Is the methodological quality of guidelines declining in the US? Comparison of the quality of US Agency for Health Care Policy and Research (AHCPR) guidelines with those published subsequently

Quality assessment of clinical guidelines for the treatment of obesity in adults: application of the AGREE II instrument

There are various guidelines for the treatment of obesity, and thus the quality of these clinical guidelines has become a matter of concern. The objective was to describe and assess the quality of clinical guidelines for treatment of obesity in adults. We collected several studies, dated from 1998 to 2016, produced by different countries. The literature search included the National Guideline Clearinghouse (NGC), Guidelines International Network (GIN), PubMed (MEDLINE), Scopus, Web of Science, webpages of health institutions from different countries, and search sites, with the criterion: "clinical guidelines for treatment of obesity in adults and published until the 2016". The guidelines were assessed with the Appraisal of Guidelines for Research & Evaluation (AGREE II), according to the domains of the instrument. The search identified 21 guidelines: nine from Europe, six from North America, three from Latin America, and one each from Asia and Oceania and a transnational association. The Australian guideline had the best assessment. Of the six guidelines with the highest scores, five had been elaborated by the government sector responsible for the country's health. The domains "scope and purpose" and "clarity of presentation" had the highest score. Except for the Canadian guideline, the three guidelines drafted before the elaboration of AGREE II had the worst quality. In the domain "stakeholder involvement", only four guidelines (Australia, Scotland, France, and England) mentioned patient participation. Guideline development and quality enhancement are ongoing processes requiring systematic appraisal of the guideline production process and existing guidelines.

Updated clinical guidelines experience major reporting limitations

BACKGROUND

The Checklist for the Reporting of Updated Guidelines (CheckUp) was recently developed. However, so far, no systematic assessment of the reporting of updated clinical guidelines (CGs) exists. We aimed to examine (1) the completeness of reporting the updating process in CGs and (2) the inter-observer reliability of CheckUp.

METHODS

We conducted a systematic assessment of the reporting of the updating process in a sample of updated CGs using CheckUp. We performed a systematic search to identify updated CGs published in 2015, developed by a professional society, reporting a systematic review of the evidence, and containing at least one recommendation. Three reviewers independently assessed the CGs with CheckUp (16 items). We calculated the median score per item, per domain, and overall, converting scores to a 10-point scale. Multiple linear regression analyses were used to identify differences according to country, type of organisation, scope, and health topic of updated CGs. We calculated the intraclass coefficient (ICC) and 95% confidence interval (95% CI) for domains and overall score.

RESULTS

We included in total 60 updated CGs. The median domain score on a 10-point scale for presentation was 5.8 (range 1.7 to 10), for editorial independence 8.3 (range 3.3 to 10), and for methodology 5.7 (range 0 to 10). The median overall score on a 10-point scale was 6.3 (range 3.1 to 10). Presentation and justification items at recommendation level (respectively reported by 27 and 38% of the CGs) and the methods used for the external review and implementing changes in practice were particularly poorly reported (both reported by 38% of the CGs). CGs developed by a European or international institution obtained a statistically significant higher overall score compared to North American or Asian institutions (p = 0.014). Finally, the agreement among the reviewers on the overall score was excellent (ICC 0.88, 95% CI 0.75 to 0.95).

CONCLUSIONS

The reporting of updated CGs varies considerably with significant room for improvement. We recommend using CheckUp to assess the updating process in updated CGs and as a blueprint to inform methods and reporting strategies in updating.

Evidence-Based Practice Guidelines and School Nursing

The use of evidence-based practice (EBP) has become the standard of health care practice. Nurses are expected to use best evidence on a wide range of topics, yet most nurses have limited time, resources, and/or skills to access and evaluate the quality of research and evidence needed to practice evidence-based nursing. EBP guidelines allow nurses and other health care workers to have research information collected, analyzed, and condensed into specific practice recommendations by experts. This article defines EBP guidelines and discusses the process of guideline development, including identification of topics, systematic literature searches, and evaluation and rating of research. Criteria for determining the quality of existing guidelines are reviewed. The steps needed to develop EBP guidelines specifically for school nursing are discussed.

Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed. Overall, most guidelines target nonspecific LBP and recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments. The recommendation to use paracetamol for acute LBP is challenged by recent evidence and needs to be revisited.

