Running head: GUIDELINE ASSESSMENT
Guideline Assessment Paper
Vaginal Birth after Cesarean: New Insights
Pediatric/Maternal/Women’s Group:
Joan Berkey, Emily Gast, Mary Groves, Mary Holstad, Jody Hosch,
Jay Jackson, Julie Johnson, Jennifer Lewis, Susan Rasmusson, DeAnne
Savick
The University of Iowa
December 2011
1
GUIDELINE ASSESSMENT
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Introduction
The guideline selected for group review is National Institutes of Health Consensus
Development Conference (NIH) statement: Vaginal birth after cesarean: New insights (NIH,
2010). The guideline addresses six clinical questions: 1. What are the rates and patterns of
utilization of trial of labor (TOL) after prior cesarean delivery, vaginal birth after cesarean
delivery (VBAC), and repeat cesarean delivery in the United States? 2. Among women who
attempt a TOL after prior cesarean delivery, what are the vaginal delivery rates and the factors
that influence it? 3. What are the short- and long-term benefits and harms to the mother of
attempting a TOL after prior cesarean versus elective repeat cesarean delivery (ERCD), and what
factors influence benefits and harms? 4. What are the short- and long-term benefits and harms to
the baby of maternal attempt at TOL after prior cesarean versus ERCD, and what factors
influence benefits and harms? 5. What are the nonmedical factors that influence the patterns and
utilization of TOL after prior cesarean delivery? 6. What are the critical gaps in the evidence for
decision-making, and what is the priority investigations needed to address these gaps (NIH,
2010)?
Childbirth in the U.S. has become a highly medicalized process. Practitioners have
learned to manage labor by mitigating crisis. The woman is still a passive patient who looks to
others to direct her actions (Gibson, 2011). This guideline was chosen for review because it
provides a meta-analysis of literature that pertains to the issue of whether confidence can be
placed in the recommendation for the patient population to undergo VBAC. Once familiar with
the NIH Consensus findings, the nurse is in a better position to translate the research findings
into practice.
Childbirth practices in the U.S. create both a problem focused trigger and a knowledge
focused trigger as defined by the Iowa Model of Evidence-Based Practice (EBP) to Promote
GUIDELINE ASSESSMENT
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Quality Care (Titler, et.al, 2001). The problem focus trigger or key element associated with this
clinical nursing problem is disparity in health care delivery as evidenced by whether a facility
offers the VBAC option (Agency for Healthcare and Research Quality, AHRQ, 2010). The
knowledge focused trigger that is a key element to this clinical nursing problem is that the NIH
recommends VBAC as safe for most women who meet criteria, and many medical institutions
have not acted in ways to follow the guideline (AHRQ, 2010).
The clinical problems associated with VBAC that nurses can influence are alluded to in
the above paragraph. In addition to medical and organizational issues, VBAC also involves
emotional and financial considerations. Decision-making about mode of birth after a cesarean
delivery presents challenges to women and to caregivers, and requires a balance of risks and
benefits according to individual circumstances (Shorten, et. al, 2005). A randomized controlled
trial (RCT) conducted by Shorten et. al in 2005 found that the use of a decision-aid tool was
effective to improve knowledge and reduce decisional conflict regarding mode of delivery.
Costs and resources directly affect the delivery of health care. Cost of health care affects
access and quality. Current indicators for cost will continue to create disparities in health care
delivery, and debates on these issues will drive improvements that will lead nurses to new roles,
tasks, and challenges in the decades ahead (Jerome-D’Emilia, 2008). TOL after previous
cesarean is unlikely to be associated with a significant cost savings for the institution as TOL is
associated with increased incidence of neonatal neurological damage. Factors other than cost
must govern decisions about TOL versus ERCD (Clark, et. al, 2000). However, risks associated
with ERCD may pose increased cost and poorer outcomes than that associated with VBAC
(Scott, 2010).
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The NIH Consensus panel, after weighing the risks and benefits continue to recommend
that a TOL is a reasonable and safe option for women with one prior low transverse uterine
incision. The panel recommends that practitioners use the six identified clinical questions to
guide them when counseling women in regard to VBAC versus ERCD. In addition, the guideline
encourages hospitals, maternity care providers, health care and professional liability insurers,
consumers, and policymakers collaborate on the development of integrated services that could
mitigate or eliminate barriers to TOL (NIH, 2010).
