OBJECTIVE: To assess the feasibility of the appropriateness method in the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Development process, and to compare the results of the appropriateness method with those obtained using evidence tables and an informal consensus method. SETTING: AHCPR Low Back Problems Clinical Practice Guideline. DESIGN: Two different group process methods with the same panel of experts were used in observational comparison of results of and satisfaction with guideline development. DATA COLLECTION: Practice guideline statements were created for topics using the conventional AHCPR method; then six months later new guideline statements for four topics were created using the appropriateness method. Panelist satisfaction with each process and resulting set of guideline statements was assessed. PRINCIPAL FINDINGS: Results of the appropriateness method for TENS, discography, and traction showed no disagreement among panel members and no appropriate indications for their use in the patient scenarios considered. These results are qualitatively similar to the guideline statements produced using evidence tables and informal consensus. Clinical practice guideline statements about electro-diagnostics created from appropriateness ratings were much more clinically specific than those created using evidence tables and informal consensus. Neither informal consensus building nor the appropriateness method was clearly preferred by a majority of panelists. CONCLUSIONS: It is feasible to use the appropriateness method in the AHCPR Clinical Practice Guideline Development process, and in some instances it produces more clinically specific guideline statements than does informal consensus.
Increasing amounts of medical knowledge, clinical data, and patient expectations have created a fertile environment for developing and using clinical practice guidelines. Electronic medical records have provided an opportunity to invoke guidelines during the everyday practice of clinical medicine to improve health care quality and control costs. In this paper, efforts to incorporate complex guidelines [those for heart failure from the Agency for Health Care Policy and Research (AHCPR)] into a network of physicians' interactive microcomputer workstations are reported. The task proved difficult because the guidelines often lack explicit definitions (e.g., for symptom severity and adverse events) that are necessary to navigate the AHCPR algorithm. They also focus more on errors of omission (not doing the right thing) than on errors of commission (doing the wrong thing) and do not account for comorbid conditions, concurrent drug therapy, or the timing of most interventions and follow-up. As they stand, the heart failure guidelines give good general guidance to individual practitioners, but cannot be used to assess quality or care without extensive "translation" into the local environment. Specific recommendations are made so that future guidelines will prove useful to a wide range of prospective users.
OBJECTIVES: To describe common barriers that limit the effect of guidelines on patient care, with emphasis on recommendations for triage in the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Clinical Practice Guideline. DATA SOURCES: Previously reported results from a prospective clinical study of 10,785 patients presenting to the emergency department (ED) with symptoms suggestive of acute cardiac ischemia. STUDY DESIGN: Design is an analysis of the AHCPR guideline with regard to recognized barriers in guideline implementation. Presentation of hypothetical scenarios to ED physicians was used to determine interrater reliability in applying the guideline to assess risk and to make triage decisions. PRINCIPAL FINDINGS: The AHCPR guideline's triage recommendations demonstrate (1) poor interobserver reliability in interpretation by ED physicians; (2) limited applicability of recommendations for outpatient management (applies to 6 percent of patients presenting to the ED with unstable angina); (3) incomplete specifications of exceptions that may require deviation from guideline recommendations; (4) unexpected effects on medical care by significantly increasing the demand for limited intensive care beds; and (5) unknown effects on patient outcomes. In addition, analysis of the guideline highlights the need to address organizational barriers, such as administrative policies that conflict with guideline recommendations and the need to adapt the guideline to conform to local systems of care. CONCLUSIONS: Careful analysis of guideline attributes, projected effect on medical care, and organizational factors reveal several barriers to successful guideline implementation that should be addressed in the design of future guideline-based interventions.
To document smoking cessation rates achieved by applying the 1996 Agency for Health Care Policy and Research (AHCPR) smoking cessation guidelines for primary care clinics, compare these quit rates with historical results, and determine if quit rates improve with an additional motivational intervention that includes education as well as spirometry and carbon monoxide measurements.
Randomized clinical trial.
Two university-affiliated community primary care clinics.
Two hundred five smokers with routinely scheduled appointments.
All smokers were given advice and support according to AHCPR guidelines. Half of the subjects received additional education with spirometry and carbon monoxide measurements.