SIGNIFICANCE

Most high-quality guidelines recommend education, staying active/exercise, manual therapy and paracetamol/NSAIDs as first-line treatments for LBP. Recommendation of paracetamol for acute LBP is challenged by recent evidence and needs updating.

Clinical practice guidelines for the management of conditions related to traffic collisions: a systematic review by the OPTIMa Collaboration

OBJECTIVE

To evaluate the methodological quality and synthesize recommendations of evidence-based guidelines for the management of common traffic injuries.

STUDY DESIGN

We conducted a systematic review and best evidence synthesis of guidelines on musculoskeletal injuries, psychological disorders and mild traumatic brain injuries (MTBI) from 1995 to 2012. Independent reviewers critically appraised eligible guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) criteria.

RESULTS

We retrieved 9863 citations. Of those, 16 guidelines were eligible for critical appraisal and eight were scientifically admissible (four targeting whiplash-associated disorders (WAD), one addressing anxiety and three addressing MTBI). The inadmissible guidelines had inadequate literature searches, inexplicit links between evidence and recommendations, and ambiguous recommendations. The literature used to develop most of the admissible guidelines was outdated. Major recommendations included: (1) Advice, education and reassurance for all conditions; (2) Exercise, return-to-activity, mobilization/manipulation, analgesics and avoiding collars for WAD; (3) Psychological first aid, pharmacotherapy and cognitive behavioral therapy as first-line interventions for anxiety; and (4) Monitoring for complications, discharge criteria, advice upon discharge from the emergency room and post-discharge care for MTBI.

CONCLUSION

Fifty percent of appraised guidelines were scientifically admissible, but most need updating. Most guidelines focus on WAD and MTBI. Few guidelines make comprehensive recommendations on a wide range of consequences from traffic collisions.

IMPLICATIONS FOR REHABILITATION

The core components of a program of care designed to manage common traffic injuries (whiplash-associated disorders - WAD, anxiety and mild traumatic brain injuries) should include advice, education and reassurance. Depending on the condition, the following specific interventions should be considered: (1) WAD: exercise, early return to activity, mobilization/manipulation, analgesics and avoidance of collars; (2) Anxiety: psychological first aid, pharmacotherapy and cognitive behavioral therapy; and (3) Mild traumatic brain injuries: use of specific discharge criteria (including no factors warranting hospital admission and support structures for subsequent care), education upon discharge from emergency room and post-discharge care (e.g. monitoring for complications, gradual return to normal activity based on tolerance of individual). The methodological quality of guidelines varies greatly; therefore, guideline developers need to adhere to established methodological standards and conform to the evaluation criteria outlined in the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

Practice parameters and strength of recommendation data: a variable compass

BACKGROUND

Practice parameters and guidelines shape and influence the method and manner in which medicine is practiced. With more than 121 scales and methods of assessing and rating evidence, a comparison of practice parameters can appear daunting. An evaluation of the evidence engenders a sense of the evolution of a specialty and a roadmap for the future.

OBJECTIVE

To assess the level of evidence underlying recommendations in allergy-immunology (AI) practice parameters.

METHODS

We analyzed the practice parameters that guide AI (n = 15), otolaryngology (n = 8), pediatrics (n = 13), and internal medicine (n = 10) as they appeared on August 30, 2012. Strength of recommendation data was compared after making adjustments for differences in rating scales.

RESULTS

The strength of recommendation calculated from strong to weak for the AI practice parameters using a standardized format yielded the following grades: A in 195 (13.9%), B in 342 (24.4%), C in 606 (43.2%), D in 231 (16.4%), and E in 29 (2.1%). Controlled trial-based evidence (A and B) demonstrated considerable variability among individual AI practice parameters (range, 1.3%-100%). Evidence from controlled trials was lower in the subspecialty fields (38.3% in AI and 38.2% in otolaryngology) compared with the primary care fields (55.6% in pediatrics and 86.1% in internal medicine).

CONCLUSION

Considerable variability exists in the strength of recommendations within the AI practice parameters. The guidelines created by the primary care fields rest on a larger base of evidence collected from controlled trials. These findings likely reflect the adopted approach of making recommendations for less well-studied conditions and practices in AI to assist practitioners and patients and at the same time highlight the myriad opportunities for future research.

Appraisal tools for clinical practice guidelines: a systematic review

INTRODUCTION

Clinical practice guidelines can improve healthcare processes and patient outcomes, but are often of low quality. Guideline appraisal tools aim to help potential guideline users in assessing guideline quality. We conducted a systematic review of publications describing guideline appraisal tools in order to identify and compare existing tools.

