Assessing the Quality of Clinical Practice Guidelines in the Middle East and North Africa (MENA) Region: A Systematic Review

Figures & data

Table 1 Eligibility Criteria

Inclusion Criteria

Exclusion Criteria

* 21 MENA countries have been identified and included. They are Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordon, Kuwait, Lebanon, Libya, Morocco, the Occupied Palestinian Territory, Oman, Qatar, SA, Somalia, Sudan, the Syrian Arab Republic, Tunisia, the United Arab Emirates, and Yemen.^Citation27,28 * Published and unpublished CPGs. * CPGs published from 2010 to 2019. * Published in English languages. * The most recent, updated CPGs will be used for appraisal if several editions were available, unless the CPG authors referred the reader to a previous version in a specific section of the guideline. * Documents that met the definition of CPGs as defined in the Introduction. * CPGs accessible online.

* Languages apart from English. * Separate recommendation papers regarding the treatment only (short summaries) or papers dedicated for patients. * Guidelines developed especially for HCPs other than doctors and/or clinical pharmacists (eg, physiotherapists and nurses). * Guidelines used for a single institution (eg, guidelines regarding infection control) or in a specific hospital. * Adopted guidelines. * Non-disease oriented, that is, guidelines on specific instructions in using certain medications.

Figure 1 Flow diagram of the selection process of CPGs.

