Scientificity, transparency, and applicability of Chinese guidelines and consensus on burn/plastic surgery published in 2022

Clinical practice guidelines (referred to as “guidelines” hereafter), are crucial for guiding the diagnostic and treatment decisions of clinical physicians and standardizing related clinical practices. High-quality guidelines are essential in the following senses: improving diagnosis and treatment levels, enhancing the scientific basis of clinical decision-making,[1] and promoting the development of medical research and medical personnel. These guidelines have been developed based on the principles of evidence-based medicine, ensuring that they are rigorous, operable, and repeatable. The emphasis on standardized, transparent, and clear reporting of the methodologies and recommendations involved in guidelines formulation is crucial for enhancing their dissemination and implementation.[2] In 2021, in response to the challenges posed by existing methods and tools for evaluating clinical practice guidelines—such as insufficient item coverage, inadequate validation, a singular dimension focus, and high workload—a significant initiative was undertaken. This was spearheaded by the World Health Organization (WHO) Guidelines Implementation and Knowledge Transfer Cooperative Center, the Chinese Medical Association Journal Society Guidelines and Standard Research Center, and the Chinese Academy of Medical Sciences Evidence Evaluation and Guidelines Research Innovation Unit. Together, they established the Scientific, Transparent, Applicable Ranking (STAR) working groups.[3] To meet the needs of the comprehensive evaluation of the Chinese guidelines/consensus, the STAR working group has developed a multidimensional rating tool for the scientific nature, transparency, applicability of the guidelines/consensus.[3] The tool is a comprehensive evaluation tool with 11 domains, 39 entries, and corresponding scores. Moreover, through evaluation, it is confirmed that STAR has good reliability, validity, and grading efficiency and can provide a comprehensive rating for the scientificity, transparency, and applicability of the Chinese guidelines.[4] In recent years, the number of guidelines and consensuses published by Chinese scholars in burn and plastic surgery has increased, but their quality varies. This study uses the STAR rating tool to assess the report quality of these consensuses published in 2022. The goal is to identify current issues and shortcomings, providing scientific standards and references for future guidelines and consensus updates in these fields. Literature search and screening results. A total of 12,412 records were retrieved. After excluding duplicates, irrelevant, outdated guidelines [Supplementary Material, https://links.lww.com/CM9/C105], a total of 334 Chinese guidelines covering various medical specialties for the year 2022 were finally included, along with 1143 consensuses.[5] Among these, there were zero guidelines and 14 consensuses (1.22%) related to burns and plastic surgery. Basic information on the included consensus. All the 14 publications were expert consensuses, including 11 in plastic surgery and 3 in burn surgery. One of these was an updated consensus, while the others were newly published. Basic information about the included guidelines is presented in Supplementary Table 1, https://links.lww.com/CM9/C105. In terms of the content covered, the plastic surgery consensus addressed topics such as labial hypertrophy, progressive hemifacial atrophy, female androgenic alopecia, hyaluronic acid injection, nasolabial fold filling, mandibular osteotomy, thread lifting, collagen periorbital filling, perioral rejuvenation, and scalp aesthetic therapy. The burn surgery consensus covered adult burn prone position treatment, burn aeromedical transport, and early clinical diagnosis and treatment of frostbite. Regarding the drafting organizations, among the 14 consensues, 10 were prepared solely by societies or associations, 3 by other academic groups, and 8 were drafted by two types of organizations. This mainly includes organizations such as the Chinese Association of Plastics and Aesthetics, China Association of Plastics and Aesthetics, and Chinese Association of Burn Surgery. As for the publication journals, 6/14 consensuses were published in journals of the Chinese Medical Association series, and 8/14 in non-Chinese Medical Association series journals. Except for 1/14 consensus published in an English journal, the remaining 13/14 were published in Chinese journals. Evaluation results. Evaluation method, quality control, and statistical methods are shown in Supplementary Material, https://links.lww.com/CM9/C105. The highest score among the included guidelines/consensus was 95.71, whereas the lowest was 8.31, with an average score of 43.89 and a median of 34.57. The highest scoring proportion in the guidelines/consensus was for the “Clinical questions” section, at 58.04%, whereas the lowest was for the “Protocol” section, at 23.21%. The domain scoring rate for each section are detailed in Figure 1. Among the specific items in each section, the top three items in terms of scoring rate were Item 8 “List the institutional affiliations of all individuals involved in developing the guideline”, Item 19 “Identify the references for evidence supporting the main recommendations”, and Item 15 “Identify the clinical questions that the guideline focuses on”. The two items with the lowest scoring rate were Item 37 “Present the guideline or recommendations visually” (14.29%) and Item 22 “Assess the risk of bias or methodological quality of the included studies” (17.86%), with the specific item scoring rates detailed in Supplementary Table 2, https://links.lww.com/CM9/C105.Figure 1: Scoring rates of the guidelines and consensus domains in burns/plastic surgery published in China in 2022. Domain scoring rate = Total score of all guidelines or consensus for items in that domain/Theoretical total score for that domain × 100%.In recent years, the specialties of burn surgery and plastic surgery have undergone rapid development, marked by substantial advancements in both clinical practice and scientific research. Chinese scholars have significantly contributed to these fields on a global scale. The publication of high-quality academic guidelines and expert consensus at this juncture is important for the continued progression of these disciplines. Clinical practice guidelines, rooted in evidence-based medicine and developed by authoritative institutions or societies, must exhibit characteristics of “rigor”, “operability”, and “repeatability”. These high-quality guidelines and consensuses are instrumental in providing targeted clinical guidance for specific conditions, thereby facilitating the effective and accurate resolution of clinical challenges. Reviewing the guidelines and consensus statements published in the fields of burn and plastic surgery in China for 2022 reveals that there is room for improvement in report quality. Notably, all 14 publications were expert consensuses, with no formal guidelines. The average STAR rating score for these burn/plastic surgery consensuses was 43.89, with a median of 34.57. This is in line with the overall STAR rating for all guidelines and consensus in China in 2022, which had an average score of 43.4 and a median of 39.0.