METHODS

Among others we searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from 1995 to May 2011 for relevant primary and secondary publications. We also handsearched the reference lists of relevant publications. On the basis of the available literature we firstly generated 34 items to be used in the comparison of appraisal tools and grouped them into thirteen quality dimensions. We then extracted formal characteristics as well as questions and statements of the appraisal tools and assigned them to the items.

RESULTS

We identified 40 different appraisal tools. They covered between three and thirteen of the thirteen possible quality dimensions and between three and 29 of the possible 34 items. The main focus of the appraisal tools were the quality dimensions "evaluation of evidence" (mentioned in 35 tools; 88%), "presentation of guideline content" (34 tools; 85%), "transferability" (33 tools; 83%), "independence" (32 tools; 80%), "scope" (30 tools; 75%), and "information retrieval" (29 tools; 73%). The quality dimensions "consideration of different perspectives" and "dissemination, implementation and evaluation of the guideline" were covered by only twenty (50%) and eighteen tools (45%) respectively.

CONCLUSIONS

Most guideline appraisal tools assess whether the literature search and the evaluation, synthesis and presentation of the evidence in guidelines follow the principles of evidence-based medicine. Although conflicts of interest and norms and values of guideline developers, as well as patient involvement, affect the trustworthiness of guidelines, they are currently insufficiently considered. Greater focus should be placed on these issues in the further development of guideline appraisal tools.

A new independent authority is needed to issue National Health Care guidelines

Health experts emphasize that getting doctors to follow clinical guidelines can save both lives and money. Less attention has been paid to how the guidelines are developed and the variability in the recommendations they include. We examined the quality and content of screening guidelines as a proxy for guidelines in general and found that the source of the guidelines affects their quality. Guidelines with inconsistent recommendations are unlikely to serve patients or physicians well. The creation of an independent organization that would work with multiple stakeholders to develop guidelines holds the potential to improve their quality.

Guidelines on chemotherapy in advanced stage gynecological malignancies: an evaluation of 224 professional societies and organizations

Background

Clinical practice guidelines are important for guiding practice, but it is unclear if they are commensurate with the available evidence.

Methods

We examined guidelines produced by cancer and gynecological societies and organizations and evaluated their coverage of and stance towards chemotherapy for advanced stage disease among 4 gynecological malignancies (breast, ovarian, cervical, endometrial cancer) where the evidence for the use of chemotherapy is very different (substantial and conclusive for breast and ovarian cancer, limited and suggesting no major benefit for cervical and endometrial cancer). Eligible societies and organizations were identified through systematic internet searches (last update June 2009). Pertinent websites were scrutinized for presence of clinical practice guidelines, and relative guidelines were analyzed.

Results

Among 224 identified eligible societies and organizations, 69 (31%) provided any sort of guidelines, while recommendations for chemotherapy on advanced stage gynecological malignancies were available in 20 of them. Only 14 had developed their own guideline, and only 5 had developed guidelines for all 4 malignancies. Use of levels of evidence and grades of recommendations, and aspects of the production, implementation, and timeliness of the guidelines did not differ significantly across malignancies. Guidelines on breast and ovarian cancer utilized significantly more randomized trials and meta-analyses. Guidelines differed across malignancies on their coverage of disease-free survival (p = 0.033), response rates (p = 0.024), symptoms relief (p = 0.005), quality of life (p = 0.001) and toxicity (p = 0.039), with breast and ovarian cancer guidelines typically covering more frequently these outcomes. All guidelines explicitly or implicitly endorsed the use of chemotherapy.

Conclusions

Clinical practice guidelines are provided by the minority of professional societies and organizations. Available guidelines tend to recommend chemotherapy even for diseases where the effect of chemotherapy is controversial and recommendations are based on scant evidence.

A novel approach to gathering and acting on relevant clinical information: SCAMPs

The current tools to adequately inform the process of improving health-care delivery consist primarily of retrospective studies, prospective trials, and clinical practice guidelines. We propose a novel and systematic approach that bridges the gap of our current tools to affect change, provides an infrastructure to improve health-care delivery, and identifies unnecessary resource utilization. The objective of this special article is to introduce the rationale and methods for this endeavor entitled "Standardized Clinical Assessment and Management Plans" (SCAMPs). SCAMPs take a relatively heterogeneous patient population and through a process of iterative analysis and modification of standardized assessment and management algorithms, SCAMPs allow the intrinsic biologic variability in a patient population to emerge and be understood. SCAMPs can be used to complement our currently available tools in order to result in incremental and sustained improvement in health-care delivery.