MEASUREMENTS AND MAIN RESULTS
Quit rate was evaluated at 9-month follow-up. Eleven percent of smokers were sustained quitters at follow-up. Sustained quit rate was no different for intervention and control groups (9% vs 14%; [OR] 0.6; 95%[CI] 0.2, 1.4). Nicotine replacement therapy was strongly associated with sustained cessation (OR 6.7; 95% CI 2.3, 19.6). Subjects without insurance were the least likely to use nicotine replacement therapy (p = .05). Historical data from previously published studies showed that 2% of smokers quit following physician advice, and additional support similar to AHCPR guidelines increased the quit rate to 5%.
The sustained smoking cessation rate achieved by following AHCPR guidelines was 11% at 9 months, which compares favorably with historical results. Additional education with spirometry did not improve the quit rate. Nicotine replacement therapy was the strongest predictor of cessation, yet was used infrequently owing to cost. These findings support the use of AHCPR guidelines in primary care clinics, but do not support routine spirometry for motivating patients similar to those studied here.
clinical trial; smoking cessation; AHCPR guidelines; spirometry; nicotine replacement therapy
One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity. A prospective study was designed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines. Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia, Basque Country (Spain), participated in the study. A total of 105 patients aged 18–65 years presenting with acute low back pain over a 6-month period were included. Immediately after consultation, a research assistant performed a structured clinical interview. The patients’ care provided by the general practitioner was compared with the Agency for Health Care Policy and Research (AHCPR) guidelines and guidelines issued by the Royal College of General Practitioners. The diagnostic process showed a low rate of appropriate use of history (27%), physical examination (32%), lumbar radiographs (31%), and referral to specialized care (33%). Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization (77%) and educational advice (65%), only 23% of patients were taught about the benign course of back pain. The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines.
Low back pain; Primary health care; Physicians, family; Practice guidelines
The Agency for Health Care Policy and Research (AHCPR) Pain Guidelines of 1994 recognized pain as a critical symptom that impacts quality of life (QOL). The barriers to optimum pain relief were classified into three categories: patient, professional and system barriers. A prospective, longitudinal clinical trial is underway to test the effects of the “Passport to Comfort” innovative intervention on pain and fatigue management. This paper reports on pre-intervention findings related to barriers to pain management. Cancer patients with a diagnosis of breast, lung, colon, or prostate cancer who reported a pain rating of ≥ 4 were accrued. Subjects completed questionnaires to assess subjective ratings of overall QOL, barriers to pain management, and pain knowledge at baseline and at one- and three-month evaluations. A chart audit was conducted at one month to document objective data related to pain management. The majority of subjects had moderate (4–6 on a zero to ten numeric rating scale) pain at the time of accrual. Patient barriers to pain management existed in attitudes and knowledge regarding addiction, tolerance, and not being able to control pain. Subjects who were currently receiving chemotherapy were reluctant to communicate their pain with health care professionals. Professional and system barriers were focused around screening, documentation, re-assessment, and follow-up of pain. Lack of referrals to supportive care services for patients was also noted. Several well-described patient, professional, and system barriers continue to hinder efforts to provide optimal pain relief. Phase II of this initiative will attempt to eliminate these barriers using the “Passport” intervention to manage cancer pain.
Pain; barriers; quality of life; QOL
The purpose of this nursing informatics and outcomes research study was to determine the effectiveness of an expert system for disseminating knowledge to ambulatory women health care consumers with urinary incontinence. Clinical knowledge from the Agency for Health Care Policy and Research (AHCPR) patient guideline for urinary incontinence and research literature for behavioral treatments provided the knowledge base for the expert system. Two experimental groups (booklet and expert system) and one control group were utilized. Study results suggest the use of an expert system as one effective communication means for disseminating clinical information in an advisory capacity to ambulatory women with urinary incontinence.
Objective: To evaluate dissemination of the Agency for Health Care Policy and Research (AHCPR) Smoking cessation clinical practice guideline in community health centres.
Design: Pre- and post-trial.
Setting: Fourteen community health centres in Rhode Island.
Subjects: Provider performance was assessed with 1798 and 1591 patient contacts, in pre-post cross sectional consecutive samples, respectively, and 891 contacts at one year follow up.
Interventions: Three, one hour on-site provider training sessions, on review of effective tobacco interventions, use of office systems, and tobacco counselling skill building.
