Rating of The Guideline Quality

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Rating of The Guideline Quality

Rating of The Guideline Quality

xisting guidelines and clinical research should be critically appraised utilizing an established appraisal method (eg, Texas Children’s Hospital has implemented the use of Appraisal of Guidelines for Research and Evaluation II [AGREE II] and28 GRADE methodologies for guidelines and clinical research, respectively29). With the review of evidence for each PICO question, unambiguous practice recommendations will be developed that give guidance to clinicians on the care of the patient. Remarks outlining the values and preferences of the patients, families, and providers can be incorporated into recommendations, especially when the desired effects of an intervention are closely balanced with the undesired effects.28 Where evidence is lacking, consensus amongst the guideline development team is needed with transparent statements to reflect the paucity of evidence.

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Assessments of existing guidelines utilizing tools should be transparently demonstrated in the guideline. AGREE II is a 23-item instrument encompassing 6 domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Each item is ranked on a 7-point Likert scale and the item ratings are used to formulate an overall rating of the guideline quality.29 Ultimately, the guideline is either adopted, adopted with modifications (most common), or rejected. Other tools in addition to the AGREE II tool, such as the Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines, also exist.30,31

For each PICO question, studies should be critically evaluated as a body of evidence using an appraisal tool, such as GRADE.32 GRADE is a widely adopted global tool that allows for a seamless, transparent process of translating the evidence into clinically useful practice recommendations. Each practice recommendation is categorized as strong or weak and is supported by high, moderate, low, or very low-quality evidence.

Limitations in study design and execution, inconsistency between studies, indirectness between the PICO question and the studies, imprecision of the studies, and publication bias can lower the overall quality of evidence. Large estimates of treatment effect, evidence of a dose-response gradient, and plausible confounding that would increase confidence in an estimate of effect can raise the quality of evidence. The strength of the recommendation is “the extent to which we can be confident that adherence to the recommendation will do more than harm.”

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