The pediatric/maternal/women’s health group selected this guideline based upon
discussion among its members. One of the members shared that she personally has experienced
three VBACs, and expressed concern about the declining VBAC rate. It has been recognized
through lecture information from Nursing Research 96:143 (Taylor, 2011) that the National
Guideline Clearinghouse (NGC) website provides high quality guidelines. Using vaginal birth
after cesarean as our search terms allowed identification of new information in the literature
regarding VBAC.
The pediatric/maternal/women’s health group used the following criteria as
recommended by M. Titler and S. Adams for developing an evidence-base practice, (LoBiondoWood & Haber, 2010) to decide to use VBAC: New insights: 1. The guideline is recent,
published in 2010, 2. The guideline is authored by practiced professionals with high levels of
expertise in synthesizing research, and 3. it is endorsed by the highly reputable National
Institutes of Health.
Other guidelines of consideration concerned use of doulas, music therapy, kangaroo care,
breastfeeding counselors, and hormone replacement therapy after a hysterectomy. Databases
utilized to search for evidence-based guidelines included CINAHL, Cochrane, National
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Guideline Clearinghouse, and PsychInfo. The group’s decision was unanimous to evaluate
VBAC: New insights (NIH, 2010) to determine whether this guideline can be utilized as a
helpful reference in the process of refining individual institution specific evidence-based
policies, procedures, or standards in efforts to apply in practice (Titler & Adams, 2010).
Scope and Purpose
The Consensus Development Conference panel’s major goal in this initiative is “to
support pregnant women with one prior transverse uterine incision to make informed decisions
about TOL compared with ERCD” (NIH, 2010, p 13). The NIH in a 1980 Consensus Conference
found VBAC as a mechanism to safely reduce the cesarean rate. The conference, at that time was
concerned with clinical issues surrounding the increasing rate of cesarean deliveries. Today, one
out of every three births is a cesarean delivery (AHRQ, 2010). The authors of the guideline
believe the guideline will benefit the patient, the community, health care delivery systems, and
health and liability insurers.
The guideline is specifically written for healthy women of reproductive age, with a
singleton gestation, in the U.S. who had prior cesarean delivery. To be eligible for TOL the
American College of Obstetrics and Gynecology (ACOG) states that the uterus must not have
more than two low, transverse uterine scars, no other forms of uterine scar/s or anomalies, or
previous ruptures. The health care team must be prepared to monitor labor, refer to cesarean, and
have personnel available on weekends and evenings (International Cesarean Awareness
Network, ICAN, 2006). In forty-three U.S. studies, 74% of those who attempted TOL delivered
vaginally (AHRQ, 2010).
Stakeholder Involvement
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The guideline development panel was established by the Eunice Kennedy Shriver
National Institute of Child Health and Human Development, and the Office of Medical
Applications of Research (OMAR) of the NIH to do a thorough evaluation of relevant research
to guide practice, education, and planning. The Agency of Health Research and Quality
(AHRQ), a department of the NIH, has established Evidence-Based Practice Centers (EPC)
geographically throughout the U.S. The AHRQ sponsors the development of evidence reports
and technology to assist the private and public sectors in efforts to improve the quality of health
care (NIH, 2010). The panel members consisted of MD’s, and advanced degree nurses working
in educational institutions.
The target users were clearly defined. The women who fall in the scope of this guideline,
as well as their caregivers were meant to gain from the recommendations in the guideline. There
was no apparent piloting of the guideline on its attended target. It was a reflection of the panel’s
assessment of medical knowledge available at the time the statement was written. The Consensus
Development panel addresses the limitations within the guideline for not piloting the
recommendations. The panel cites ethical reasons and that further data analysis methods will
need to be created to better inform outcomes (NIH, 2010). Once the guideline was drafted, it was
sent to federal agencies, maternity and pediatric clinicians, advocacy groups, payers,
policymakers, content experts, and researchers. These stakeholders cover a vast range of
professional and public service realms.
Rigor of Development
An extensive literature search was done in collection of data to be used for the guideline.
The databases used were MEDLINE, DARE, and Cochrane. The search terms were not given,
however studies chosen addressed the questions given in the introduction, which addressed the
GUIDELINE ASSESSMENT
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benefits and harms of the clinical intervention (Oregon Health & Science University EPC, 2007).
Data was also obtained from systematic reviews, hand searches, web sites, and expert
consultation. Dates included in the search were 1996 through September 2009.
