the Management of Adrenal Lesions

- Methods

A comprehensive search for guidelines was undertaken to identify the relevant guidelines to consider for adaptation.
Inclusion/ exclusion criteria followed in the search and retrieval of guidelines to be adapted:
Selecting only evidence-based guidelines (guideline must include a report on systematic literature searches and explicit links between individual recommendations and their supporting evidence)
Selecting only national and/or international guidelines
Specific range of dates for publication (using Guidelines published or updated within the last five years)
Selecting peer reviewed publications only.
Selecting guidelines written in English language.
Excluding guidelines written by a single author, not on behalf of an organization to be valid and comprehensive, a guideline ideally requires multidisciplinary input
Excluding guidelines published without references as the panel needs to know whether a thorough literature review was conducted and whether current evidence was used in the preparation of the recommendations
The following characteristics of the retrieved guidelines were summarized in:
Developing organization/authors
Date of publication, posting, and release
Country/language of publication
Date of posting and/or release
Dates of the search used by the source guideline developers
All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least three members. The panel decided on a cut-off point (any guideline scoring above 50% on the rigor dimension was retained). The GDG decided to adapt the European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors, 2023,⁽¹⁾.
Evidence assessment
According to WHO Handbook for Guidelines, we used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to assess the quality of a body of evidence, develop and report recommendations. GRADE methods are used by WHO because these represent internationally agreed standards for making transparent recommendations. Detailed GRADE information is available on the following sites:
•           GRADE working group: https://www.gradeworkinggroup.org/
•           GRADE online training modules: http://cebgrade.mcmaster.ca/
Specifically, the quality of evidence was graded as ‘High’, ‘Moderate’, ‘Low’ or ‘Very low’, (table 2& 3).
The strength of the recommendation
The strength of a recommendation communicates the importance of adherence to the recommendation.
Strong recommendations
With strong recommendations, the guideline communicates the message that the desirable effects of adherence to the recommendation outweigh the undesirable effects. This means that in most situations the recommendation can be adopted as policy.
Conditional recommendations
These are made when there is greater uncertainty about the four factors above or if local adaptation has to account for a greater variety in values and preferences, or when resource use makes the intervention suitable for some, but not for other locations. This means that there is a need for substantial debate and involvement of stakeholders before this recommendation can be adopted as policy.
When not to make recommendations
When there is lack of evidence on the effectiveness of an intervention, it may be appropriate not to make a recommendation.