'EMERGE': Construction of a simple quality appraisal tool for rapid review of laparoscopic surgery guidelines during COVID-19 pandemic.

Editor

The theoretical danger of virus transmission during Laparoscopic Surgery (LS) via surgical smoke and laparoscopy gas prompted several academic/ national associations to issue many rapidly emerging guidelines for laparoscopic during COVID-19 pandemic. Conventional appraisal tools like GRADE and AGREE II, which assess the quality of evidence and methodological rigor in the development of guidelines, have very rigorous exhaustive checklists[4,5]. This makes them impractical for the evaluation of rapidly emerging guidelines in a pandemic scenario. Additionally, recommendations from these guidelines have not been evaluated in terms of their consequences on already resource-constrained surgical services in low and middle-income countries (LMICs) A simple quality appraisal tool was developed to address these research gaps by following the key steps to the development of a new appraisal tool.

A simple objective framework to assess the quality of rapidly emerging guidelines — EMERGE (Evidence, Methodology, Ease, Resource, Geography & Economy) - was constructed. In addition to evidence and methodology, it included 4 other domains: ease of understanding, optimization with available resources, the inclusion of input for different geographical areas, and economic implications with each domain having two rating items being rated by two appraisers. Details of this framework and scoring are shown in . EMERGE was validated by conducting an online survey of 32 laparoscopic surgeons having more than 10 years experience who used the EMERGE tool via Google forms. The Cronbach's α coefficient was 0·95 (reliable) and Cα for each domain was more than 0·7. The inter-rater reliability showed moderate agreement (ICC = 0·571, p < 0·001, 95% CI, 0·428 < ICC < 0·717).

Table 1

EMERGE Tool for evaluation of the quality of rapidly emerging recommendations during a pandemic

Domain category	Item tool	Total Points (Minimum-Maximum)
Evidence support	High Class of evidence utilized High Level of evidence utilized	2-14
Methodology of development	Clearly defined methodology of development Supported by evidence-based guidelines	2-14
Easy understanding	Clarity available in recommendations Point-wise conclusions available	2-14
Resource optimization	Implementable without procuring of new resources Utilization of existing resources and indigenous low-cost alternatives	2-14
Geographical inclusion	Inclusion of opinion from different parts of the world as authors/ contributor Inclusion of supporting evidence from different parts of the world	2-14
Economic implications	Economic consideration included Minimum Economic impact of adopting recommendations.	2-14

Maximum possible score for a domain = 7 (strongly agree) x 2 (items) x 2 (appraisers) = 28

Minimum possible score = 1 (strongly disagree) x 2 (items) x 2 (appraisers) = 4

Obtained score — Minimum possible score (4)

Suspicion was raised earlier also about lack of quality of evidence and methodology by systemic review for each recommendation in guidelines. When appraised by EMERGE, all guidelines revealed low evidence base and poor methodological rigor; as an urgent need for a prompt production of laparoscopic surgery guidelines may have led to a temporary suspension of fundamental scientific principles in conducting evidence synthesis. Similarly, issues of resource optimization, geographical inclusion, and economic implications drew poor scores. The end of COVID-19 is nowhere in sight and its impact on global health will be long-lasting. Therefore it is important for the quality of such rapidly emerging recommendations to be assessed in terms of infrastructure, resource, workforce, and financial challenges apart from the level of evidence and methodology.

The speed and severity of this unprecedented COVID19 pandemic are posing critical challenges to the resources of even high-income countries. Most guidelines recommend use of negative pressure ORs and commercial smoke evacuators. However, exorbitant costs of these are unbearable for already resource-constrained surgical services in global south. Frugal innovations in response to these challenges may not be ideal but have the potential to provide good enough healthcare in the best way possible under given constraints. These low-cost ideas are in sync with the resource, geographic and economic domains of EMERGE tool; which has an additional advantage of its simple structure which allows quick appraisal of rapidly emerging guidelines (). The acronym ‘EMERGE’ also coincides with the ambitions of ‘Emerging Economies’ as the countries from the ‘global south’ aspire to be called rather than ‘LMICs’ or ‘developing countries’.