Outcome measures: Chart documentation of four A's (Ask, Advise, Assist, and Arrange follow up) at most recent primary care visit.
Results: While average performance rates increased for Ask and Advise (from 30% to 44%, and 19% to 26%, pre-post, respectively), significant increases were found only for some visit types, with further differences by patient sex. There were significant increases for Ask for all except obstetric/gynaecological (ob/gyn) visit types. Patients at yearly physicals and first visits were more likely to be asked at all time points, while males were more likely to be asked at acute visits than were females. There were no significant increases for Advise, Assist, and Arrange across time, although female patients showed a differential increase in Advise post-training. Advise was significantly more likely in yearly physicals and first visits, and less likely in ob/gyn visits, at all time points.
Conclusions: This guideline dissemination effort resulted in quite different provider counselling rates across patient sexes, and visit types. Guideline implementation may require more sustained efforts, with multiple strategies, which are reinforced at higher policy levels, to more fully integrate tobacco interventions into routine primary care practice with all patients who smoke.
Clinical guidelines are considered important instruments to improve quality in health care. Since 1998 the Royal Dutch Society for Physical Therapy (KNGF) produced evidence-based clinical guidelines, based on a standardized program. New developments in the field of guideline research raised the need to evaluate and update the KNGF guideline program.
Purpose of this study is to compare different guideline development programs and review the KNGF guideline program for physical therapy in the Netherlands, in order to update the program.
Six international guideline development programs were selected, and the 23 criteria of the AGREE Instrument were used to evaluate the guideline programs. Information about the programs was retrieved from published handbooks of the organizations. Also, the Dutch program for guideline development in physical therapy was evaluated using the AGREE criteria. Further comparison the six guideline programs was carried out using the following elements of the guideline development processes: Structure and organization; Preparation and initiation; Development; Validation; Dissemination and implementation; Evaluation and update.
Compliance with the AGREE criteria of the guideline programs was high. Four programs addressed 22 AGREE criteria, and two programs addressed 20 AGREE criteria. The previous Dutch program for guideline development in physical therapy lacked in compliance with the AGREE criteria, meeting only 13 criteria.
Further comparison showed that all guideline programs perform systematic literature searches to identify the available evidence. Recommendations are formulated and graded, based on evidence and other relevant factors. It is not clear how decisions in the development process are made. In particular, the process of translating evidence into practice recommendations can be improved.
As a result of international developments and consensus, the described processes for developing clinical practice guidelines have much in common. The AGREE criteria are common basis for the development of guidelines, although it is not clear how final decisions are made. Detailed comparison of the different guideline programs was used for updating the Dutch program. As a result the updated KNGF program complied with 22 AGREE criteria. International discussion is continuing and will be used for further improvement of the program.
OBJECTIVE: To assess the outcomes of the Agency for Healthcare Research and Quality's (AHRQ; formerly the Agency for Health Care Policy and Research, AHCPR) first decade of focus on outcomes and effectiveness research (OER) and to identify needs and opportunities for the study of OER in the coming years. DATA SOURCE: Study findings were collected in response to an inquiry by the Center for Outcomes and Effectiveness Research at AHRQ in July 1997 to all principal investigators (PIs) funded between 1989 and 1997. The request was for investigators to identify their "most salient findings" and supply material for up to three slides. STUDY DESIGN: A taxonomy of 11 non-mutually exclusive categories was used to group the investigators' salient findings by characteristics of methodology or purpose. Two health services researchers assigned findings to up to three categories for each discrete study. PRINCIPAL FINDINGS: Responses were received from 61 (64 percent) of the 91 PIs, reporting on 115 studies. Of the 246 category assignments made, descriptive epidemiology was the most common (24 percent), followed by comparative effectiveness (17 percent) and economic assessments (12 percent). Most studies were retrospective analyses of administrative data. Viewed within a conceptual framework for assessing the impact of research, OER has built a solid foundation for future quality improvement efforts by identifying problems, generating hypotheses, and developing new methodologies and has had limited impact on health care policies, practices and outcomes. CONCLUSIONS: OER has had moderate but significant success meeting initial expectations for the field. Challenges for the next generation of OER include advancing from hypothesis generation to definitive studies of effectiveness, and acceleration of the process by which findings effect policy, practice, and outcomes.