Table 2 Characteristics of CPGs

CPG ID	CPG Title	Specialty	Year	Country
Haddad et al^Citation107	The 2018 Lebanese Society of Infectious Diseases and Clinical Microbiology Guidelines for the use of antimicrobial therapy in complicated intra-abdominal infections in the era of antimicrobial resistance.	Infectious disease	2019	Lebanon
Jazieh et al31	Saudi lung cancer prevention and screening guidelines.	Oncology	2018	SA
Al Amro et al32	Practical guidelines for screening and treatment of retinopathy of prematurity in Saudi Arabia.	Ophthalmology	2018	SA
Abusamra et al43	The Saudi Clinical Management guidelines for prostate cancer.	Oncology	2018	SA
Alharbi et al54	The Saudi Clinical Management Guidelines for Urothelial Cell Carcinoma of the Urinary Bladder	Oncology	2018	SA
Bazarbashi et al109	The Saudi Clinical Management guidelines for renal cell carcinoma	Oncology	2018	SA
Husni et al77	The Lebanese society of infectious diseases and clinical microbiology guidelines for the treatment of urinary tract infections.	Infectious disease	2017	Lebanon
Jazieh et al60	Saudi lung cancer management guidelines 2017.	Oncology	2017	SA
Al-Hameed et al61	The Saudi clinical practice guideline for the prophylaxis of venous thromboembolism in long-distance travelers.	Hematology	2017	SA
Al-Jahdali et al62	The Saudi Thoracic Society guidelines for diagnosis and management of noncystic fibrosis bronchiectasis.	Respiratory disorders	2017	SA
Bashiri et al63	Management of convulsive status epilepticus in children: An adapted clinical practice guideline for pediatricians in Saudi Arabia.	Neurology	2017	SA
Al-Jazairi et al64	Guidelines for the secondary prevention of rheumatic heart disease: Endorsed by Saudi Pediatric Infectious Diseases Society (SPIDS).	Rheumatology	2017	SA
Al-Hameed et al33	The Saudi clinical practice guideline for the prophylaxis of venous thromboembolism in medical and critically ill patients.	Hematology	2016	SA
Alfadda et al34	The Saudi clinical practice guideline for the management of overweight and obesity in adults	Metabolic disorders	2016	SA
Alotaibi et al35	Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for testicular germ cell tumors.	Oncology	2016	SA
Alfadhel et al75	Guidelines for acute management of hyperammonemia in the Middle East region.	Acid Base disorders	2016	ME
Al-Moamary et al36	The Saudi Initiative for Asthma-2016 update: Guidelines for the diagnosis and management of asthma in adults and children.	Respiratory disorders	2016	SA
Al-Salam et al37	The golden hour approach: Practical guidelines of the Saudi neonatology society on managing very low birth weight infants in the first hour of life.	Neonatology	2016	SA
Al-Mandeel et al38	Clinical practice guidelines on the screening and treatment of precancerous lesions for cervical cancer prevention in Saudi Arabia.	Oncology	2014	SA
Alavian et al87	Recommendations for the clinical management of hepatitis C in Iran: A consensus-based national guideline.	Hepatology	2016	Iran
Alsanea et al39	National Guidelines for Colorectal Cancer Screening in Saudi Arabia with strength of recommendations and quality of evidence.	Oncology	2015	SA
Al-Hameed et al40	Prophylaxis and treatment of venous thromboembolism in patients with cancer: The Saudi clinical practice guideline.	Hematology	2015	SA
Al-Hameed et al41	The Saudi clinical practice guideline for the diagnosis of the first deep venous thrombosis of the lower extremity.	Hematology	2015	SA
Al-Saleh et al42	2015 guidelines for osteoporosis in Saudi Arabia: Recommendations from the Saudi Osteoporosis Society.	Endocrinology	2015	SA
Al-Hameed et al44	The Saudi clinical practice guideline for the treatment of venous thromboembolism: Outpatient versus inpatient management.	Hematology	2015	SA
Alothman et al74	Clinical practice guidelines for the management of invasive Candida infections in adults in the Middle East region: Expert panel recommendations.	Infectious diseases	2014	ME
Ibrahim et al88	The Egyptian Hypertension Society: Egyptian hypertension guidelines.	Cardiology	2014	Egypt
Khan e al^Citation45	Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Pregnancy in pulmonary hypertension.	Pulmonology	2014	SA
Khan et al47	The Saudi guidelines for the diagnosis and management of COPD.	Respiratory disorders	2014	SA
Al-Abdely et al73	Clinical practice guidelines for the treatment of invasive Aspergillus infections in adults in the Middle East region: Expert panel recommendations.	Infectious diseases	2014	ME
Moghnieh et al78	The Lebanese Society for Infectious Diseases and Clinical Microbiology (LSIDCM) guidelines for adult Community-Acquired Pneumonia (CAP) in Lebanon.	Infectious diseases	2014	Lebanon
Idrees et al46	Saudi guidelines on the diagnosis and treatment of pulmonary hypertension: 2014 updates.	Pulmonary hypertension	2014	SA
Abdo et al48	Saudi guidelines for the diagnosis and management of hepatocellular carcinoma: Technical review and practice guidelines.	Oncology	2012	SA
Al Jahdali et al49	Saudi guidelines for testing and treatment of latent tuberculosis infection.	Infectious diseases	2010	SA