Critical appraisal of quality of clinical practice guidelines for treatment of psoriasis vulgaris, 2006-2009

Numerous international clinical guidelines for management of psoriasis have recently been published. We evaluated the quality of guidelines published between 2006 and December 2009 using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Eight guidelines from five separate working groups fulfilled inclusion criteria and were evaluated. Four used the standards established by the AGREE instrument in the process of development of their guidelines. Each of the guidelines uniformly received high domain scores (i.e., > 90%) for scope and purpose (range of 94-100%), and clarity and presentation (range of 92-100%). Nevertheless, each of the eight guidelines had important shortcomings (item scores < or = 2/4, in which 4 indicates strongly agree and 1 indicates strongly disagree that specific items have been adequately addressed) in at least one item including: stakeholder involvement (by lack of piloting and inadequate determination of patient views), development rigor (inadequate procedure for updating), applicability (by lack of discussion on organizational barriers), and editorial independence (from funding body). Despite the use of predefined standards in their development, important deficiencies exist in the most recent clinical treatment guidelines for psoriasis.

Knowledge to action: a challenge for neck pain treatment

SYNOPSIS

For clinicians, systematic reviews can enhance incorporation into practice of the large volumes of information emerging from research on effectiveness and risks. But we believe that these reviews are most useful with simplified tools to facilitate translation of this knowledge into practice. We provide a "Neck Care Tool Kit" that gives a diagrammatic approach to prioritizing intervention. The evidence from a series of 11 systematic reviews by the Cervical Overview Group is depicted in decision flow-charts and tables to enhance clinical interpretation of the overview findings. On simple visual inspection of symbols in a table, the reader can establish where there is evidence of benefit or no benefit, the strength of the recommendation, and if these data represent short- or long-term findings. Where possible, we guide clinicians to dosage of specific treatment methods. There is no consensus as to which outcome measures to prioritize among the large number in use. This clinical commentary guides clinicians to view the evidence in enough detail to integrate it into their clinical practice environment. We conclude by delineating research gaps and proposing future research directions.

LEVEL OF EVIDENCE

Therapy, level 5.

Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions

OBJECTIVE

To assess the quality of Australian clinical guidelines for chronic diseases and their relevance to older people with multiple comorbid conditions.

DESIGN

Selection and assessment of national clinical guidelines for chronic conditions listed as National Health Priority Areas: cardiovascular health, diabetes mellitus, mental health, asthma, arthritis and musculoskeletal conditions, and cancer.

MAIN OUTCOME MEASURES

Standardised mean scores obtained with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument (criteria grouped into six domains: scope and purpose; stakeholder involvement; rigour of development; clarity and presentation; applicability; and editorial independence). Relevance of guidelines for older people with multiple comorbid conditions.

RESULTS

17 guidelines were included in the study. Guidelines approved by the National Health and Medical Research Council (NHMRC) scored significantly better than those not approved by the NHMRC in all domains except for editorial independence and clarity and presentation. The mean quality of guidelines not approved by the NHMRC was below 50% in all domains except clarity and presentation. Half of the guidelines addressed treatment for older patients or for patients with one comorbid condition, but only one addressed treatment for older patients with multiple comorbid conditions.

CONCLUSIONS

Professional societies and charities should be encouraged and supported to develop clinical guidelines in compliance with NHMRC requirements. Future guidelines should place more emphasis on the management of older people with multiple comorbid conditions.

Industry influence in the creation of pay-for-performance quality measures

With the impact of pay for performance likely to broaden and deepen in the coming years, ensuring that the quality measures used in these initiatives are based on the best possible clinical evidence and expert consensus is paramount. Two types of organizations greatly influence the content of quality measures: measure development organizations-such as the National Committee for Quality Assurance-and medical professional societies. The process by which emerging measures of quality are created is subject to bias resulting from organizational and individual conflicts of interest in both types of organizations. This article examines the financial ties between those who-both directly and indirectly-help create the standards used in pay-for-performance programs and those firms whose revenues will increasingly depend on the substance of these measures. Several examples of inappropriate industry influence in the drafting of clinical practice guidelines by professional societies illustrate that these groups' future management of conflicts of interest may ultimately affect the success of pay-for-performance programs. Finally, policy options for minimizing the effects of these conflicts on the development of quality measures are discussed.