Evidence-based guidelines are used in health care systems throughout the world to aid in treatment decisions and to ensure quality and consistency in patient care. In breast oncology, guidelines for care are published by several internationally recognized organizations, including those from the United States, Canada, and the United Kingdom. The present study compared clinical breast cancer guidelines from the American Society of Clinical Oncology (asco, United States), Cancer Care Ontario (cco, Canada), and the National Institute for Health and Clinical Excellence (nice, United Kingdom) to determine the quality and consistency of content across international organizations.
We searched for breast cancer guidelines published by asco, cco, and nice. Guidelines on the same theme were identified across organizations and appraised by 4 independent reviewers using the Appraisal of Guidelines for Research and Evaluation (agree) instrument. Content of each guideline was also scored for consistency in overall recommendations across organizations and for consistency in cited evidence.
The quality of breast cancer guidelines produced by the targeted organizations was consistently good in the areas of Scope and Purpose, Rigor of Development, and Clarity and Presentation, but variable in the domains of Stakeholder Involvement, Applicability, and Editorial Independence. The content of the guidelines varied slightly in the strength of their recommendations.
Our review demonstrated consistency in quality and content for breast cancer practice guidelines published by various organizations. Future guidelines developed by these organizations should focus on how to implement and measure uptake of a guideline.
Breast cancer; practice guidelines; agree instrument; quality of care
To determine the effectiveness of screening and treatment for depression among ambulatory indigent patients visiting resident physicians.
Two-group randomized trial (N = 33 intervention, N = 28 usual care) with baseline, 6-month, and 12-month outcome measurements.
Internal Medicine Residency Clinic.
Clinic patients over 18 years of age who screened positive for depression on the PRIME-MD during a visit to their resident physician. Patients were not receiving treatment nor seeking care for any emotional problems. All patients were either enrolled in Medicaid or had income below the poverty line.
Resident physicians were educated to follow AHCPR (AHRQ; Agency for Healthcare Research and Quality) guidelines for diagnosis and treatment of depression in a primary care setting. For the intervention group patients, a screening nurse advised residents regarding the positive screen, handed them a standardized protocol outline, and attempted to arrange behavioral care. The patients in the usual care group were provided the results of the screen by the screening nurse before their visit with the resident, and advised to seek care for their symptoms.
Results for the primary outcome of depression symptoms measured with the Beck Depression Inventory (BDI) demonstrated that intervention was successful in reducing symptoms relative to usual care (difference = −4.9 BDI points, P = .05, 95% confidence interval [CI], −9.8 to −0.005 effect size = −0.41). During the 12-month follow-up, 70% of intervention patients were treated for depression (of these, 91% with antidepressants), while 15% of usual care patients were treated with antidepressants for depression. Another 18% of the usual care group had depression noted, but no treatment was identified. BDI differences between intervention and control groups were similar at the 6- and 12-month measures. Quality of life and costs were also measured, but differences between the groups were not significant in this regard.
Screening and treatment for depression by resident physicians was successful in reducing symptoms relative to usual care in an indigent population. Almost twice as many intervention patients as usual care controls demonstrated a substantial reduction (10 BDI points) in symptoms related to depression.
depression treatment; low-income patients; randomized trial
A guideline on pelvic girdle pain (PGP) was developed by “Working Group 4” within the framework of the COST ACTION B13 “Low back pain: guidelines for its management”, issued by the European Commission, Research Directorate-General, Department of Policy, Coordination and Strategy. To ensure an evidence-based approach, three subgroups were formed to explore: (a) basic information, (b) diagnostics and epidemiology, and (c) therapeutical interventions. The progress of the subgroups was discussed at each meeting and the final report is based on group consensus. A grading system was used to denote the strength of the evidence, based on the AHCPR Guidelines (1994) and levels of evidence recommended in the method guidelines of the Cochrane Back Review group. It is concluded that PGP is a specific form of low back pain (LBP) that can occur separately or in conjunction with LBP. PGP generally arises in relation to pregnancy, trauma, arthritis and/or osteoarthritis. Uniform definitions are proposed for PGP as well as for joint stability. The point prevalence of pregnant women suffering from PGP is about 20%. Risk factors for developing PGP during pregnancy are most probably a history of previous LBP, and previous trauma to the pelvis. There is agreement that non risk factors are: contraceptive pills, time interval since last pregnancy, height, weight, smoking, and most probably age. PGP can be diagnosed by pain provocation tests (P4/thigh thrust, Patrick’s Faber, Gaenslen’s test, and modified Trendelenburg’s test) and pain palpation tests (long dorsal ligament test and palpation of the symphysis). As a functional test, the active straight leg raise (ASLR) test is recommended. Mobility (palpation) tests, X-rays, CT, scintigraphy, diagnostic injections and diagnostic external pelvic fixation are not recommended. MRI may be used to exclude ankylosing spondylitis and in the case of positive red flags. The recommended treatment includes adequate information and reassurance of the patient, individualized exercises for pregnant women and an individualized multifactorial treatment program for other patients. We recommend medication (excluding pregnant women), if necessary, for pain relief. Recommendations are made for future research on PGP.
