Appraisal Guideline for Research and Evaluation (AGREE)

Critical Appraisal of Practice Guidelines

Directions: Perform the following tasks to complete this assignment:

1. Using the AGREE II instrument as your guide, create a table that
   discusses a practice guideline in which you might have questioned the
   recommendations. (Note: You may be able to copy and paste the instrument into a
   new Word document and complete the information.)
2. Each domain must have its own cell (similar to the one shown in the
   manual) and add domain scores and an overall guideline assessment. Be sure to
   include comments and additional considerations that influenced your rating
   decision and cite any sources used.

Critical Appraisal of Practice Guidelines

Appraisal Guideline for Research and Evaluation (AGREE) II is a tool for assessing
various clinical guidelines (AGREE Next Steps Consortium, 2016). The Society has developed
management of venous leg ulcers (VLU) for Vascular Surgery and American Venous Forum
(O’Donnell, Passman, Marston, Ennis, Dalsing, Kistner, & Stoughton, 2014). The following is

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 2

an assessment of the VLU management guidelines using the AGREE II. The domain and quality
scores and additional comments will be presented.
SCOPE AND PURPOSE

1. The overall objective(s) of the guideline is (are) specifically described.
   1
   Strongly
   Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score awarded for the objectives of the guidelines is 4. The guideline for the
management of VLU only identifies only two objectives: to achieve uniformity in the
management of VLU and to reduce the economic cost of managing the condition. The guideline
does not describe how it achieves the two mentioned objectives (O’Donnell et al., 2014).

2. The health question(s) covered by the guideline is (are) specifically described.
   1
   Strongly
   Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:

The score given for this item is 1. Questions that specify the gaps that the guidelines
addresses are not presented in the document (O’Donnell et al., 2014).

3. The population (patients, public, amongst others) to whom the guideline is meant
   to apply is accurately described.

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 3

1
Strongly
Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score awarded for the target population is 4. The guideline generally identifies
the target populations for the use of the guidelines as the VLU patients. The guideline also
identifies other patient subgroups such as; patients with vascular stenosis and occlusion and
perforated leg ulcers and ulcer reflux as target groups of the guideline (O’Donnell et al.,
2014).
The quality score for the domain is 6.
STAKEHOLDER INVOLVEMENT

4. The guideline development group includes individuals from all relevant
   professional groups.
   1
   Strongly
   Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score awarded is 7. The guidelines identify persons who contributed to the
development as the members of the Joint Clinical Guidelines Committee. The members have
been listed with their positions in the committee alongside their institutions of affiliation.

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 4

However, the guideline does not give specific roles of the members (Mauck, Asi, Undavalli,
Elraiyah, Nabhan, Altayar, & Murad, 2014).

5. The views and preferences of the target population (patients, public, etc.) have
   been sought.

1
Strongly
Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score awarded is 1.
The views of the target group for the use of the guideline have not been included.
The guideline presents the view and recommendations of the committee members only
(O’Donnell et al., 2014).

6. The target users of the guideline are clearly defined.
   1
   Strongly
   Disagree

2 3 4 5 6 7
Strongly
Agree
A score of 1 has been given for the item. The guideline on the management of VLUs
has not specified the professionals who are meant to use the guideline. The document only
gives recommendations meant for the general healthcare professionals (O’Donnell et al.,
2014).
The quality score for the domain is 8.

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 5

RIGOUR OF DEVELOPMENT

7. Systematic methods were used to search for evidence.
   1
   Strongly
   Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score awarded for the item is 1. The guidelines for the management of VLUs do not
provide the methodology for acquiring the evidence but presents the evidence gathered through
several studies in general (O’Donnell et al., 2014).

8. The criteria for selecting the evidence are clearly described.
   1
   Strongly
   Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score awarded is 1. The guidelines have not provided for the method of choosing
the research findings used to draw the guidelines (O’Donnell et al., 2014).

9. The strengths and limitations of the body of evidence are clearly described.
   1
   Strongly
   Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 6

The score awarded is one since the guidelines lack a discussion of the strengths and
weakness of the research findings used in drawing recommendations for managing VLUs
(O’Donnell et al., 2014).

10. The methods for formulating the recommendations are clearly described.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score awarded for the item is 1. The document offers the specific guidelines on
managing VLUs as a universal statement but does not give details on how the consensus was
arrived at (O’Donnell et al., 2014).

11. The health benefits, side effects, and risks have been considered in formulating
    the recommendations.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score given is 3. The guideline gives the benefits of the various guidelines on
managing VLUs. However, the associated risks and side effects of each have not been
presented (O’Donnell et al., 2014).

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 7

12. There is an explicit link between the recommendations and the supporting
    evidence.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score awarded is 7. Every recommendation is followed by in-depth evidence of
literature on its benefits (O’Donnell et al., 2014).

