation\u003csup\u003e(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e)\u003c/sup\u003e. We consider that a score over 60% is more than acceptable for \u0026ldquo;rigor of development\u0026rdquo;, which achieved this score due to most guidelines were partly penalized for being unclear with the description of external experts\u0026rsquo; assessment and for not having an explicit updating statement.\u003c/p\u003e \u003cp\u003eThe domains \"stakeholder involvement\" and \"editorial independence\" obtained scores slightly over 60% (60.90% and 62.02%, respectively; Fig.\u0026nbsp;3), which indicates that the views and preferences of patients still need to be considered when the CPG is drafted and that an expert methodologist/epidemiologist should be included in the guideline drafting group. In addition, both domains achieved low scores due to the limited information most guidelines provided in terms of funding and its influence on the guidelines\u0026rsquo; content, as well as the lack of detail they included regarding conflicts of interest and how these conflicts were dealt. Considering these limitations on the development of CPGs could contribute to their improvement.\u003c/p\u003e \u003cp\u003eThe \u0026ldquo;applicability\u0026rdquo; domain was the worst scored domain in this review with an average score of 26.60% (Fig.\u0026nbsp;3), well below the 60% cut-off point for this domain. The main reason for this is that most guideline developers do not fully consider guideline\u0026rsquo;s implementation in terms of facilitators and barriers for guidelines\u0026rsquo; applicability or they do not fully consider the resources and tools that are available in a specific context. We also noted that most of the guidelines did not consider the economic impact of their recommendations on resources and health budgets, for example, most guidelines did not include health economists in the guideline development group or did not perform cost-benefit analysis. The limitations and omissions that have been observed in the included guidelines restraint the translation of these documents into clinical practice, thus hindering its operability.\u003c/p\u003e \u003cp\u003eRegarding quality change over time, this study failed to demonstrate statistically significant differences between guidelines published during the 2012\u0026ndash;2017 period versus guidelines published between 2018 and 2022 (see Table\u0026nbsp;4) for any domain covered by AGREE II. This finding may be due to the small sample size in this study, which is associated to the specific inclusion criteria applied in the selection of CPGs as well as the large variety of CPGs for IBD (clinical, surgical, preventive, etc.) we encountered when screening. In addition, the time ranges we compared were too short since guidelines\u0026rsquo; development in terms of IBD and our study\u0026rsquo;s criteria has been an early activity. However, one point to highlight is the implementation and dissemination of the GRADE methodology in the development of guidelines, especially in those produced in the last 4 years; our study found that 17 out of the 26 included CPGs had used this methodology as a framework for grading the evidence and formulating their recommendations.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.2 The context of this review with other literature\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWhile this review is not the first to evaluate clinical practice guidelines on inflammatory bowel disease, it is the first to evaluate a large sample of CPGs as there was no date restriction in its search, which gave us a much broader picture of what has been produced in the past and current time. Thus, in line with other reviews of CPG for IBD conducted by other investigators, and addressing different contexts of inflammatory bowel disease, the domains with the highest scores were \u0026ldquo;clarity of presentation\u0026rdquo; and \u0026ldquo;scope and purpose\u0026rdquo; and the domains with the lowest scores were \u0026ldquo;stakeholder involvement\u0026rdquo; and \u0026ldquo;applicability\u0026rdquo;. \u003csup\u003e(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e)\u003c/sup\u003e These results are also similar to previous CPG evaluations for other clinical-surgical areas such as interventional radiology, pediatrics or dermatology. \u003csup\u003e(\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn addition, other studies that investigated quality changes over time for clinical practice guidelines in other specialties did not find evidence of significant changes in quality in the different evaluated periods of time. \u003csup\u003e(\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e)\u003c/sup\u003e These results are consistent with the findings of this study. However, studies by Bhatt et al. \u003csup\u003e(\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e)\u003c/sup\u003e for pediatric type II diabetes CPG and Acu\u0026ntilde;a-Izcaray et al. \u003csup\u003e(\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e)\u003c/sup\u003e for asthma CPG, found statistically significant differences in quality over time for the selected periods