9.8.7 Guidelines and Protocols
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Guidelines and Protocols: Critically Appraises Clinical Practice Guidelines
Clinical practice guidelines are systematically developed recommendations that aim to assist clinicians and patients in making appropriate healthcare decisions based on the best available evidence. As guidelines have become a cornerstone of clinical decision-making, it is essential to critically appraise them to ensure that they are based on robust and valid evidence.
The following are key steps to critically appraise clinical practice guidelines:
- Assess the development process: It is essential to evaluate the development process to ensure that it is transparent, rigorous, and systematic. Guidelines should be developed using a multidisciplinary approach that includes experts in the relevant field, patients, and methodologists. The process should involve a comprehensive search for the best available evidence and an explicit and transparent method for formulating recommendations.
- Evaluate the quality of evidence: Guidelines should be based on the best available evidence. It is essential to evaluate the quality of the evidence used to support the recommendations. The GRADE system (Grading of Recommendations Assessment, Development and Evaluation) is a widely used framework for assessing the quality of evidence.
- Consider the balance between benefits and harms: Guidelines should consider both the potential benefits and harms of interventions. It is essential to evaluate the potential benefits and harms of each recommendation and consider the balance between them.
- Assess the clarity and applicability of recommendations: Guidelines should be clear, specific, and actionable. It is essential to evaluate the clarity and applicability of each recommendation to ensure that it is relevant and feasible for clinical practice.
- Consider the potential conflicts of interest: Conflicts of interest can potentially bias guideline development. It is essential to evaluate the potential conflicts of interest of guideline developers and assess whether appropriate steps have been taken to manage them.
One useful tool for critically appraising clinical practice guidelines is the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation II). The instrument includes 23 items that cover six domains: scope and purpose, stakeholder involvement, the rigour of development, clarity of presentation, applicability, and editorial independence.
| Aspect | Considerations |
| Scope and purpose | Is the guideline’s purpose clearly defined? Are the target population and clinical questions stated clearly? |
| Stakeholder involvement | Was the guideline developed with input from a multidisciplinary team, including patients and relevant stakeholders? |
| Rigour of development | Was a systematic and explicit approach used to collect and appraise evidence? Was the guideline subject to independent review and pilot testing? |
| Clarity and presentation | Is the guideline written in clear and concise language? Are the recommendations and their strength graded appropriately? |
| Applicability | Is the guideline feasible and relevant in the context of clinical practice? Are potential barriers to implementation and strategies to overcome them discussed? |
| Editorial independence | Was the guideline developed and funded independently of external sources of potential bias, such as pharmaceutical companies or other industry groups? |
| Updating | Is there a plan for updating the guideline? Is there a process for monitoring the literature and revising the guideline as needed? |
References:
- Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, … & Littlejohns P. (2010). AGREE II: advancing guideline development, reporting and evaluation in health care. Canadian Medical Association Journal, 182(18), E839-E842.
- Institute of Medicine. (2011). Clinical practice guidelines we can trust. National Academies Press (US).