Bohlega et al72	Guidelines for the pharmacological treatment of peripheral neuropathic pain: Expert panel recommendations for the middle east region.	Neurology	2010	ME
Okasha et al67	Arab treatment guidelines for the management of major depressive disorder.	Psychiatry	2017	Arab
Shatila et al79	LSN MS guidelines for the management of multiple sclerosis.	Neurology	2012	Lebanon
Jassim et al68	Pan Arab Osteoporosis Society Guidelines for Osteoporosis Management	Endocrinology	2017	Arab
Jordanian Osteoporosis Prevention Society^Citation89	Jordanian Osteoporosis Prevention Society Guideline-2017	Endocrinology	2017	Jordan
EBHC guidelines on Venous Thromboembolism in Patients with Stroke^Citation51	Clinical Practice Guideline on Prevention of Venous Thromboembolism in Patients with Stroke	Hematology	2014	SA
EBHC guideline on Allergic Rhinitis in Asthma^Citation52	Clinical Practice Guideline on Allergic Rhinitis in Asthma	Ear, Nose and Throat	2014	SA
EBHC guideline on the Diagnosis of First Deep Vein Thrombosis of Lower Extremity^Citation110	Clinical Practice Guideline on the Diagnosis of Suspected First Deep Vein Thrombosis of Lower Extremity	Hematology	2014	SA
EBHC guideline on the Use of Thrombolytic Therapy in Acute Stroke^Citation53	Clinical Practice Guideline on the Use of Thrombolytic Therapy in Acute Stroke	Neurology	2014	SA
EBHC guideline on Fracture Prevention in Elderly^Citation55	Clinical Practice Guideline on the Role of Vitamin D, Calcium and Exercise in Fracture Prevention in Elderly	Endocrinology	2014	SA
EBHC guideline on Antithrombotic Treatment of Patients with Non-valvular Atrial Fibrillation^Citation56	Clinical Practice Guideline on Antithrombotic Treatment of Patients with Non-valvular Atrial Fibrillation	Cardiology	2014	SA
EBHC guideline on the Treatment of Venous Thromboembolism^Citation57	Clinical Practice Guideline on the Treatment of Venous Thromboembolism	Hematology	2014	SA
EBHC guideline on Screening Strategies for the Detection of Breast Cancer^Citation58	Clinical Practice Guideline on the Use of Screening Strategies for the Detection of Breast Cancer	Oncology	2014	SA
Alhasan et al50	Clinical Practice Guideline on the Timing of Initiation of Dialysis	Nephrology	2015	SA
Bahrain MOH guidelines on Middle East Respiratory Syndrome coronavirus^Citation84	Guideline On Middle East Respiratory Syndrome coronavirus (MERS-CoV)	Infectious diseases	2014	Bahrain
Bahrain MOH guidelines for Management of Suspected or Confirmed Cholera^Citation85	Guideline for Management of Suspected or Confirmed Cholera	Infectious diseases	2015	Bahrain
Bahrain MOH guidelines for Management of Influenza A (H1N1)^Citation86	Management of Influenza A (H1N1) and Influenza like Illness (ILI)	Infectious diseases	2015	Bahrain
Lebanese Ministry of public health guidelines for Tuberculosis Prevention, Care^Citation80	National Guidelines for Tuberculosis Prevention, Care and Elimination in LEBANON- 2017	Infectious diseases	2017	Lebanon
Ziadé et al81	Protocol for prescription and follow up of biologics and targeted Synthetic Disease Modifying AntiRheumatic Drugs (b/tsDMARDS) in the management of Chronic Inflammatory Rheumatic Diseases (CIRDs): Rheumatoid Arthritis (RA), Axial Spondylo Arthritis (AxSpa), Psoriatic Arthritis (PsA)	Rheumatology	2018	Lebanon
Mokhbat et al82	National Guidelines for diagnosis and management of HIV infected adults. ANTIRETROVIRAL THERAPY MANAGEMENT	HIV infection	2012	Lebanon
Fuleihan et al83	(Osteoporosis Assessment and Treatment) FRAX Based Lebanese Osteoporosis Guidelines 2013	Osteoporosis	2013	Lebanon
Abulkhair et al65	Modification and implementation of NCCN guidelines on breast cancer in the Middle East and North Africa region.	Oncology	2010	MENA
Yusuf et al71	Modification and implementation of NCCN guidelines on hepatobiliary cancers in the Middle East and North Africa region.	Oncology	2010	MENA
Bazarbachi et al66	Modification and implementation of NCCN guidelines on lymphomas in the Middle East and North Africa region.	Oncology	2010	MENA
Hassen et al70	Modification and implementation of NCCN guidelines on prostate cancer in the Middle East and North Africa region.	Oncology	2010	MENA
İçli et al69	Modification and implementation of NCCN guidelines on colon cancer in the Middle East and North Africa region.	Oncology	2010	MENA
Jazieh et al76	Modification and implementation of NCCN guidelines on non-small cell lung cancer in the Middle East and North Africa region.	Oncology	2010	MENA

Abbreviations: EBHC, Evidence-Based Health Care; SA, Saudi Arabia; ME, Middle East; MOH, Ministry of Health; MENA, Middle East and North Africa.

Table 3 Summary of the Domain Scores of CPGs Using the AGREE II Instrument (N = 61)

Domains	Clinical Practice Guidelines (n=61)				Domain Score >60% No. (%)
	Mean	Median	SD	Range
Scope and purpose	63%	61%	22.62%	3–100	37 (60.6%)
Stakeholder involvement	53%	53%	23.06%	14–97	20 (32.7%)
Rigor of development	28%	20%	21.44%	0–71	7 (11.5%)
Clarity of Presentation	82%	83%	15.20%	39–100	58 (95%)
Applicability	29%	23%	19.37%	0–75	5 (8%)
Editorial independence	59%	63%	40.60%	0–100	32 (52.5%)

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