Rigorous development does not ensure that guidelines are acceptable to a panel of knowledgeable providers

BACKGROUND

Rigorous guideline development methods are designed to produce recommendations that are relevant to common clinical situations and consistent with evidence and expert understanding, thereby promoting guidelines' acceptability to providers. No studies have examined whether this technical quality consistently leads to acceptability.

OBJECTIVE

To examine the clinical acceptability of guidelines having excellent technical quality.

DESIGN AND MEASUREMENTS

We selected guidelines covering several musculoskeletal disorders and meeting 5 basic technical quality criteria, then used the widely accepted AGREE Instrument to evaluate technical quality. Adapting an established modified Delphi method, we assembled a multidisciplinary panel of providers recommended by their specialty societies as leaders in the field. Panelists rated acceptability, including "perceived comprehensiveness" (perceived relevance to common clinical situations) and "perceived validity" (consistency with their understanding of existing evidence and opinions), for ten common condition/therapy pairs pertaining to Surgery, physical therapy, and chiropractic manipulation for lumbar spine, shoulder, and carpal tunnel disorders.

RESULTS

Five guidelines met selection criteria. Their AGREE scores were generally high indicating excellent technical quality. However, panelists found 4 guidelines to be only moderately comprehensive and valid, and a fifth guideline to be invalid overall. Of the topics covered by each guideline, panelists rated 50% to 69% as "comprehensive" and 6% to 50% as "valid".

CONCLUSION

Despite very rigorous development methods compared with guidelines assessed in prior studies, experts felt that these guidelines omitted common clinical situations and contained much content of uncertain validity. Guideline acceptability should be independently and formally evaluated before dissemination.

Falling on stony ground? A qualitative study of implementation of clinical guidelines' prescribing recommendations in primary care

OBJECTIVES

We aimed to explore key themes for the implementation of guidelines' prescribing recommendations.

METHODS

We interviewed a purposeful sample of 25 participants in British primary care in late 2000 and early 2001. Thirteen were academics in primary care and 12 were non-academic GPs. We asked about implementation of guidelines for five conditions (asthma, coronary heart disease prevention, depression, epilepsy, menorrhagia) ensuring variation in complexity, role of prescribing in patient management, GP role in prescribing and GP awareness of guidelines. We used the Theory of Planned Behaviour to design the study and the framework method for the analysis.

RESULTS

Seven themes explain implementation of prescribing recommendations in primary care: credibility of content, credibility of source, presentation, influential people, organisational factors, disease characteristics, and dissemination strategy. Change in recommendations may hinder implementation. This is important since the development of evidence-based guidelines requires change in recommendations. Practitioners do not have a universal view or a common understanding of valid 'evidence'. Credibility is improved if national bodies develop primary care guidelines with less input from secondary care and industry, and with simple and systematic presentation. Dissemination should target GPs' perceived needs, improve ownership and get things right in the first implementation attempt. Enforcement strategies should not be used routinely.

CONCLUSIONS

GPs were critical of guidelines' development, relevance and implementation. Guidelines should be clear about changes they propose. Future studies should quantify the relationship between evidence base of recommendations and implementation, and between change in recommendations and implementation. Small but important costs and side effects of implementing guidelines should be measured in evaluative studies.

Do clinical guidelines enhance safe practice in obstetrics and gynaecology?

Clinical guidelines are increasingly used to promote a more uniform standard of high-quality evidence-based health care. International agencies advocate guideline development methods founded on three principles: that recommendations are evidence-based, are explicitly linked to the type and quality of evidence, and are developed by multidisciplinary stakeholder groups. Numerous interventions have been described to support the implementation of guidelines. Systematic reviews suggest that most interventions produce modest to moderate improvements in care; multifaceted interventions appear to be no more effective than single interventions, and the lowest-cost implementation strategy (dissemination of printed materials) may improve care and be feasible in many settings. Given the considerable costs of developing valid guidelines de novo, we advocate local adaptation of existing guidelines if available. We suggest a pragmatic framework to assist policy-makers and clinicians in deciding how best to use the scarce resources available for quality-improvement activities.

