Development and validity testing of the AGREE-REX, a tool to evaluate the clinical credibility and implementability of clinical practice guideline recommendations

Tags: Oral
Brouwers M1, Spithoff K1, Kerkvliet K1, Florez I1
1McMaster University

Background: While there is growing evidence that clinical practice guidelines (CPGs) can improve clinical and health-system outcomes, their degree of impact is influenced by their quality and implementability. Resources exist to improve overall methodological quality of CPGs; however, few resources are available to optimise clinical credibility and implementability of CPG recommendations.

Objectives: To develop and validate a tool to evaluate the clinical credibility and implementability of CPG recommendations.

Methods: The 11-item AGREE Recommendation EXcellence (AGREE-REX) tool was developed based on a realist review of the literature and input from the international CPG community. International CPG developers and users were recruited to apply the draft AGREE-REX to an assigned CPG and complete an online survey about the usability of the tool. The survey consisted of questions using a 7-point Likert response scale and open-ended questions.

Results: Three hundred and two individuals applied the AGREE-REX to a CPG and completed the AGREE-REX usability survey. Participants agreed that the AGREE-REX was easy to use (mean [m]=5.42/7) and they felt confident in applying the tool (m=5.05). Respondents also agreed that the AGREE-REX would be useful for CPG evaluation (m=5.83); development and reporting of CPGs (m=5.97); and, deciding whether to adapt/endorse (m=5.73) or implement (m=5.68) a CPG. Multiple participants suggested the addition of more guidance about how to apply each of the AGREE-REX items to a CPG, including examples. AGREE-REX scores indicated that there are areas for improvement in CPGs related to consideration of values and preferences of all stakeholders and implementation issues.

Conclusions: Results indicate that CPG developers and users find the tool useful for assessing factors related to CPG clinical credibility and implementability. Survey results were used to further refine the tool for better application. The AGREE-REX will assist CPG developers to create clinically credible recommendations and assist CPG users to assess and select CPGs with trustworthy recommendations that are appropriate for implementation in their setting.