Setting standards for the standards

What follows is excerpted from “The convergence of quality and efficiency.” Click here to read the full paper or view citations.


The Appraisal of Guidelines Research & Evaluation (AGREE) instrument consists of 23 items organized into six domains, each of which captures a separate dimension of guideline quality. The domains are scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence.



The intent of AGREE is to determine the quality of clinical guidelines. Determining that a guideline is of high quality means that potential biases have been adequately addressed, that the recommendations are valid, and that the guidelines are feasible for practice. The assessment includes judgment about the methodology of guideline development, the content of the final recommendations, and factors that may operate to influence guideline uptake.     The assessment does not address the impact of the guideline on patient outcomes, although some guidelines may include this information.


A critical element of the AGREE score for guideline development is editorial independence— independence from vested interests, including provider groups (e.g., medical specialty societies or hospital consortia) and payors (e.g., health plans or CMS). Healthcare reform proposals do—and must—require that the arbiters of standards of care be independent. Many organizations that develop guidelines endorse the AGREE instrument: The World Health Organization (WHO) endorses it in policy papers, the U.K.’s National Institute for Health and Clinical Excellence (NICE) adheres to the AGREE principles in developing guidelines, and the American College of Surgeons uses the AGREE instrument in support of guidelines for surgical care.

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