Managing conflict of interest in clinical practice

Conflict of interest, even the appearance of potential conflict, has long been a concern for physicians and scientists. Conflict of interest arises when an activity is accompanied by a divergence between personal or institutional benefit when compared to the responsibilities to patients and to society; it arises in the context of research, purchasing, leadership, and investments. Conflict of interest is of concern because it compromises the trust of the patient and of society in the individual physician or the medical center.

Adoption of the ASPAN Clinical Guideline for the Prevention of Unplanned Perioperative Hypothermia: A Data Collection Tool

Perioperative hypothermia remains a common occurrence despite the development and dissemination of a clinical practice guideline for the prevention of unplanned perioperative hypothermia by ASPAN. Unfortunately, a process for measuring compliance with and adoption of this guideline has yet to be developed. The purpose of this article is to describe a medical record abstraction method for determining the degree of adoption of the ASPAN Clinical Guideline for the Prevention of Unplanned Perioperative Hypothermia in the perianesthesia setting. Use of the instrument for future research is also explored.

Conflict between guideline methodologic quality and recommendation validity: a potential problem for practitioners

BACKGROUND

It is not clear if good methodologic quality in current practice guidelines necessarily leads to more valid recommendations, i.e., those that are supported with consistent research evidence or, when evidence is conflicting or lacking, with sufficient consensus among the guideline development team. To help clarify this issue, we assessed whether there is a link between methodologic quality and recommendation validity in practice guidelines for the use of laboratory tests in the management of patients with non-small cell lung cancer (NSCLC).

METHODS

We conducted a systematic review of data on laboratory tests in NSCLC published in English or in French within the last 10 years and retrieved 11 practice guidelines for the use of these tests. The guidelines were critically appraised and scored for methodologic quality and recommendation validity based on the Appraisal of Guidelines Research and Evaluation (AGREE) criteria and on the systematic review.

RESULTS

Overall, these 11 guidelines had considerable shortcomings in methodologic quality and, to a lesser extent, in recommendation validity. Practice guidelines with the best methodologic quality were not necessarily the most valid in their recommendations, and conversely.

CONCLUSIONS

Poor methodologic quality and lack of recommendation validity in laboratory medicine call for methodologic standards of guideline development and for international collaboration of guideline development agencies. We advise readers of guidelines to critically evaluate the methods used as well as the content of the recommendations before adopting them for use in practice.

[The periodic health examination: a comparison of United States and Canadian recommendations]

OBJECTIVE

To compare recommendations of the Canadian Task Force on Preventive Health Care with those of the United States Preventive Services Task Force for periodic health examinations (PHEs), following the usual sequence of a medical interview.

QUALITY OF EVIDENCE

Each task force reviewed the literature exhaustively and created a system of classification that indicated the quality of the evidence.

MAIN MESSAGE

Two tables sum up the conclusions of the task forces with respect to preventive measures to be included in PHEs: one for adults generally and one for women specifically. Three other tables show measures for which recommendations are different or conflicting, as well as measures that might be excluded. Several forms and other materials for PHEs based on these comparisons can be found at http://medecinefamiliale.com/umf/emc/emp_guide.htm. Many recommendations are similar; in spite of this, many physicians fail to include them in PHEs. Certain factors could explain the differences between the recommendations, including the challenge of arriving at a standard scientific process for reviewing data, the fact that formulating recommendations is a social as well as a scientific process, and the fact that the CTFPHC is seriously underfunded.

CONCLUSION

A scientific review of the literature, even when performed by experts using strict criteria, is not easy to standardize. The differences that our comparison revealed, some of which are substantial, highlight the need to further examine how recommendations are formulated. More research in this field would be helpful.

An independent AGREE evaluation of the Occupational Medicine Practice Guidelines

BACKGROUND AND CONTEXT

A large number of practice guidelines are being produced by numerous organizations. Health-care professionals need to critically evaluate these practice guidelines to understand whether they are well constructed and representative of the preponderance of evidence. The guideline development process should be precise and rigorous to ensure that the results are reproducible and not vague.

PURPOSE

To evaluate the quality of the second edition of the practice guidelines published by the American College of Occupational and Environmental Medicine (ACOEM Guidelines).

STUDY DESIGN/SETTING

Four appraisers used the AGREE (Appraisal of Guidelines Research and Evaluation) guideline evaluation instrument to evaluate the ACOEM Guidelines.