Pelvic girdle pain; Pelvic pain; Ankylosing spondylitis; Sacroiliac joint; Symphysis
Numerous agencies have developed clinical practice guidelines for the management of postmenopausal osteoporosis. The study objective was to conduct a systematic assessment of the quality of osteoporosis guidelines produced since 1998.
Guidelines were identified by searching MEDLINE (1998+), the world wide web, known guideline developer websites, bibliographies of retrieved guidelines, and through consultation with content experts. Each guideline was then assessed by three independent appraisers using the 'Appraisal Instrument for Clinical Guidelines' (version 1) by Cluzeau.
We identified 26 unique guidelines from 1998–2001 and 21 met our inclusion criteria. Of the 21 guidelines reviewed, 8 were developed by medical societies, 6 by national groups, 6 by government agencies, and 1 by an international group. Twelve of the guidelines were published, 7 were organizational reports, and 2 were accessible only from the web. Half or more of the 20 items assessing the rigor of guideline development were met by 15% (median quality score 23%, range 5–80%, (95% CI 16.5, 34.7)), 81% met at least half of the 12 items assessing guideline content and context (median score 58%, range 17–83%, (95% CI 50.8, 65.5)), and none met half or more of the items assessing guideline application (median score 0%, range 0–47%, (95% CI -0.5 to 12.6)). Eight guidelines described the method used to assess the strength of evidence, and in 6 there was an explicit link between recommendations and the supporting evidence. Ten guidelines were judged not suitable for use in practice, 10 were acceptable with modification, and one was acceptable for use without modification.
The methodological quality of current osteoporosis guidelines is low, although their scores for clinical content were higher. Virtually no guidelines covered dissemination issues. Few guidelines were judged as acceptable for use in their current format.
The long-term cardiovascular outcomes of a population-based cohort presenting to the emergency department (ED) with chest pain and classified with a clinical risk stratification algorithm are not well documented. The Olmsted County Chest Pain Study is a community-based study that included all consecutive patients presenting with chest pain consistent with unstable angina presenting to all Olmsted County EDs. Patients were classified according to the Agency for Health Care Policy and Research (AHCPR) criteria. Patients with ST elevation myocardial infarction and chest pain of non-cardiac origin were excluded. Main outcome measures were major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days and a median follow up of 7.3 years, and mortality through a median of 16.6 years. The 2271 patients were classified: 436 (19.2%) as high-, 1,557 (68.6%) as intermediate- and 278 (12.2%) as low-risk. Thirty-day MACCE occurred in 11.5% in high-risk, 6.2% in intermediate-risk, and 2.5% in the lowrisk group (p<0.001). At 7.3 years, significantly more MACCE were recorded in the intermediate (HR 1.91; 95% CI 1.33–2.75) and high-risk groups (HR 2.45; 95% CI 1.67–3.58). Intermediate- and high-risk patients demonstrated a 1.38 fold (95% CI 0.95–2.01, p=0.09) and a 1.68 fold (95% CI 1.13–2.50, p = 0.011) higher mortality compared to lowrisk patients at 16.6 years. At 7.3 and 16.6 years of follow-up, biomarkers were not incrementally predictive of cardiovascular risk. In conclusion, a widely-applicable rapid clinical algorithm using AHCPR criteria can reliably predict long-term mortality and cardiovascular outcomes. This algorithm, when applied in the ED, affords an excellent opportunity to identify patients who might benefit from optimization of their cardiovascular risk management.