13. Experts have externally reviewed the guideline before its publication
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score awarded is 7. The guideline records that it was endorsed by the American
College of Phlebology before publication and lists the experts involved in its endorsement
(O’Donnell et al., 2014).

14. A procedure for updating the guideline is provided.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 8

Comments:
The score awarded is 1. The guidelines lack information on the procedure for
updating the guidelines. The guideline only presents recommendations as derived from the
already existing body of evidence (O’Donnell et al., 2014).
The quality score for the domain is 22.
CLARITY OF PRESENTATION

15. The recommendations are specific and unambiguous.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The item has been given a score of 6. The guidelines are specific for every patient
case and divided into several subsections. The guidelines further specify what the authors do
not recommend for various subsections of recommendations (O’Donnell et al., 2014).

16. The different options for management of the condition or health issue are
    presented.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 9

Comments:
The score given is 3. The guidelines offer several management approaches for VLUs.
However, for each patient subgroups affected by VLUs, the guideline does not give
alternative management approaches (O’Donnell et al., 2014).

17. Key recommendations are easily identifiable
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score given is 7. The recommendations are presented as headings that have been
underlined followed by supporting evidence (O’Donnell et al., 2014).
The quality score for the domain is 13.
APPLICABILITY

18. The guideline describes facilitators and barriers to its application.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score awarded is 1. The guideline on the management of VLUs does not identify
the factors that will facilitate the implementation of the recommendation nor the barriers that
hinder their implementation (O’Donnell et al., 2014).

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 10

19. The guideline provides advice and tools on how the recommendations can be put
    into practice.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The item has been awarded a score of 1 since the guideline has not provided the
procedure for its implementation with device and tools and equipment for use (O’Donnell et
al., 2014).

20. The potential resource implications of applying the recommendations have been
    considered.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The score given is 1. Since the guideline document does not provide the
implementation of the recommendations, the implication on the resources regarding
equipment and staff has not been presented as well (O’Donnell et al., 2014).

21. The guideline presents monitoring and auditing criteria.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 11

Comments:
The score awarded is 4. Some of the recommendations provide measurable
indicators, for example, the required pressure of compressing therapy in managing VLUs
while others do not provide indicators for evaluation (Andriessen, Apelqvist, Mosti, Partsch,
Gonska, & Abel, 2017).
The quality score for the domain is 11.
EDITORIAL INDEPENDENCE

22. The views of the funding body have not influenced the content of the guideline.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The item has been scored 1. The guideline document has not disclosed the funding
body, and therefore its influence on the recommendations has not been stated (O’Donnell et
al., 2014).

23. Competing interests of guideline development group members have been
    recorded and addressed.
    1
    Strongly
    Disagree

2 3 4 5 6 7
Strongly
Agree

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 12

Comments:
Score awarded is 1. Authors of the guidelines on managing VLU have not made a
declaration concerning conflict of interests in writing the guidelines (O’Donnell et al., 2014).
The quality score for the domain is 2.
OVERALL GUIDELINE ASSESSMENT

1
Strongly
Disagree

2 3 4 5 6 7
Strongly
Agree

Comments:
The overall score gives to the guideline is 4. The guideline offers specific
management recommendations for VLU. However, the guideline has omitted details
concerning strengths, weakness, and resources required for its implementation (O’Donnell et
al., 2014).

RECOMMENDATION FOR USE
Yes
Yes, with Modifications I would recommend the use of the
document since it provides detailed
recommendations on various symptoms

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presenting in VLUs. However, details on the
resources required, the risk, benefits and side
effects of the recommendations need to be
included.

No

References

AGREE Next Steps Consortium. (2016). The AGREE Reporting Checklist: a tool to improve
reporting of clinical practice guidelines. bmj, 352, i1152.
Andriessen, A., Apelqvist, J., Mosti, G., Partsch, H., Gonska, C., & Abel, M. (2017).
Compression therapy for venous leg ulcers: risk factors for adverse events and

CRITICAL APPRAISAL OF PRACTICE GUIDELINES 14

complications, contraindications–a review of present guidelines. Journal of the European
Academy of Dermatology and Venereology, 31(9), 1562-1568.
Mauck, K. F., Asi, N., Undavalli, C., Elraiyah, T. A., Nabhan, M., Altayar, O., … & Murad, M.
H. (2014). Systematic review and meta-analysis of surgical interventions versus
conservative therapy for venous ulcers. Journal of vascular surgery, 60(2), 60S-70S.
O’donnell, T. F., Passman, M. A., Marston, W. A., Ennis, W. J., Dalsing, M., Kistner, R. L., … &
Stoughton, J. (2014). Management of venous leg ulcers: Clinical practice guidelines of
the Society for Vascular Surgery® and the American Venous Forum. Journal of Vascular
Surgery, 60(2), 3S-59S.