METHODS

The Guidelines were evaluated with the AGREE guideline evaluation instrument. The AGREE instrument has been widely adopted around the world, and the authors recommended that it be adopted as the standard of guideline construction process evaluation in the United States. The instrument standardizes the quantitative assessment of quality for a guideline's development process across six domains that include: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application, and editorial independence. Scores from four assessors were collected and interpreted. Additionally, each evaluator selected one of four global assessment choices: "strongly recommended for use in practice," "recommended for use with some modification or proviso," "not recommended as suitable for use in practice," or "unsure".

RESULTS

The ACOEM Guidelines scored highest in the dimensions that evaluated reporting of the guideline's scope and purpose (79.63) as well as clarity and presentation (86.81). The guideline scored much lower in the remaining areas that included stakeholder involvement (46.06), rigor of development (26.59), application (31.48), and editorial independence (19.17). The global assessment was unanimous with all four evaluators assessing the guideline as recommend with proviso.

CONCLUSIONS

Many of the Guidelines recommendations were consistent with current literature and guidelines; however, the AGREE assessment instrument evaluates the guideline development process and not the content. All the evaluators thought the content of the guidelines was substantially better than the documentation of the guideline construction process. The ACOEM Guidelines appear to have content consistent with their stated objectives, but the reporting of the guidelines construction process, particularly the rigor of recommendation development, is flawed, and the recommendations may not be valid owing to possible evidence selection deficiencies. The reader should consider these flaws and limitations when using the guideline. The reader should consider utilizing guidelines of higher quality when possible. Future guidelines should incorporate better reporting and give closer attention to guideline construction.

Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP) publications

BACKGROUND

Although practice protocols exist for SMT and functional rehabilitation, no practice protocols exist for structural rehabilitation. Traditional chiropractic practice guidelines have been limited to acute and chronic pain treatment, with limited inclusion of functional and exclusion of structural rehabilitation procedures.

OBJECTIVE

(1) To derive an evidence-based practice protocol for structural rehabilitation from publications on Clinical Biomechanics of Posture (CBP((R))) methods, and (2) to compare the evidence for Diversified, SMT, and CBP((R)).

METHODS

Clinical control trials utilizing CBP(R) methods and spinal manipulative therapy (SMT) were obtained from searches in Mantis, CINAHL, and Index Medicus. Using data from SMT review articles, evidence for Diversified Technique (as taught in chiropractic colleges), SMT, and CBP((R)) were rated and compared.

RESULTS

From the evidence from Clinical Control Trials on SMT and CBP((R)), there is very little evidence support for Diversified (our rating = 18), as taught in chiropractic colleges, for the treatment of pain subjects, while CBP((R)) (our rating = 46) and SMT for neck pain (rating = 58) and low back pain (our rating = 202) have evidence-based support.

CONCLUSIONS

While CBP((R)) Technique has approximately as much evidence-based support as SMT for neck pain, CBP((R)) has more evidence to support its methods than the Diversified technique taught in chiropractic colleges, but not as much as SMT for low back pain. The evolution of chiropractic specialization has occurred, and doctors providing structural-based chiropractic care require protocol guidelines for patient quality assurance and standardization. A structural rehabilitation protocol was developed based on evidence from CBP((R)) publications.

The use of clinical guidelines for asthma, diabetes, and hypertension in primary health care

OBJECTIVE

To investigate which clinical guidelines primary health care staff refer to regarding asthma, diabetes, and hypertension, the number of existing guidelines, and the organizational level at which they were drawn up, and whether there are different guidelines for the same disease, either in different primary health care centres or within individual centres.

DESIGN

The study is descriptive. Data were obtained by telephone interviews and by procuring clinical guidelines regarding asthma, diabetes, and hypertension from primary health care centres.

SETTING

Forty-one primary health care centres in one county in southeastern Sweden.

STUDY PARTICIPANTS

General practitioners and registered nurses in primary health care.

RESULTS

The telephone interviews showed that the staff referred to several guidelines covering each of the three diseases and these guidelines had been drawn up at five different organizational levels. The length of the clinical guidelines varied from 1 to 257 pages, and the number of guidelines for each disease ranged between 1 and 5.

CONCLUSION

It was found that there were several documents covering the same disease that primary care staff referred to as 'guidelines', and that the length of the guidelines varied and they had been drawn up at different levels. A finding with possible serious consequences was that an old version of an asthma guideline was used in all primary health care centres in the study.