Designed as an instrument to summarize and incorporate vast bodies of evidence into practical recommendations to guide care by front-line clinicians, CPGs have emerged as an important knowledge translation tool.
CPGs rely on the principles of systematic literature search, appraisal, synthesis and presentation, weighing various outcomes to subsequently guide the composition of recommendations. Over the past decade, there has been an exponential growth in the number of guidelines produced, many of which address the same topics. Furthermore, in many cases, guidelines have presented conflicting recommendations (3
). This inconsistency was likely attributable to variability in guideline development methodology and to the lack of a ‘gold standard’ for the production and presentation of guidelines. In a review of 279 published guidelines, Shaynefelt et al (4
) found that only 17% of guidelines stated the method for identifying primary evidence, 8% reported the use of formal methods to combine scientific data (eg, meta-analysis) or, when data were lacking, to determine expert opinion (eg, the Delphi method), and 13% graded recommendations according to the strength of the evidence (4
). In a separate review, guidelines produced by specialty societies in particular performed no better (5
). Finally, over the past decade, the emergence of literature detailing ‘care gaps’ – disparities between evidence-based CPG recommendations and actual clinical practice – has forced researchers to reconsider not only CPG implementation but also CPGs themselves in light of this failure.
Given the vast number of existing guidelines, their heterogeneity and the prevalent methodological threats to their validity, and driven by a desire to enhance the role of CPGs as a vehicle for implementation of best evidence, researchers from around the world have since developed a suite of tools and instruments to guide valid CPG production and evaluation.
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) (6
) instrument has emerged as a widely adopted standard by which to rate and present the quality of evidence underlying guideline recommendations. The Appraisal of Guidelines for Research and Evaluation (AGREE) (7
) instrument is a validated and generic instrument designed to appraise the quality of clinical guidelines. Constituting a gold standard for quality, it acts as a ‘blueprint’ for guideline developers. The ADAPTE process seeks to facilitate adaptation of existing guidelines to a new context to avert duplicate guideline production by different societies (8
). Finally, the GuideLine Implementability Appraisal (GLIA) tool targets the ability of CPGs to bridge care gaps by providing a framework for measuring and improving guideline ‘implementability’ (9
). These tools provide uniformity and new benchmarks for guideline process and content validity.
Incorporation of these tools into the CTS guideline production process may improve the quality and validity of our guidelines, facilitate subsequent implementation efforts and concurrent measurements of effects, and enable resource savings through guideline adaptation rather than de novo guideline production whenever possible. Both the American College of Chest Physicians and the American Thoracic Society have committed to similar guideline processes, and both organizations have also designated the GRADE system for grading strength of recommendations and quality of evidence in all of their future guidelines (10
). Furthermore, the establishment of the CRGC will enable previously independent disease subcommittees to share resources, methodological expertise and guideline development experience, and enable uniform methodology, rigour, structure and appearance for all CTS guidelines (a detailed guideline methodology document is posted online at www.respiratoryguidelines.ca