Title:
References Supporting Recommendations in Obstetrical Green Top
Guidelines: an Overview Authors:
Halime Meryem Soylu,1 Hector
Mendez-Figueroa,2 Suneet P Chauhan,2Benjamin JF Huntley,21. Department
of Obstetrics, Gynecology, and Reproductive Sciences, the University of
California at San Diego, San Diego, California
2. Department of Obstetrics, Gynecology, and Reproductive Sciences,
McGovern Medical School, Division of Maternal Fetal Medicine, the
University of Texas Health Science Center at Houston, Houston, Texas
Corresponding author:
Halime Meryem Soylu
3855 Health Sciences Drive
San Diego, CA 92037
+1 619 653-9395
hsoylu@health.ucsd.edu
Running
title: Green Top Guideline References
Acknowledgments: None
Disclosures: No conflicts of interest to disclose
Contribution to Authorship:
- Halime Meryem Soylu (HMS) – Data Extraction, Formal
Analysis, Writing - Original Draft
- Hector Mendez-Figueroa (HMF) - Methodology, Writing - Review
& Editing
- Suneet P. Chauhan (SPC) – Conceptualization, Methodology,
Writing - Review & Editing
- Benjamin JF Huntley (BJFH) – Conceptualization, Methodology,
Project Administration, Data Audit, Writing - Review & Editing
Details of Ethics Approval: not applicable (no medical records,
procedures, or involvement of human or animal subjects)
Funding: none
REFERENCES SUPPORTING RECOMMENDATIONS IN OBSTETRICAL GREEN TOP
GUIDELINES (584 words)
Halime Meryem Soylu, Hector Mendez-Figueroa, Suneet P Chauhan, Benjamin
JF Huntley
Introduction (82 words)
Green-top guidelines
(GTGs), published by the Royal College of Obstetrics and Gynaecology
(RCOG), guide clinical practice and foster research initiatives. Prior
analyses of GTG noted that the majority (88-91%) of the recommendations
were not supported by the Grade A evidence1, and do
not consistently meet the high-quality standards and applicability
expected of guidelines produced by professional
bodies.2 In this study we examined the evidence
supporting the obstetrical-related GTGs. Our aim was to characterize the
quality of evidence (i.e., references) underpinning these
recommendations.
Method (194 words)
From the list of GTGs
available in July 2023, we identified all current obstetrical-related
RCOG GTGs. We reviewed the body of each GTG and catalogued both the
grade of every recommendation and the classification of reference levels
for citations deemed to support the recommendation of interest,
according to the Clinical Governance Advice No.1: Development of RCOG
Green-top Guidelines. Each reference’s source journal was identified and
categorized as to whether it was published in weekly journals (New
England Journal of Medicine, Journal of the American Medical
Association, or The Lancet), one of three top OB/GYN journals (American
Journal of Obstetrics & Gynecology, British Journal of Obstetrics and
Gynaecology, and Obstetrics & Gynecology), or others. Each citation was
verified within the PubMed database to confirm if it was a randomized
controlled trial (RCT). In addition, recommendations without discernable
references were tracked. A random audit of 10% of manually entered data
(182 of 1822 recommendations) was performed by the senior author
(B.J.F.H.). Consensus regarding which references, if any, supported a
recommendation was reached by deliberation and resolved by discussion
with a third reviewer (S.P.C.). All data were entered in an Excel
spreadsheet (Microsoft, Seattle, WA) and summarized.
Results (167 words)
Thirty-seven obstetrical-related GTGs were identified at the RCOG
website
(https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines),
published between 04/2010 – 06/2023, and analyzed. Of 1822
recommendations in the GTG, 6% are grade A, 10% grade B, 14% grade C,
28% grade D, and 42% are Good Practice Points (GPP). While 1267 (70%)
recommendations were supported by references, 555 (30%) did not have a
discernible supporting reference. When omitting GPPs from the analysis,
89% of GTG recommendations are supported by references, and 10% are
recommendation strength A
Of the 3652 references supporting the recommendations, of which 4%
Evidence level 1++, 8% Evidence level 1+, 3% Evidence level 1-, 9%
Evidence level 2++, 19% Evidence level 2+, 10% Evidence level 2-, 18%
Evidence level 3, and 20% Evidence level 4. Additionally, 9% of the
references were not assigned an evidence level. While 4% of all
references cited were published in the “weekly journals”, 23% were
published in the “top 3 journals”, and 55% were published in other
journals. Lastly, approximately 7% of references were RCT (Table).
Conclusion (141 words)
Though only 6% of GTG recommendations were strength A, 70% of them are
supported by references. Excluding GPP, almost 90% of the
recommendations have supportive references. A prior publication
comparing the same topics in obstetric guidelines published by the
American College of Obstetrics and Gynecology (ACOG) and RCOG, revealed
the heterogeneity on the type of recommendations and source of
references.3 Similar to our findings, Practice
Bulletins (PBs) published by ACOG 70% of recommendations lack
identifiable references, and 8 out of 10 references in ACOG PBs aren’t
linked with recommendations, indicating the necessity for improved
transparency in supporting recommendations.4 While
insufficient qualities of evidence should not prevent guideline
formation, the distribution of these findings are comparable with those
published 1 and 2 decades ago,1,2 which may serve as a
call to action to encourage further research related to evidence-based
obstetrical care.