The purpose of this paper was to evaluate the quality and scope of the published literature on functional impairment due to cataract in adults as reviewed for the Agency for Health Care Policy and Research Clinical Practice Guideline. We examined the method of literature retrieved and analysis performed in the course of development of literature-based recommendations for the guideline panel. To collect data, we reviewed the process of literature acquisition and identification and the quality assessments made by reviewers of 14 individual topics composed of 77 issues related to the guideline. We collated this information to provide an assessment of the quality and scope of the relevant literature. Less than 4% (310) of the approximately 8,000 articles initially identified as potentially relevant to the guideline were ultimately used. The majority covered three topics (surgery and complication, 100; Nd:YAG capsulotomy, 77; and potential vision testing, 40). Three other topics--indications for surgery, preoperative medical evaluation, and rehabilitation--were devoid of articles meeting inclusion criteria. For 43 issues, there was no identifiable relevant literature. With few exceptions, the quality of the literature was rated fair to poor owing to major flaws in experimental design. Case series (256 reports) of one type or another accounted for the majority of the included literature. There were 17 random controlled trials. This review revealed a sparse and generally low-quality literature relevant to the management of functional impairment due to cataract, despite a relatively large data base in reputable peer-reviewed journals.
In 2007, the World Health Organization (WHO) received a criticism for a lack of transparency and systematic methods in the development of guidelines, which were at that time perceived as substantially driven by expert opinion. In this paper we assessed the quality of maternal and perinatal health guidelines developed since then. We used the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool to evaluate the quality of methodological rigour and transparency of four different WHO guidelines published between 2007 and 2011. Our findings showed high scores among the most recent guidelines on maternal and perinatal health suggesting higher quality. However, there is still potential for improvement, especially in including different stakeholder views, transparency of guidelines regarding the role of the funding body and presentation of the guideline document.
We examined the methodological quality of guidelines on syndromes conferring genetic susceptibility to breast cancer.
PubMed, EMBASE, and Google were searched for guidelines published up to October 2010. All guidelines in English were included. The Appraisal of Guidelines, Research and Evaluation (AGREE) instrument was used to assess the quality of the guidelines, and their reported evidence base was evaluated.
Thirteen guidelines were deemed eligible: seven had been developed by independent associations, and the other six had national/state endorsements. Four guidelines performed satisfactorily, achieving a score of greater than 50% in all six AGREE domains. Mean ± SD standardized scores for the six AGREE domains were: 90 ± 9% for 'scope and purpose', 51 ± 18% for 'stakeholder involvement', 55 ± 27% for 'rigour of development', 80 ± 11% for 'clarity and presentation', 37 ± 32% for 'applicability', and 47 ± 38% for 'editorial independence'. Ten of the thirteen guidelines were found to be based on research evidence.
Given the ethical implications and the high costs of genetic testing for hereditary breast cancer, guidelines on this topic should provide clear and evidence-based recommendations. Our analysis shows that there is scope for improving many aspects of the methodological quality of current guidelines. The AGREE instrument is a useful tool, and could be used profitably by guidelines developers to improve the quality of recommendations.
Breast cancer; BRCA1/2; Familial breast/ovarian cancer; Cancer screening; Cancer surveillance
Main problem: Little is known about the methodological quality of guidelines for low back pain treatment. We evaluated the methods used by the developers according to established standards. Methods: PubMed, guideline databases, and the World Wide Web were used to identify guidelines. Seventeen guidelines met the inclusion criteria: interventions for low back pain stated, recommendations based on or explicitly linked to evidence, and English version available. Guidelines were evaluated independently by two appraisers using a practical tool for this purpose, Users’ Guides to the Medical Literature, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Results: Thirteen guidelines (76%) specified the most important therapies applied, but only nine (53%) included a complete description of the target population. Explicit processes to identify, select, and combine evidence were described in only six guidelines (35%). Few guidelines (3; 18%) explicitly considered all main outcomes when formulating therapeutic recommendations, and none contained a process to determine the relative value of different outcomes. Methodological criteria for grading the strength of the recommendations varied, and were often insufficiently specified. None of the guidelines assessed the impact of uncertainty associated with the evidence and values used. According to AGREE the quality score was highest for the scope and purpose, and clarity and presentation domains, and lowest for editorial independence and applicability. With regard to the recommendations, there was consensus for some of the interventions for acute pain (analgesics and NSAIDs, maintaining physical activity, and avoiding excessive bed rest), but explicit recommendations were lacking or ambiguous for 41% of the interventions. Most of the guidelines did not contemplate specific recommendations for chronic pain. Conclusions: A small number of the available guidelines for low back pain treatment achieved acceptable results for specific quality criteria. In general, the methods to develop the guidelines’ therapeutic recommendations need to be more rigorous, more explicit and better explained. In addition, greater importance should be placed on the recommendations for chronic pain.