Of the 3,134 citations retrieved in the literature search, two hundred and three were
selected for review and synthesis after applying the inclusion and exclusion criteria. Inclusion
and exclusion criteria were described as well as the rationale. For example: Studies done in the
United States or developed countries were included, and studies from developing countries were
excluded in order to ascertain that “maternal and infant outcomes were applicable” (NIH, 2010, p
2). The target population was “women with previous cesarean delivery who are eligible for a trial
of labor (TOL) or elective repeat cesarean delivery” (NIH, 2010, p 2).
Once the scope of the guideline was written, a search guided by the identified clinical
questions was accomplished by two investigators who reviewed a random set of titles and
abstracts for full text review until an appropriate level of reliability was reached (NIH, 2010).
The data used was retrieved from meta-analysis, review of published meta-analysis, and
systematic review with evidence tables. Website searches of specialty organizations such as
ACOG and AWHONN resulted in similar recommendations for practice when planning mode of
delivery.
The EPC further divided the studies depending on the type and level of evidence
obtained. They were primarily concerned with TOL that resulted in VBAC, induction of labor
(IOL), finding predictors of VBAC success, what models are being used to predict VBAC,
maternal outcomes, neonatal outcomes, uterine rupture, abnormal placentation, obesity, multiple
cesarean sections, and direction of uterine scar (NIH, 2010). Only high and moderate strength of
evidence was used and rating of the studies was individualized based upon the type of study
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design. The criteria to rate study designs was developed by the U.S. Preventative Services Task
Force (USPSTF). Rating methods from the National Health Service Center for Reviews and
Dissemination, based at the University of York in England was also used to rate the studies
(NIH, 2010). Disagreements about quality of research were solved through consensus based
upon the ratings that the reviewers assigned to the studies.
Measures to reduce bias were explained in the guideline under the heading: Strength of
available evidence (NIH, 2010). Before publication of the guideline, a review of the Oregon
Health & Science EPC’s findings was done by the NIH and the AHRQ. To address all
stakeholders, the guideline was introduced for review by the public prior to publication. This was
accomplished via a question and answer session at the NIH Consensus Development Conference
in June of 2010. The guideline was formed using current evidence. It clearly recognizes the need
for continued research and revision as gaps in the literature are being identified and strategies to
address the gaps are being developed.
Health benefits for the mother who achieve VBAC include shorter hospitalization, less
incidence of deep vein thrombosis, and a decreased risk for maternal mortality. Mortality for the
mother increases when subjected to ERCD due to RCD’s association with abnormal
placentation. Health benefits for the infant who is born vaginally include less respiratory distress,
earlier contact with mother and earlier opportunities for feeding/breastfeeding (NIH, 2010).
Uterine rupture is identified as the primary risk associated with TOL. The guideline
acknowledges limitations that include the absence of the ability to predict uterine rupture.
Studies of moderate quality were available on the incidence of uterine rupture. The occurrence of
uterine rupture is increased with TOL and IOL versus spontaneous labor, but many other factors
GUIDELINE ASSESSMENT
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such as direction of uterine scar, gestational age, demographics, current and past obstetrical
history, and hospital type can influence the risk (NIH, 2010).
The panel provides strategies for how to address gaps in the literature, and possibly
improve mode of delivery decision making. The strategies include initiation of a National
Childbirth Study in which participants are recruited into the study early in their pregnancies, the
development of prediction tools, improve consistency of identifying concepts and variables that
are to be studied and translate these concepts into operational definitions, (LoBiondo-Wood &
Haber, 2010), and creating a model reimbursement scheme to enhance financial incentives for
institutions to provide VBAC (Oregon Health & Science University EPC, 2007).
Clarity and Presentation
The Consensus Development Conference addressed emerging issues in the literature
regarding VBAC, and provided recommendations with level of evidence. The evidence
summarized contains data with high-moderate grade and also low-absent data. “We intentionally
identify outcomes without supporting data to stimulate further research and highlight the variety
of important issues that may not be well studied” (NIH, 2010, p 7).
Specific recommendations for practice concerning this guideline are based on best
available evidence and will always be based upon consultation with the physician in regard to
current pregnancy factors, previous births (vaginal or C-section), medical history (obesity),
hospital capability, and physician preference. “Liability risks associated with maternal and
perinatal mortality and morbidity have a major impact on the willingness of physicians and
healthcare institutions to offer trial of labor” (NIH, 2010, p 27).
