Pediatric Informatics: Computer Applications in Child Health (Health ...

11 Clinical Practice Guidelines: Supporting Decisions, Optimizing Care 151
11.4 Selection of Guideline Topics
Because guideline development is resource-intensive, organizations that develop
guidelines often apply explicit criteria to prioritize the topics they address.
A number of parameters are regularly considered:
The prevalence of a health problem
The degree of variability that exists in current practice in managing a problem
The health burden (e.g., mortality, morbidity) endured by those suffering from
a problem
The economic burden of a problem (including its prevention, diagnosis, treatment,
and management)
The potential improvement of health outcomes
The availability of scientific evidence upon which recommendations will be based
The ethical, legal, and social impact of a guideline
Although efforts have been made to weight these criteria using a standardized formula,
the results have been, on the whole, unsatisfactory. Therefore, topic selection,
in many cases, is based on a less formal consensus process.
11.5 Assessment of Guideline Quality
Over the last 15 years, ad hoc standards for “high-quality” guidelines have emerged
from several sources. In 1990, the Institute of Medicine described characteristics of
valid and usable guidelines. In 1999, Shaneyfelt created a set of 25 quality criteria,
the Guidelines Quality Assessment Questionnaire (GQAQ) 5 that contains ten items
to evaluate the process of guideline development and format, ten items to evaluate
evidence identification and synthesis, and five items to evaluate formulation of recommendations.
When a large number of guidelines were tested according to these
criteria, most guidelines failed almost half of them.
In 2002, a Conference on Guideline Standardization (COGS) at Yale 6 brought
together guideline authors, disseminators, and implementers to define information
that should be incorporated in CPGs to assure their validity and usability. The
resulting COGS checklist is best applied while guidelines are being created to
assure inclusion of critical elements. In 2001, a large international collaborative
effort created an Appraisal of Guidelines Research and Evaluation (AGREE) instrument
7 that offers a systematic framework for appraisal of guideline quality. AGREE
is best applied once a guideline has been published.
However, none of the aforementioned quality appraisal tools focuses on implementation
issues. In 2005, the Guideline Implementability Appraisal (GLIA) 8 was
released. This tool addresses each recommendation of a guideline as a unit of
implementation and focuses potential problems that might be anticipated. The two
most critical dimensions assessed by GLIA are a recommendation’s decidability
(the precise conditions under which the recommendation is to be performed) and