Editor's Choice - European Society for Vascular Surgery Clinical Practice Guideline Development Scheme: An Overview of Evidence Quality Assessment Methods, Evidence to Decision Frameworks, and Reporting Standards in Guideline Development.

OBJECTIVE: A structured and transparent approach is instrumental in translating research evidence to health recommendations and evidence informed clinical decisions. The aim was to conduct an overview and analysis of principles and methodologies for health guideline development. METHODS: A literature review on methodologies, strategies, and fundamental steps in the process of guideline development was performed. The clinical practice guideline development process and methodology adopted by the European Society for Vascular Surgery are also presented. RESULTS: Sophisticated methodologies for health guideline development are being applied increasingly by national and international organisations. Their overarching principle is a systematic, structured, transparent, and iterative process that is aimed at making well informed healthcare choices. Critical steps in guideline development include the assessment of the certainty of the body of evidence; evidence to decision frameworks; and guideline reporting. The goal of strength of evidence assessments is to provide well reasoned judgements about the guideline developers' confidence in study findings, and several evidence hierarchy schemes and evidence rating systems have been described for this purpose. Evidence to decision frameworks help guideline developers and users conceptualise and interpret the construct of the quality of the body of evidence. The most widely used evidence to decision frameworks are those developed by the GRADE Working Group and the WHO-INTEGRATE, and are structured into three distinct components: background; assessment; and conclusions. Health guideline reporting tools are employed to ensure methodological rigour and transparency in guideline development. Such reporting instruments include the AGREE II and RIGHT, with the former being used for guideline development and appraisal, as well as reporting. CONCLUSION: This guide will help guideline developers/expert panels enhance their methodology, and patients/clinicians/policymakers interpret guideline recommendations and put them in context. This document may be a useful methodological summary for health guideline development by other societies and organisations.

Prognostic factors for survival following emergency Hartmann's procedure.

INTRODUCTION: Patients presenting with peritonitis require rapid treatment initiation including laparotomy. In the older population, this often leads to Hartmann's procedure being performed. The decision to perform surgery may be a difficult, multidisciplinary decision balancing premorbid comorbidity and quality of life with knowledge of the postoperative outcome. However, the evidence for survival outcome of emergency surgery based on age is lacking. The aim of this study was therefore to assess the survival implication of age and other prognostic factors on the outcome after Hartmann's procedure. METHODS: A retrospective review of prospectively collected data of all patients undergoing emergency (National Confidential Enquiry into Patient Outcome and Death category 1-3) Hartmann's procedure in one NHS Health Board over a 5-year period. RESULTS: 129 patients underwent Hartmann's procedure between November 2004 and November 2009. The largest group, 61 patients (47.3%) had the procedure performed for perforated sigmoid diverticular disease. When examined at 5-year stratifications around the median, the most significant survival difference was seen at the age of 75 years (log rank χ(2) 11.246, p=0.001). Patients over 75 years had median survival significantly lower than those aged <75 years (p<0.001). However, Cox regression analysis showed that preoperative American Society of Anesthesiologists (ASA) status and haemoglobin were more significant independent predictors of mortality than this age strata (p=0.001 and 0.045 vs 0.660, respectively), adjusting for diagnosis. DISCUSSION: ASA grade and common blood abnormalities were more predictive of mortality after Hartmann's procedure than the most significant age stratification. Furthermore, age was not independently associated with survival. It would therefore be unreasonable to refuse Hartmann's procedure based on an age alone.

The PERCEIVE quantitative study: PrEdiction of Risk and Communication of outcome following major lower-limb amputation: protocol for a collaboratiVE study.

BACKGROUND: Accurate prediction of outcomes following surgery with high morbidity and mortality rates is essential for informed shared decision-making between patients and clinicians. It is unknown how accurately healthcare professionals predict outcomes following major lower-limb amputation (MLLA). Several MLLA outcome-prediction tools have been developed. These could be valuable in clinical practice, but most require validation in independent cohorts before routine clinical use can be recommended. The primary aim of this study is to evaluate the accuracy of healthcare professionals' predictions of outcomes in adult patients undergoing MLLA for complications of chronic limb-threatening ischaemia (CLTI) or diabetes. Secondary aims include the validation of existing outcome-prediction tools. METHOD: This study is an international, multicentre prospective observational study including adult patients undergoing a primary MLLA for CLTI or diabetes. Healthcare professionals' accuracy in predicting outcomes at 30-days (death, morbidity and MLLA revision) and 1-year (death, MLLA revision and ambulation) will be evaluated. Sixteen existing outcome-prediction tools specific to MLLA will be examined for validity. Data collection began on 1 October 2020; the end of follow-up will be 1 May 2022. The C-statistic, Hosmer-Lemeshow test, reclassification tables and Brier score will be used to evaluate the predictive performance of healthcare professionals and prediction tools, respectively. STUDY REGISTRATION AND DISSEMINATION: This study will be registered locally at each centre in accordance with local policies before commencing data collection, overseen by local clinician leads. Results will be disseminated to all centres, and any subsequent presentation(s) and/or publication(s) will follow a collaborative co-authorship model.