A significant contribution realized by this guideline is the identification of predictors of
who will be likely to successfully VBAC, and the development of prediction tools. The evidence
GUIDELINE ASSESSMENT
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finds that African and Hispanic women achieve VBAC less than Caucasian women, although
African and Hispanic women attempt TOL at greater rates than Caucasian women. In addition,
women whose infants are greater than 4Kg, and women who give birth in rural or private
hospitals also VBAC less. Conversely, predictors indicate that women who had previously
delivered vaginally and/or who began TOL with a higher Bishop score had increased success
with VBAC (Oregon Health & Science University EPC, 2007).
Screening tools for predicting VBAC have been developed by three scientists. They are
the scored model by Flamm, the scored model by Grobman, and the Troyer model. A decision
analysis of any scored model would need to achieve a sensitivity and specificity of 85%, which
none of these tools achieved. The details of the models can be located in the evidence report
Appendix N of the Oregon Health & Science University EPC meta-analysis on VBAC: New
insights, 2007.
Overall, scoring models provide reasonable ability to identify women who are good
candidates for VBAC, but none have discriminating ability to consistently identify women who
are at risk for RCD (Oregon Health & Science University EPC, 2007). Due to lack of high level
evidence and physician/ hospital liability threats, this topic continues to need large amounts of
research.
Application
The NIH and guideline development panel recognizes that in order to implement the
VBAC trials, they will have to take into consideration each hospital’s policies, level of care they
are able to provide, and ensure that patient safety is priority, “the American College of
Obstetricians and Gynecologists recommends that TOL only be performed in institutions
equipped to respond to obstetric emergencies” (NIH, 2010, p 26).
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Several screening tools and decision aids have been proposed to help women understand
the risks, benefits, and implications of TOL compared with ERCD. A list of implementation
strategies was collected to assist in implementation of the guideline. “Screening questions; such
as maternal age, body mass index, prior cesarean indication, cervical dilation and effacement at
admission, have the ability to predict the likelihood of successful TOL” (NIH, 2010, p 12) is an
example. These screening tools will aid the woman and her physician in the shared decision
making process throughout her pregnancy to make the final decisions related to birthing
methods. Key recommendations that ACOG and the American Society of Anesthesiologists
should provide to all patients are information about the risks and benefits of VBAC, possible
emergency situations, and to make public their TOL policies.
The panel is concerned that medical-legal considerations add to and in many instances
exacerbates barriers to TOL due to fear of a medical lawsuit. The panel recommends supporting
the women and their informed decision about TOL and having the clinicians incorporate an
evidence-based approach into the decision-making process. Organizational changes may be
necessary to support implementation of the guideline and would include establishment of a
steering committee within the organization, and the provision of training sessions (Titler &
Adams, 2010). Cost containment along with consumer demand may drive these changes (Clark,
2000).
Editorial Independence
“The panel was made up of fifteen members representing the fields of obstetrics and
gynecology, urogynecology, maternal and fetal medicine, pediatrics, midwifery, clinical
pharmacology, medical ethics, internal medicine, family medicine, perinatal and reproductive
psychiatry, anesthesiology, nursing, biostatistics, epidemiology, healthcare regulation, risk
management, and a public representative” (NIH, 2010). The panelists who participated in this
GUIDELINE ASSESSMENT
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conference signed forms attesting that they had no financial or scientific conflict of interest
(NIH, 2010). Twenty experts from pertinent fields were also present to provide data to the panel
and conference audience (NIH, 2010). The NIH Consensus and State-of-the-Science Statements
are prepared by independent panels of health professionals and public representatives on the
basis of results of systematic literature, presentations by investigators working in relevant areas,
questions and statements from conference attendees during open discussion periods, and closed
deliberations by the panel (NIH, 2010). The panel did their best to assess the medical
information available at the time and provide a statement of the knowledge to healthcare
providers, patients, and the general public with a reasonable assessment of currently available
data on VBAC.
Level of Evidence
The panel writing the guideline went to great lengths to ensure strength of evidence and
bias reduction. Individual studies’ strength of evidence were graded by the USPSTF and
National Health Service Center that included RCTs, cohort, case-control, and case series studies
(NIH, 2010, p 4). Only studies of high and moderate strength were used except in cases where
there was no other research available. Therefore, when analyzing the evidence, the panelists were
able to determine in which categories higher levels of evidence is required.