[4] Interestingly, four out of the 14 consensuses ranked in the top 300 of the 2022 Guidelines/Consensus STAR rating. Of these, three were published in the Chinese Journal of Plastic Surgery, and one in the Chinese Journal of Burns and Wound Healing, with the highest scoring at 95.71. This score indicates the presence of high-quality expert consensus in the burn/plastic surgery field. Despite being consensuses, their development strictly adhered to the guidelines’ drafting regulations, a practice that merits strong endorsement. The consensus topics in 2022 mainly focused on clinical issues. In plastic surgery, the focus was primarily on cosmetic procedures, covering topics such as labial hypertrophy, progressive hemifacial atrophy, female androgenic alopecia, hyaluronic acid injections, and so on. Burn surgery consensus topics mainly focused on addressing adult burn prone position treatment, aeromedical transport for burn patients, and the early clinical diagnosis and treatment of frostbite. This diversity of topics reflects the current trends and developmental hotspots in the fields of burn and plastic surgery, showcasing the main advancements. Notably, in plastic surgery, the predominance of cosmetic surgery-related issues is evident. There is a growing need to formulate guidelines and consensus in other areas, particularly in deformity correction. The essence of guideline development is rooted in evidence-based medicine, with evidence as its central focus. An evaluation of the item scoring rates from the rating tool reveals that the formulation process for burn/plastic surgery consensus lacks “transparency”. This highlights a need for strengthening in the areas of evidence utilization and protocol. The WHO recommends the use of the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) system for grading the quality of evidence and the strength of recommendations.[6] Out of the 14 consensuses reviewed, only four included registration numbers, five specified standards for grading the quality of evidence, and two utilized the GRADE system for strength grading. The development of guidelines and consensus should consider the following aspects: (1) the registration and record-keeping processes; (2) the writing and accessibility of protocol; (3) the role of funding in guideline development; (4) involvement of methodologists or experts in evidence-based medicine; (5) distribution of responsibilities among personnel; (6) criteria for inclusion and exclusion of evidence; (7) assessment of bias risk or methodological quality of evidence; and (8) diversity and presentation in versions. In conclusion, most of the opinions released by burn/plastic surgery scholars in China are on consensus, with a notable need for improvement in overall report quality. “Transparency” in the formal process is necessary, which highlighted the need for greater emphasis on protocol and evidence evaluation. More attention should be given to the importance of protocols, evidence quality, and evaluation. By using the STAR rating tool to evaluate the guidelines/consensus within the industry, it can serve as a warning to medical professionals and relevant institutions: guideline developers are advised to master relevant research and evaluation tools for guidelines, to fully report the details and key contents of guideline/consensus, and to enhance the scientific nature, transparency, and applicability of guideline reports. Committee members (the list is ordered alphabetically by last name): Yang Chen, Xijing Hospital; Hao Guan, Xijing Hospital; Xiaoshuang Guo, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Jianying Gu, Zhongshan Hospital, Fudan University; Chao Ji, Changhai Hospital; Haiyue Jiang, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Shizhao Ji, Changhai Hospital; Xiaolei Jin, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Leren He, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Chunjun Liu, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Guangping Liang, The Southwest Hospital of AMU; Chinese Journal of Burns; Gaoxing Luo, The Southwest Hospital of AMU; Xiaojun Wang, Peking Union Medical College Hospital; Jie Luan, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Haisheng Li, The Southwest Hospital of AMU; Lei Yi, Ruijing Hospital, Shanghai Jiaotong University School of Medicine; Shangshan Li, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Xiao Long, Peking Union Medical College Hospital; Yi Liu, The Second Hospital & Clinical Medical School, Lanzhou University; Chenhao Ma, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Yu Mo, Chinese Journal of Burns; Qingfeng Li, Shanghai Ninth People Hospital, Shanghai JiaoTong University School of Medicine; Jiaming Sun, Union Hospital Tongji Medical College Huazhong University of Science and Technology; Yafei Tian, The Second Hospital & Clinical Medical School, Lanzhou University; Jingning Xun, Ruijing Hospital, Shanghai Jiaotong University School of Medicine; Lu Wang, Zhongshan Hospital, Fudan University; Rongrong Wang, Union Hospital Tongji Medical College Huazhong University of Science and Technology; Nanze Yu, Peking Union Medical College Hospital; Jinxiu Yang, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Jia Zhou, Shanghai Ninth People Hospital, Shanghai JiaoTong University School of Medicine. Funding This study was funded by a grant from the CAMS Innovation Fund for Medical Sciences (No. 2021-12M-1-001). Conflicts of interest None.