E839C linical practice guidelines, which are systematically developed statements aimed at helping people make clinical, policy-related and system-related decisions, 1,2 frequently vary widely in quality. 3,4 A strategy was needed to differentiate among guidelines and ensure that those of the highest quality are implemented.An international team of guideline developers and researchers, known as the AGREE Collaboration (Appraisal of Guidelines, Research and Evaluation), was established to create a generic instrument to assess the process of guideline development and reporting of this process in the guideline. Based on rigorous methodologies, the result of the collaboration's efforts was the original AGREE instrument, which is a 23-item tool comprising six quality-related domains that was released in 2003 (www.agreetrust.org).As with any new assessment tool, ongoing development was required to improve its measurement properties, usefulness to a range of stakeholders and ease of implementation. Over the years, a number of issues were identified. For example, the original four-point response scale used to answer each item of the AGREE instrument is not in compliance with methodologic standards of health measurement design. This noncompliance threatens the performance and reliability of the instrument. 5 In addition, data on the usefulness of the AGREE items has never been gathered systematically from the perspectives of different groups of users. Further, we were interested in identifying strategies to make the evaluation process more efficient, such as reducing the number of items or the number of required raters, while ensuring the instrument was reliable and valid. Therefore, an exploration of the role of shorter versions of the AGREE instrument, comprising fewer items that are tailored to the unique priorities of different stakeholders, was warranted. Finally, there was a need to establish the fundamentals of construct validity -in other words, whether the AGREE items could measure what they purport to measure, and that is variability in quality of practice guidelines. Redesign of AGREEIn response to these issues, the AGREE Next Steps Consortium was established and undertook two studies.6,7 As part of the first study, the consortium introduced a new seven-point response scale and evaluated its performance and measurement properties, analyzed the usefulness of the AGREE items for decisions made by different stakeholders, and systematically elicited stakeholders' recommendations for changes to the AGREE items and domains. 6 In the second study, the consortium evaluated the construct validity of the tool and designed and evaluated new supporting documentation aimed at facilitating efficient and accurate use of the tool. 7The following key findings emerged from the two studies:• Ratings of the quality of the AGREE domains are good predictors of outcomes associated with implementation of guidelines. 6• Participants (i.e., guideline developers or researchers, policy-makers, and clinicians) evaluated AGREE items and dom...

Direct evidence from randomized controlled trials does not support the routine use of adjuvant chemotherapy for patients with stage II colon cancer. Patients and oncologists who accept the relative benefit in stage III disease as adequate indirect evidence of benefit for stage II disease are justified in considering the use of adjuvant chemotherapy, particularly for those patients with high-risk stage II disease. The ultimate clinical decision should be based on discussions with the patient about the nature of the evidence supporting treatment, the anticipated morbidity of treatment, the presence of high-risk prognostic features on individual prognosis, and patient preferences. Patients with stage II disease should be encouraged to participate in randomized trials.

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BackgroundGuidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines.MethodsA guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team.ResultsThe final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic.ConclusionsNumerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.

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Delay in the initiation of RT is associated with an increase [corrected] in LRR in breast cancer and head and neck cancer. Delays in starting RT should be as short as reasonably achievable.

E vidence-based guidelines are systematically developed statements aimed at assisting clinicians and patients in decisions about appropriate health care for specific clinical circumstances.1 Guidelines assist decisionmakers in solving system-level and population-level challenges. 2,3 The potential benefits of guidelines, however, are only as good as the quality of the guidelines themselves.Rigorous development and strategies for reporting are important precursors to successful implementation of the resulting recommendations. 4The quality of guidelines is variable, often falling short of basic standards. [5][6][7] To address this variability, an international team of guideline developers and researchers, the AGREE Collaboration (Appraisal of Guidelines, Research and Evaluation), created a generic instrument to assess the process of guideline development and reporting. The result of this work was the AGREE instrument, a 23-item tool targeting six quality-related domains. 8,9 It became accepted by many as the standard for guideline evaluation. 10As with any new assessment tool, ongoing development of the instrument is required. The AGREE Next Steps Consortium was established to conduct a program of research aimed at improving the AGREE and advancing the overall guideline enterprise. We report on the first of two studies designed to achieve these goals. This study focused on four key issues related to methodology and implementation (Figure 1).First, the original four-point response scale was not in keeping with standards for test construction that are intended to maximize the reliability and discriminability of an instrument and minimize the number of appraisers required to evaluate a guideline.11 To address this issue, we introduced a seven-point response scale, tested its performance and conducted a preliminary analysis of some of its measurement properties.Second, to be of value, the AGREE instrument needs to be easy to apply and needs to generate information that is useful. To generate a reliable estimate of guideline quality, it is recommended that the 23 items of the AGREE instrument be applied by four independent reviewers. 8,9 This process can be Background:We undertook research to improve the AGREE instrument, a tool used to evaluate guidelines. We tested a new seven-point scale, evaluated the usefulness of the original items in the instrument, investigated evidence to support shorter, tailored versions of the tool, and identified areas for improvement.