for each individual domain, while a statistical significance has not been found for all domains at the same time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Strengths and limitations\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAlthough a strength of our systematic review was the broad and exhaustive approach of our search \u0026ndash; carried out in databases, compiling entities and guideline developers, with a sensitive strategy designed for this purpose \u0026ndash; it is possible that our review may have missed some CPGs that were not adequately indexed or that dealt with other contexts related to inflammatory bowel disease. Likewise, our study only included CPGs published in English or Spanish, factors that could have contributed to a potential selection bias.\u003c/p\u003e \u003cp\u003eLikewise, having chosen CPGs with well-defined inclusion criteria, it is likely that our results have overestimated the score obtained by selecting guidelines that would score higher than the entire possible universe of CPGs for IBD. Therefore, our conclusions acquire more relevance when evaluating this type of guidelines.\u003c/p\u003e \u003cp\u003eOn the other hand, although the degree of agreement reached by the reviewers was moderate (ICC\u0026thinsp;=\u0026thinsp;0.74), this may be due to the fact that the AGREE II instrument weights each item with a 7-point Likert-type scale, where only the extreme values of this scale are well defined, but it is prone to subjectivity for intermediate values 3, 4 and 5 on the scale. As our research had a large number of reviewers (six), reaching a higher value for the intraclass correlation coefficient (ICC) to improve reliability was difficult. However, we consider that the value achieved does provide adequate reliability.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn addition, since the implementation of the AGREE II tool in 2010, it has become the most widely used and popular resource for assessing the quality of CPGs, choosing a cut-off point above which a guideline can be defined as having good quality is subjective and this selection will depend on the context in which the review is being performed. As Brouwers et al.\u003csup\u003e(\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e)\u003c/sup\u003e noted, \u0026ldquo;there is no evidence that if a guideline exceeds a certain score, the recommendations are eas\u0026ldquo;er to adopt, or improve processes of care, or lead to better patient outcomes than guidelines that do not achieve that score\u0026rdquo;.\u003csup\u003e(67, p.195)\u003c/sup\u003e That is, the validity of the overall assessment may be limited, as there are no clear rules yet on how to weigh the different domain scores to make a decision on whether or not to recommend guidelines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e4.4 What is new and conclusion\u003c/h2\u003e \u003cp\u003eOverall, this study determined that the quality of clinical practice guidelines for the diagnosis and treatment of inflammatory bowel disease is acceptable and that there is still room for improvement, especially in terms of stakeholder participation (inclusion of patients, expert methodologists/epidemiologists) and applicability (enablers, barriers, optimization of resources, external review). It is desirable that guideline developers consider these shortcomings in the future for the overall improvement of guidelines\u0026rsquo; quality to reduce clinical practice heterogeneity in IBD.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCPG\u0026nbsp;\u003c/strong\u003e(Clinical practice guideline)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAGREE\u0026nbsp;\u003c/strong\u003e(Appraisal of Guidelines, Research, and Evaluation)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGRADE\u003c/strong\u003e (Grading of Recommendations, Assessment, Development and Evaluation)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePRISMA\u003c/strong\u003e (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIBD\u0026nbsp;\u003c/strong\u003e(Inflammatory bowel disease)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCD\u0026nbsp;\u003c/strong\u003e(Crohn\u0026apos;s disease)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUC\u0026nbsp;\u003c/strong\u003e(Ulcerative colitis)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICC\u0026nbsp;\u003c/strong\u003e(Intraclass correlation coefficient)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e (Interquartile range)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e (Standard deviation)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQi\u0026nbsp;\u003c/strong\u003e(Quartile)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCI\u003c/strong\u003e (Confidence interval)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research study has not received any funding from the public or private sector or from any non-profit entity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDH, AV-G and CM-G conceived the idea for this research and designed the study. RZ-S, PA-M, CM-G and CME-L searched the literature. DH, CM-G, RZ-S, PA-M and RV screened and selected the guidelines according to the inclusion criteria. DH, CM-G, RZ-S, PA-M, JAF and RV rated and evaluated the guidelines with the AGREE II tool. RZ-S and PA-M conducted the statistical analysis and interpreted the results. RZ-S, PA-M and CM-G wrote the first draft of the report. CM-G, JAF, DS-R, CME-L, RV, AV-G contributed to the review and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the University UTE and the Center for Research in Public Health and Epidemiology (CISPEC) for their support, collaboration and work in the editorial process of this publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, et al. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00535-021-01784-1\u003c/span\u003e\u003cspan address=\"10.1007/s00535-021-01784-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeuerstein JD, Ho EY, Shmidt E, Singh H, Falck-Ytter Y, Sultan S, et al. AGA Clinical Practice Guidelines on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn\u0026rsquo;s Disease. Gastroenterology. 2021;160(7):2496\u0026ndash;508.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Simone B, Davies J, Chouillard E, Di Saverio S, Hoentjen F, Tarasconi A, et al. WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting. World J Emerg Surg. 2021;16(1):1\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Rheenen PF, Aloi M, Assa A, Bronsky J, Escher JC, Fagerberg UL, et al. The Medical Management of Paediatric Crohn\u0026rsquo;s Disease: An ECCO-ESPGHAN Guideline Update. J Crohn\u0026rsquo;s Colitis. 2021;15(2):171\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eŁodyga M, Eder P, Gawron-Kiszka M, Dobrowolska A, Gonciarz M, Hartleb M, et al. Guidelines for the management of patients with Crohn\u0026rsquo;s disease. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology. Prz Gastroenterol. 2021;16(4):257\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTorres J, Bonovas S, Doherty G, Kucharzik T, Gisbert JP, Raine T, et al. ECCO guidelines on therapeutics in Crohn\u0026rsquo;s disease: Medical treatment. J Crohn\u0026rsquo;s Colitis. 2020;14(1):4\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med [Internet]. 2016;15(2):155\u0026ndash;63. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.jcm.2016.02.012\u003c/span\u003e\u003cspan address=\"10.1016/j.jcm.2016.02.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoffmann-E\u0026szlig;er W, Siering U, Neugebauer EAM, Brockhaus AC, McGauran N, Eikermann M. Guideline appraisal with AGREE II: Online survey of the potential influence of AGREE II items on overall assessment of guideline quality and recommendation for use. BMC Health Serv Res. 2018;18(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng H, Ma Z, Yu B, Liu X, Tian C, Zhong X, et al. Quality assessment of clinical guidelines on probiotics therapy in children with IBD using the AGREE II instrument. J Clin Pharm Ther. 2021;46(4):1155\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X, Yang YM, Yang T, An LY, Chen XZ, Qi YX, et al. Evaluation of pharmacotherapy recommendations in guidelines for inflammatory bowel disease. J Clin Pharm Ther. 2021;46(3):599\u0026ndash;609.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiao BH, Ma XD, Lv JJ, Yang T, Liu XJ, An LY, et al. Systematic evaluation of the diagnostic approach of inflammatory bowel disease guidelines. Int J Clin Pract. 2021;75(10):0\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZanardo M, Gerasia R, Giovannelli L, Scurto G, Cornacchione P, Cozzi A, et al. A critical appraisal of the quality of guidelines for radiation protection in interventional radiology using the AGREE II tool: A EuroAIM initiative. Eur J Radiol [Internet]. 2021;143(May):109906. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejrad.2021.109906\u003c/span\u003e\u003cspan address=\"10.1016/j.ejrad.2021.109906\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiappini E, Bortone B, Galli L, Martino M De. Guidelines for the symptomatic management of fever in children: Systematic review of the literature and quality appraisal with AGREE II. BMJ Open. 2017;7(7):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWerner RN, Marinovic B, Rosumeck S, Strohal R, Haering NS, Weberschock T, et al. The quality of European dermatological guidelines: Critical appraisal of the quality of EDF guidelines using the AGREE II instrument. J Eur Acad Dermatology Venereol. 2016;30(3):395\u0026ndash;403.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimancas-Racines D, Montero-Oleas N, Vernooij R, Arevalo-Rodriguez I, Fuentes P, Gich I, et al. Quality of clinical practice guidelines about red blood cell transfusion. J Evid Based Med. 2018;12(2):113\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarajas-Nava L, Sol\u0026agrave; I, Delgado-Noguera M, Gich I, Villagran CO, Bonfill X, et al. Quality assessment of clinical practice guidelines in perioperative care: A systematic appraisal. Qual Saf Heal Care. 2010;19(6).