To the Editor: Pulmonary nodules are defined as localized opacities of up to 30 mm in diameter, surrounded by pulmonary parenchyma or located adjacent to the pleura.[1] The ideal management for pulmonary nodules is to diagnose and treat malignant nodules as early as possible and minimize radiation exposures, based on the general guidance. Clinical practice guidelines (CPGs) always provide efficient recommendations based on systematic reviews of high-quality evidence and reporting to optimize patient care.[2] Accumulating evidence shows that adherence to the guidelines improves patient outcomes.[3] However, the reporting quality of CPGs seems poor.[4] Several instruments have been generated to evaluate the quality of CPGs. The International Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist is widely used to evaluate the reporting quality of CPGs and provides a systematic reporting framework to inform the creation, reporting, and assessment of CPGs.[5] The RIGHT checklist with an explanation and elaboration statement can assist developers in reporting guidelines, support journal editors and peer reviewers when considering guideline reports, and help healthcare practitioners understand and implement a guideline. In this study, we evaluated the reporting quality of the CPGs for pulmonary nodules published from 2012 to 2022 with the RIGHT checklist to support more transparent, clear, and explicit guideline reporting in future.

We systematically searched the MEDLINE database and websites of thoracic societies for CPGs on screening, diagnosis, management, or follow-up of pulmonary nodules published in English or Chinese from January 2012 to October 2022. Translations or protocols of guidelines for pulmonary nodules were excluded. Older versions when a new one was available were also excluded, as well as those guidelines for which the full text was unable to be retrieved. After screening the titles, abstracts, and full texts of all records, CPGs were extracted for evaluation using the RIGHT checklist containing 22 items, some of which are further divided into several subitems for a total of 35 items that are important for good reporting of CPGs.[5]

Dichotomy was used to assess the guideline reporting adherence to each item in the RIGHT checklist. If relevant information in the item was provided in the guideline, it was defined as “reported”; if relevant information in the item was completely missing, it was defined as “not reported”; and if an item in the checklist did not apply to the guideline, it was defined as “not applicable (NA).” Subsequently, we analyzed the reporting rates of the CPGs according to each of the 35 checklist subitems, as well as overall items and items within each domain. The reporting rate was defined as the number of items rated as “reported” divided by the total number of subitem. The reporting rate of each of the 35 checklist subitems was defined as the sum of all reported guidelines divided by the total number of guidelines. The mean reporting rates of each guideline, each domain, and each item over all CPGs were calculated.

Twelve CPGs out of 124 records on pulmonary nodules were eventually included. Six guidelines focused on the management of pulmonary nodules, four emphasized the screening of pulmonary nodules, and two focused on the benign and malignant evaluation of pulmonary nodules. Notably, only one guideline exclusively dealt with pediatric pulmonary nodules. Trusted CPGs are developed by a multidisciplinary panel of experts. In this study, most (11/12) of the guidelines were developed by multidisciplinary international or national expert panels. Of the 12 guidelines, 11/12 were written in English and 1/12 was written in Chinese. Additionally, 5/12 guidelines were developed by thoracic societies from the United States, 4/12 from China, 1/12 from Canada, 1/12 from South Africa, and 1/12 from the United Kingdom. These results showed that the guidelines for pulmonary nodules were mainly developed by societies from the United States and China and that the number of the guidelines tended to grow in the recent three years. The details of the included guidelines are shown in Table 1. Notably, the reporting quality varied among the included guidelines. The reporting rates across the guidelines ranged from 37.1% to 94.3%, with a mean reporting rate of 66.9%. The reporting rates of 7/12 were >60%, and 4/12 of those guidelines were >80%. One guideline developed by the CHEST Expert Panel achieved the highest reporting rate of 94.3%, whereas one guideline developed by a Chinese expert panel had the lowest reporting rate of 37.1%. The mean reporting rates of the seven domains across the guidelines ranged from 37.5% to 81.9%. The overall reporting rates were 81.9% for the basic information domain; 80.2% for the background domain; 58.3% for the evidence domain; 60.7% for the recommendations domain; 37.5% for the review and quality assurance domain; 47.9% for the funding, declaration, and management of interest domain; and 75% for the other information domain.