Low back pain; Guidelines; Practice guidelines; Quality assurance; Health care
In social insurance, the evaluation of work disability is becoming stricter as priority is given to the resumption of work, which calls for a guarantee of quality for these evaluations. Evidence-based guidelines have become a major instrument in the quality control of health care, and the quality of these guidelines' development can be assessed using the AGREE instrument. In social insurance medicine, such guidelines are relatively new. We were interested to know what guidelines have been developed to support the medical evaluation of work disability and the quality of these guidelines.
Five European countries that were reported to use guidelines were approached, using a recent inventory of evaluations of work disability in Europe. We focused on guidelines that are disease-oriented and formally prescribed in social insurance medicine. Using the AGREE instrument, these guidelines were appraised by two researchers. We asked two experts involved in guideline development to indicate if they agreed with our results and to provide explanations for insufficient scores.
We found six German and sixteen Dutch sets of disease-oriented guidelines in official use. The AGREE instrument was applicable, requiring minor adaptations. The appraisers reached consensus on all items. Each guideline scored well on 'scope and purpose' and 'clarity and presentation'. The guidelines scored moderately on 'stakeholder involvement' in the Netherlands, but insufficiently in Germany, due mainly to the limited involvement of patients' representatives in this country. All guidelines had low scores on 'rigour of development', which was due partly to a lack of documentation and of existing evidence. 'Editorial independence' and 'applicability' had low scores in both countries as a result of how the production was organised.
Disease-oriented guidelines in social insurance medicine for the evaluation of work disability are a recent phenomenon, so far restricted to Germany and the Netherlands. The AGREE instrument is suitably applicable to assess the quality of guideline development in social insurance medicine, but some of the scoring rules need to be adapted to the context of social insurance. Existing guidelines do not meet the AGREE criteria to a sufficient level. The way patients' representatives can be involved needs further discussion. The guidelines would profit from more specific recommendations and, for providing evidence, more research is needed on the functional capacity of people with disabilities.
A key mandate of the Canadian Thoracic Society (CTS) is to promote evidence-based respiratory care through clinical practice guidelines (CPGs). To improve the quality and validity of the production, dissemination and implementation of its CPGs, the CTS has revised its guideline process and has created the Canadian Respiratory Guidelines Committee to oversee this process. The present document outlines the basic methodological tools and principles of the new CTS guideline production process. Important features include standard methods for choosing and formulating optimal questions and for finding, appraising, and summarizing the evidence; use of the Grading of Recommendations Assessment, Development and Evaluation system for rating the quality of evidence and strength of recommendations; use of the Appraisal of Guidelines for Research and Evaluation instrument for quality control during and after guideline development and for appraisal of other guidelines; use of the ADAPTE process for adaptation of existing guidelines to the local context; and use of the GuideLine Implementability Appraisal tool to augment implementability of guidelines. The CTS has also committed to develop guidelines in new areas, an annual guideline review cycle, and a new formal process for dissemination and implementation. Ultimately, it is anticipated that these changes will have a significant impact on the quality of care and clinical outcomes of individuals suffering from respiratory diseases across Canada.
