AGREE II: advancing guideline development, reporting and evaluation in health care

As recently pointed out by Djulbegovic, Bennett, and Guyatt [1, 2], if we are to improve delivery of health care, there must be an awareness that QI initiatives that fail to rigorously process underlying evidence and adapt this evidence to the local environment may prove wasteful and even harmful. Maybe, almost ten years after AGREE-II has been launched, this wise statement begins to be applicale to the AGREE-II initiative [3] ?

AGREE-II focuses on quality of guideline development, whereas it has been shown that methodologic quality is not sufficient to ensure that recommendations are appropriate/accurate [4-12]. Maybe it is a good starting point for health care professional to evaluate guideline quality, but then they should also evaluate guideline content before they decide to implement any recommandation in daily practice.

Among the hundreds of guidelines methodologic evaluations with the help of the AGREE instrument, that have been published so far [some of which have been reviewed in references 13-15], only a small minority also evaluated guidelines content. Maybe we could not affirm for sure that AGREE has been harmful, but if AGREE-II were not able to improve in the near future, then it might well end up becoming wasteful.

Maybe it is time now to think about AGREE-III, where Djulbegovic, Bennett, and Guyatt's proposal would be taken into account ?

References:
[1] Djulbegovic B, Bennett CL, Guyatt G. Failure to place evidence at the centre of quality improvement remains a major barrier for advances in quality improvement. J Eval Clin Pract. 2019 Jun;25(3):369-372. Doi: 10.1111/jep.13146.
[2] Djulbegovic B, Bennett CL, Guyatt G. A unifying framework for improving health care. J Eval Clin Pract. 2019 Jun;25(3):358-362. doi: 10.1111/jep.13066.
[3] Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010 Dec 14;182(18):E839-42. doi: 10.1503/cmaj.090449. http://www.cmaj.ca/content/182/18/E839
 [4] Burgers JS. Guideline quality and guideline content: are they related? Clin Chem. 2006 Jan;52(1):3-4.
[5] Watine J, Friedberg B, Nagy E, Onody R, Oosterhuis W, Bunting PS, Charet JC, Horvath AR. Conflict between guideline methodologic quality and recommendation validity: a potential problem for practitioners. Clin Chem. 2006 Jan;52(1):65-72.
[6] Watine JC, Bunting PS. Mass colorectal cancer screening: methodological quality of practice guidelines is not related to their content validity. Clin Biochem. 2008 May;41(7-8):459-66. doi: 10.1016/j.clinbiochem.2007.12.020.
[7] Matthys J, De Meyere M. Quality evidence important for quality guidelines. CMAJ. 2010 Sep 21;182(13):1449-50. doi: 10.1503/cmaj.110-2105.
[8] Matthys J, De Meyere M, van Driel ML, et al. Differences among international pharyngitis guidelines : not just academic. Ann Fam Med. 2007;5:436–43.
[9] Nuckols TK, Lim YW, Wynn BO, Mattke S, MacLean CH, Harber P, Brook RH, Wallace P, Garland RH, Asch S. Rigorous development does not ensure that guidelines are acceptable to a panel of knowledgeable providers. J Gen Intern Med. 2008 Jan;23(1):37-44.
[10] Eikermann M, Holzmann N, Siering U, Rüther A. Tools for assessing the content of guidelines are needed to enable their effective use--a systematic comparison. BMC Res Notes. 2014 Nov 26;7:853. doi: 10.1186/1756-0500-7-853.
[11] Coates D, Homer C, Wilson A, Deady L, Mason E, Foureur M, Henry A. Induction of labour indications and timing: A systematic analysis of clinical guidelines. Women Birth. 2019 Jul 5. pii: S1871-5192(19)30141-6. doi: 10.1016/j.wombi.2019.06.004.
[12] Pallari E, Fox AW, Lewison G. Differential research impact in cancer practice guidelines' evidence base: lessons from ESMO, NICE and SIGN. ESMO Open. 2018 Jan 6;3(1):e000258. doi: 10.1136/esmoopen-2017-000258.
[13] Alonso-Coello P, Irfan A, Solà I, Gich I, Delgado-Noguera M, Rigau D, Tort S, Bonfill X, Burgers J, Schunemann H. The quality of clinical practice guidelines over the last two decades: a systematic review of guideline appraisal studies. Qual Saf Health Care. 2010 Dec;19(6):e58. doi: 10.1136/qshc.2010.042077.
[14] Armstrong JJ, Goldfarb AM, Instrum RS, MacDermid JC. Improvement evident but still necessary in clinical practice guideline quality: a systematic review. J Clin Epidemiol. 2017 Jan;81:13-21. doi: 10.1016/j.jclinepi.2016.08.005.
[15] Gagliardi AR, Brouwers MC. Do guidelines offer implementation advice to target users? A systematic review of guideline applicability. BMJ Open. 2015 Feb 18;5(2):e007047. doi: 10.1136/bmjopen-2014-007047.