Table 1 - Characteristics of the included guidelines of pulmonary nodules. Guideline title Publication year Reporting rate (%) Developer Country Journal or website of publication Management of lung nodules and lung cancer screening during the COVID-19 pandemic: CHEST Expert Panel report 2020 82.9 CHEST Expert Panel United States CHEST Screening for lung cancer CHEST Guideline and Expert Panel report 2021 94.3 CHEST Guideline and Expert Panel United States CHEST Recommendations for lung cancer screening in Southern Africa 2019 48.6 South African Thoracic Society South Africa Journal of Thoracic Disease Expert consensus workshop report: Guidelines for preoperative assisted localization of small pulmonary nodules 2020 54.3 China Minimally Invasive Diagnosis and Treatment in Lung Cancer Group China Journal of Cancer Research and Therapeutics Malignancy risk stratification for solitary pulmonary nodule: A clinical practice guideline 2022 71.4 Multidisciplinary Expert Panel China Journal of Evidence-Based Medicine British Thoracic Society guidelines for the investigation and management of pulmonary nodules 2015 85.7 British Thoracic Society United Kingdom Thorax Guidelines for management of incidental pulmonary nodules detected on CT images: From the Fleischner Society 2017 2017 68.6 Multidisciplinary International Expert Panel United States Radiology Pediatric pulmonary nodules imaging guidelines and recommendations 2022 54.3 Teresa I Liang and Edward Y Lee Canada Radiologic Clinics of North America NCCN guidelines version 1.2023 lung cancer screening 2022 54.3 NCCN United States NCCN website Evaluation of pulmonary nodules: Clinical practice consensus guidelines for Asia 2016 80.0 Multidisciplinary Asian Expert Panel China CHEST Chinese guidelines for classification, diagnosis, and treatment of pulmonary nodules (2016 Edition) 2016 37.1 Chinese Expert Panel on early diagnosis and early treatment of Lung cancer China Chinese Journal of Lung Cancer Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society 2013 71.4 Expert Panel United States Radiology

COVID-19: Coronavirus disease 2019; CT: Computerized tomography; NCCN: National Comprehensive Cancer Network.

The reporting rate for each item highly varied [Supplemental Table 1, https://links.lww.com/CM9/B901]. The discovery of the causes behind low reporting rates for certain items can contribute to the development of strategies for improving reporting quality. For each item, only three guidelines stated the publication year in the title (item 1b). Items 1a (with “guideline” or “recommendation” in the title), 1c (focus of the guideline, such as screening, diagnosis, treatment, or others), 3 (abbreviations and acronyms), 7 (target population), 9 (guideline development groups), 13a (clear, precise, and actionable recommendations), and 13b (separate recommendations for important subgroups) were reported by all 12 guidelines, with a reporting rate of 100%. However, no guideline described the role of the funder in the different stages of guideline development and in the dissemination and implementation of the recommendations (item 18b). The updated guideline often contained the latest evidence, and the presence of the publication year in title is easy for readers to see immediately whether the recommendations within the guideline are up to date. By contrast, all guidelines described the identification and focus of the guideline within the title (items 1a and 1c) and the target population of the guideline (item 7), making it convenient for readers to find the target guideline from the database. Items 4 (corresponding developer), 5 (brief description of the health problem), 19 (declaration and management of interest), 20 (access), and 11b (referencing of existing systematic reviews with descriptions of how they were identified and assessed) were well reported, each having a reporting rate of >80%. By contrast, items 1b (publication year of the guideline), 8b (intended setting of the guideline), 10 (healthcare questions), 14 (rationale/explanation of recommendations), 16 (external review), 17 (quality assurance), and 18a (specific sources of funding for all stages of guideline development) were described by fewer than half of the guidelines. Only half of the guidelines described the intended primary users and settings of the guideline (item 8). Because the application of the guidelines varied with different medical conditions and drug accessibility from different users and settings, item 8 should be described in detail. The reporting quality of item 10 (healthcare questions) was significantly poor, with a reporting rate of <50%. Statement of the key questions for the recommendations and an indication of the selection and sorting of outcomes can greatly assist readers in understanding the evidence and evaluating the accuracy of the CPGs. Most of the CPGs did not describe the values and preferences of the target population (item 14a), cost and resource implications (14b), or equity, feasibility, and acceptability (14c) in the formulation of recommendations of the guidelines, which prevents healthcare workers from easily adapting the guidelines in compliance with different clinical conditions. The reporting rates of items 16 and 17 in the review and quality assurance domain were low. Since an independent review and quality assurance process will enhance the rigor of the guidelines, the absence of such information is likely to make readers doubt the quality of the guidelines.

Above all, the mean reporting rate across all the guidelines was 66.9%, with five CPGs having a reporting rate of <60%. Four of the 12 CPGs adhered to >80% of the items, which usually had common characteristics including publishment in official journals of national associations and development by medical professional societies who may have systematic, clear, and rigorous internal methods of guideline development. However, the RIGHT checklist did not address the quality of the published guidelines but the reporting quality of the guidelines. Therefore, although a higher reporting rate indicated better reporting quality, the recommendations in the guidelines were not necessarily in line with best practices for disease management. Five guidelines adhered to <60% of the checklist items, indicating the need for improvement. Among these five guidelines, one developed by a Chinese expert panel on early diagnosis and treatment of lung cancer had the lowest reporting rate of 37.1% for the items in the RIGHT checklist. Chinese guideline developers should improve their adherence to the RIGHT statements when developing guidelines to provide clear, complete, and transparent recommendations in the future.

Finally, the reporting quality of the guidelines for pulmonary nodules was suboptimal. In particular, the items related to the review and quality assurance, evidence, and rationale/explanation of the recommendations were poorly reported. We encourage the use of the RIGHT checklist to improve standardization of reporting for pulmonary nodules to provide better medical service.

Conflicts of interest

None.

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