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayawi LM, Graham ID, Tugwell P, Yousef S. Screening for osteoporosis: A systematic assessment of the quality and content of clinical practice guidelines, using the AGREE II instrument and the IOM Standards for Trustworthy Guidelines (PLoS ONE (2018) 13: 12 (e0208251) DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0208251\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0208251\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). PLoS One. 2019;14(4):1\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatt M, Nahari A, Wang PW, Kearsley E, Falzone N, Chen S, et al. The quality of clinical practice guidelines for management of pediatric type 2 diabetes mellitus: A systematic review using the AGREE II instrument 11 Medical and Health Sciences 1117 Public Health and Health Services. Syst Rev. 2018;7(1):1\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcu\u0026ntilde;a-Izcaray A, S\u0026aacute;nchez-Angarita E, Plaza V, Rodrigo G, De Oca MM, Gich I, et al. Quality assessment of asthma clinical practice guidelines: A systematic appraisal. Chest. 2013;144(2):390\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrouwers MC, Spithoff K, Lavis J, Kho ME, Makarski J, Florez ID. What to do with all the AGREEs? The AGREE portfolio of tools to support the guideline enterprise. J Clin Epidemiol [Internet]. 2020;125:191\u0026ndash;7. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jclinepi.2020.05.025\u003c/span\u003e\u003cspan address=\"10.1016/j.jclinepi.2020.05.025\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Inflammatory bowel disease, Crohn disease, Ulcerative colitis, Clinical practice guidelines, Systematic review.","lastPublishedDoi":"10.21203/rs.3.rs-1754875/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1754875/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The incidence and diagnosis of inflammatory bowel disease (IBD) has increased considerably in recent years. Many clinical practice guidelines (CPG) have been developed for the management of this disease across different clinical contexts, however, little evidence exists on their methodological quality. Therefore, we aimed to systematically evaluate the quality of CPGs for the diagnosis and treatment of IBD using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe identified CPGs by searching databases (MEDLINE - PubMed, EMBASE, CINAHL, LILACS) and other sources of gray literature on January 2022. We included guidelines with specific recommendations for the diagnosis and treatment of IBD and evaluated them with the AGREE II instrument to assess their methodological quality. Six independent reviewers assessed the quality of the guidelines and resolved conflicts by consensus. We assessed the degree of agreement using the intraclass correlation coefficient (ICC) and change in quality over time was appraised in two periods: from 2012 to 2017 and from 2018 to 2022.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWe analyzed and evaluated 26 CPGs that met the inclusion criteria. The overall agreement among reviewers was moderate (ICC: 0.74; 95% CI 0.36 - 0.89). The mean scores of the AGREE II domains were: \"Scope and purpose\" 84.51%, \"Stakeholder involvement\" 60.90%, \"Rigor of development\" 69.95%, \"Clarity of presentation\" 85.58%, \"Applicability\" 26.60%, and \"Editorial independence\" 62.02%. No changes in quality were found over time.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u0026nbsp;\u003c/strong\u003eThe quality of the CPGs evaluated was generally good, with a large majority of the assessed guidelines being \"recommended\" and \"recommended with modifications\"; despite this, there is still room for improvement, especially in terms of stakeholder involvement and applicability. Efforts to develop high quality CPGs for IBD need to be further optimized.\u003c/p\u003e","manuscriptTitle":"Quality assessment of Clinical Practice Guidelines (CPG) for the diagnosis and treatment of Inflammatory Bowel Disease using the AGREE II instrument: A Systematic Review.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-08-04 18:08:00","doi":"10.21203/rs.3.rs-1754875/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-08-29T07:40:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-08-16T22:20:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-08-14T08:48:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b492d7cf-410e-46d4-b363-701781e6f667","date":"2022-08-12T09:11:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f4513af7-c15a-4204-bb2a-442e46abb57b","date":"2022-08-10T13:44:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-08-10T13:19:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-08-10T13:13:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-08-03T07:57:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-08-03T07:54:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2022-06-13T21:03:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c7ef2bdc-8978-4bf1-833b-c5c4d6889d2a","owner":[],"postedDate":"August 4th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-10-14T07:14:20+00:00","versionOfRecord":[],"versionCreatedAt":"2022-08-04 18:08:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1754875","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1754875","identity":"rs-1754875","version":["v1"]},"buildId":"ApUGefWb6u5IBVtyqm6d5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}