Françoise Cluzeau, Coordinator of AGREE, Department of Public Health Sciences, St George's Hospital Medical School, London

To be effective, clinical guidelines need to be methodologically sound and accompanied by coherent implementation strategies. Despite recent progress, there is worldwide concern that many fall short of the necessary requirements.1 There have been renewed calls for the establishment of comparable standards.2

In response, an international collaboration called AGREE (Appraisal of Guidelines Research and Evaluation) has been engaged in a research programme funded by the EU. The Collaboration brings together researchers from 13 countries, based in research institutions and government agencies, with extensive experience and expertise in the field of clinical guidelines.

It aims to establish comparable frameworks for the development, assessment and monitoring of clinical guidelines that take into account the multicultural dimensions of healthcare systems as well as the need for scientifically based healthcare.

A key objective of the programme has been the construction and validation of a generic instrument (AGREE) for assessing the quality of clinical guidelines internationally. The instrument assesses core aspects of guideline quality including the evidence used, methods of development, the content of their final recommendations, and factors linked to their uptake.

It comprises 23 items grouped into six dimensions of quality. Each item is scored on a 4-point Likert scale. A guide designed to help users interpret the terms and concepts accompanies the instrument.

A first draft of the instrument was recently tested on a sample of guidelines from 11 countries. After revisions a second draft was tested and the data are being analysed. The final version of the instrument is expected early next year.

The AGREE instrument is the first appraisal instrument for clinical guidelines to be validated on an international scale. It provides a generic methodology that can be applied within and across countries.

It also offers a framework for common standards of reporting in guideline production. The WHO is already using the appraisal instrument to assess its guidelines, and NICE will adopt the AGREE methodology in its guideline programme. It is anticipated that other countries will use the instrument as a tool to assist with further research and quality assurance activities.

At an individual level, the AGREE instrument can also be adapted for use by clinicians in their own clinical practice. A concise and easy-to-use appraisal tool would enable them to make their own assessment about the quality of guidelines they may wish to use.

Ensuring that clinical guidelines are sound is of international importance. The potential implications of the AGREE work are considerable. First, it will create an evaluative framework that can be used worldwide. In addition, there may be resources that could be shared internationally. Finally, the programme is expected to create a basis for more research-generated policy initiatives in the future.

All countries place considerable emphasis on quality improvement strategies, and there is a growing need to share this experience through multi-national collaboration.3

The AGREE research provides a valuable contribution to this effort by creating an appropriate environment in which methodologies and approaches from individual countries can be usefully combined to improve the quality of clinical guidelines.

  1. The AGREE Collaboration. Guideline development in Europe: an international comparison. Int J Technol Assess Health Care 2000; 16(4): 1036-46.
  2. Grilli R et al. Practice guidelines developed by specialty societies. The need for a critical appraisal. Lancet 2000; 355: 103-6.
  3. Leatherman S et al. International collaboration: harnessing differences to meet common needs in improving quality of care. Qual Health Care 2000; 9(3): 143-4

Guidelines in Practice, December 2000, Volume 3
© 2000 MGP Ltd
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