Data from the studies were entered into tables and summarized. “Benefits and adverse
effects of mode of delivery were considered equally important and both types of outcomes were
abstracted” (NIH, 2010, p 3). Meta-analyses were done to synthesize data and qualitative data is
used when meta-analysis was not appropriate. Given the existing research in which evidence
ranged from Level I to Level VII, the panelists assessed the overall strength of the evidence for
each key question. The purpose to grade the body of evidence overall is to provide information
beyond study design hierarchy and internal validity assessment. Parameters thought important to
GUIDELINE ASSESSMENT
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policymakers included quantity of evidence, assessment of risk of bias, precision, directness, and
consistency (NIH, 2010).
Conclusion
The purpose of this guideline is to evaluate if women can safely undergo a VBAC.
As noted on the AGREE Overall Guideline Assessment table on p. 23 of this paper, our group
overall recommends this guideline with modifications. Areas that seemed adequately
investigated were the scope and purpose, clarity of presentation, and editorial independence of
this guideline. Areas that the group felt needed improvement or modifications were stakeholder
involvement, rigor of development, and applicability.
This guideline has a clearly stated purpose, and the panel proposing this guideline feels
that using the specific questions listed will help patients and caregivers make informed decisions
regarding the decision to have a VBAC delivery, or an ERCD. The clarity and presentation
scores from the groups AGREE table were overall good, but it is also noted that this topic still
needs research due to the lack of high level evidence which is most likely due to the physicians
and hospitals risk of liability. Editorial independence was also clearly stated and the panelists
signed forms attesting that they had no scientific or financial conflict of interest (NIH, 2010).
Areas of this guideline the group felt needed improvement included stakeholder
involvement, as there was no apparent piloting of this guideline to the target users. The guideline
was drafted with panel members consisting of MD’s and advanced degree nurses that used their
assessment of medical knowledge available at that time. Only high and moderate strength of
evidence was used to develop this policy except when no other studies were available which
speaks of the rigor of development, however, there was disagreement about the quality of
research which was not explained in detail. The NIH and guideline panel recognizes limitations
to the use of this guideline which refers to the applicability of using this guideline. The main
GUIDELINE ASSESSMENT
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limitation to a VBAC delivery that needs to be considered is the individual hospital’s policy and
their ability to respond to an obstetric emergency (NIH, 2010, p. 26).
As noted in the introduction to this paper, childbirth practices in the U.S. create a
problem focused trigger as well as a knowledge focused trigger as defined by the Iowa Model of
EBP to Promote Quality Care (Titler, et.al., 2001), and the knowledge focused trigger is a key
element to the development of this guideline: The NIH recommends VBAC as safe for most
women who meet specific criteria, and many hospitals have not acted in ways that follow this
guideline (AHRQ, 2010). Even with a few drawbacks, this guideline has many good attributes
that can help women take an active role in deciding how they want to delivery their babies and
this group recommends utilizing this guideline—even with its limitations.
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References
Clark, S. L., Scott, J. R., Porter, T. F., Schlappy, D. A., McClellan, V., & Burton, D.A. (2000). Is
vaginal birth after cesarean less expensive than repeat cesarean delivery? American
Journal of Obstetrics & Gynecology, 182, 599-602.
Gibson, F. (2011). Traveling through time to normal birth. Issues in perinatal care, 38, pp. 266268. doi: 10.1111/j.1523-536X.2011.00493.x
Guise, J.M., Eden, K., Emeis, C., Denman, M.A., Marshall, N., Fu, R., Janik, R., &et.al. (2007).
Vaginal Birth after Cesarean: New Insights. Evidence Report/Technology Assessment
No.191. Oregon Health & Science University Evidence-based Practice Center under Contract
No. 290-2007-10057-I. AHRQ Publication No. 10-E003. Rockville, MD: Agency for
Healthcare Research and Quality.
International Cesarean Awareness Network, (2006) VBAC: Vaginal birth after cesarean. Retrieved
from www.americanpregnancy.org/labornbirth/vbac.html on 12-4-2011.
Jerome-D’Emilia, B. (2008). Public health and primary health care systems and health care
transformation. In M. Stanhope & J. Lancaster (Eds.), Public health nursing: Populationcentered health care in the community, 7th ed. (pp. 46-66). St. Louis, MO: Mosby.