Clinical practice guideline; Evidence-based medicine; Guideline adherence; Practice guidelines
BACKGROUND: Many policy and research documents on the treatment of depression in primary care suggest that general practitioners (GPs) should make use of clinical guidelines. AIM: To describe the content of peer-reviewed guidelines for the detection and treatment of depression in primary care and help GPs identify the one most useful to their own needs. METHOD: Guidelines were evaluated by an explicit method using the Institute of Medicine assessment instrument and according to six key clinical management questions identified as important by GPs and psychiatrists. RESULTS: Only five (30%) of the published guidelines identified met all the pre-defined inclusion criteria. Total scores for development process and content ranged from 54% to 82%. Validity scores ranged from 52% to 88%. No guideline answered all the key questions identified by clinicians. CONCLUSIONS: Only two guidelines conform to the quality standard of a clinical practice guideline. One covers all aspects of detection and management of depression in primary care but gives no advice on first-line choice of antidepressant, while the other focuses only on medication and fails to explore problems of case detection or to consider non-pharmacological treatments. However, taken together they do cover most of the key clinical issues in a reliable and valid manner. The identified guidelines vary considerably in both utility and clinical applicability.
The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000. Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity. For chronic low back pain, consistent features included supervised exercises, cognitive behavioural therapy and multidisciplinary treatment. However, there are some discrepancies for recommendations regarding spinal manipulation and drug treatment for acute and chronic low back pain. The comparison of international clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations are generally similar. There are also some differences which may be due to a lack of strong evidence regarding these topics or due to differences in local health care systems. The implementation of these clinical guidelines remains a challenge for clinical practice and research.
Low back pain; Clinical guidelines; Review; Diagnosis; Treatment
A proportion of women planning to give birth in a midwifery unit will experience complications during labour that necessitate transfer to an obstetric unit. Local guidelines for the transfer of women in labour have the potential to impact on quality of care and the safety of the transfer process.
To systematically appraise the quality of local NHS guidelines on the transfer of women from midwifery unit to obstetric unit during labour.
Guidelines were requested from all 52 NHS hospital trusts in England with midwifery units. The Appraisal of Guidelines for Research and Evaluation Instrument was used to evaluate the quality of the guidelines received.
Relevant guidelines were received from 34 (65%) trusts. No guidelines scored on the ‘editorial independence’ domain. The mean score on ‘scope and purpose’ (56.2%), concerned with the aims, clinical questions and target patient population of the guideline, was higher than for other domains: ‘clarity and presentation’ (language and format) 45.3%, ‘stakeholder involvement’ (representation of users’ views) 15.3%, ‘rigour of development’ (process used to develop guideline) 15.0%, ‘applicability’ (organisational, behavioural and cost implications of applying guideline) 7.1%. Only three guidelines were recommended for use in clinical practice.
We believe this to be the first systematic appraisal of the quality of local NHS guidelines. Overall these local guidelines were of poor quality. It is not clear whether the quality of these midwifery guidelines is typical of local guidelines in other clinical areas, but this study raises fundamental questions about the appropriate development of high-quality local clinical guidelines.
While many women and infants have an uneventful course during the postpartum period, others experience significant morbidity. Effective postpartum care in the community can prevent short, medium and long-term consequences of unrecognised and poorly managed problems. The use of rigorously developed, evidence-based guidelines has the potential to improve patient care, impact on policy and ensure consistency of care across health sectors. This study aims to compare the scope and content, and assess the quality of clinical guidelines about routine postpartum care in primary care.
PubMed, the National Guideline Clearing House, Google, Google Scholar and relevant college websites were searched for relevant guidelines. All guidelines regarding routine postpartum care published in English between 2002 and 2012 were considered and screened using explicit selection criteria. The scope and recommendations contained in the guidelines were compared and the quality of the guidelines was independently assessed by two authors using the AGREE II instrument.
Six guidelines from Australia (2), the United Kingdom (UK) (3) and the United States of America (USA) (1), were included. The scope of the guidelines varied greatly. However, guideline recommendations were generally consistent except for the use of the Edinburgh Postnatal Depression Scale for mood disorder screening and the suggested time of routine visits. Some recommendations lacked evidence to support them, and levels or grades of evidence varied between guidelines. The quality of most guidelines was adequate. Of the six AGREE II domains, applicability and editorial independence scored the lowest, and scope, purpose and clarity of presentation scored the highest.
Only one guideline provided comprehensive recommendations for the care of postpartum women and their infants. As well as considering the need for region specific guidelines, further research is needed to strengthen the evidence supporting recommendations made within guidelines. Further improvement in the editorial independence and applicability domains of the AGREE ll criteria would strengthen the quality of the guidelines.
Postpartum care; Clinical guidelines; AGREE II; Maternal health; Infant health