National Institutes of Health. (2010). National Institutes of Health Conference statement: Vaginal
birth after cesarean: New insights. Retrieved from www.guideline.gov/index.aspx on 11-202011.
Scott, J. (2010). Solving the vaginal birth after cesarean dilemma. Obstetrics and Gynecology,
115(6), 1112-1113. doi: 10.1097/AOG.0b013e3181e0d1b6
Shorten A., Shorten, B., Keogh, J., West, S., & Morris, J. (2005). Making choices for childbirth:
A randomized controlled trial of a decision-aid for informed birth after cesarean. Issues in
Perinatal Care, 32, pp. 252-261. doi: 10.1111/j.0730-7659.2005.00383.x
GUIDELINE ASSESSMENT
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Sullivan-Bolyai, S., & Bova, C. (2010). Data-collection methods. In G. LoBiondo-Wood & J.
Haber (Eds.), Nursing research: Methods and critical appraisal for evidence-based
practice, 7th ed. (pp. 268-284). St. Louis, MO: Mosby.
Taylor, J. (2011). Application of research and evidence-based guidelines. 96:143 Research for
nursing practice. The University of Iowa. Iowa City, Iowa.
Titler, M., & Adams, S. (2010). Developing an evidence-based practice. In G. LoBiondo-Wood,
& J. Haber (Eds.). Nursing research: Methods and critical appraisal for evidence-based
practice, 7th ed. (pp. 385-437). St. Louis, MO: Mosby.
Titler, M., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett, L., Buckwaiter, K., & et.al.
(2001). The Iowa model of evidence-based practice to promote quality care. Critical
Care Clinics of North America, 13, 497-509.
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Appraisal Instrument Summary for
Vaginal birth after cesarean: New insights (NIH, 2010).
AGREE Table 1
DOMAIN 1SCOPE &
PURPOSE
Appraiser 1
Appraiser 2
Appraiser 3
Appraiser 4
Appraiser 5
Emily/Julie
Jay/Mary G
Jennifer/
Jody/Susan
Joan/Mary
H
DeAnne
TOTAL
The overall
objective is
the
guideline is
specifically
described
7/7
7/6
7/7
7/7
7/7
69
The clinical
question
covered by
the
guideline is
specifically
described
6/6
6/6
6/7
7/6
6/6
62
The
population
to whom
the
guideline is
meant to
apply is
specifically
described
7/7
7/7
7/7
7/7
7/7
70
TOTAL
40
39
41
41
40
201
GUIDELINE ASSESSMENT
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AGREE Table 2
DOMAIN 2
STAKEHOLDER
INVOLVEMENT
Appraiser 1
Appraiser 2
Appraiser 3
Appraiser 4
Appraiser 5
Emily/Julie
Jay/Mary G
Jennifer/
Jody/Susan
Joan/Mary
H
DeAnne
TOTAL
4. Guideline
development
group involves
individuals
from all
relevant
professional
groups
6/6
6/6
6/5
6/6
5/6
58
5. The views
and
preferences of
the target
population
have been
sought
2/1
4/1
1/1
1/1
2/1
15
6. The target
users of the
guideline are
clearly defined
6/7
7/7
6/7
7/6
7/7
67
TOTAL
28
31
26
27
28
140
GUIDELINE ASSESSMENT
19
AGREE Table 3
DOMAIN 3
RIGOUR OF
DEVELOPMENT
Appraiser
1
Appraiser
2
Appraiser
3
Appraiser
4
Emily/Julie
Jay/Mary G
Jennifer/
Jody/Susan
Joan/Mary
H
Appraiser5
TOTAL
De Anne
7. Systematic
methods were
used to search for
evidence
8. The criteria for
selecting the
evidence are
clearly described
9. The strength
and limitations of
the body of
evidence are
clearly described
10. The methods
for formulating
the
recommendations
are clearly
described
11. The health
benefits, side
effects, and risks
have been
considered in
formulating the
recommendations
12. There is an
explicit link
between the
recommendations
and the
supporting
evidence
13. The guideline
has been
externally
reviewed by
experts prior to
7/6
7/6
6/7
5/5
7/7
63
7/7
7/7
7/7
7/7
7/7
70
6/5
6/6
6/3
6/6
6/5
55
6/6
7/4
6/6
5/3
6/6
55
6/6
7/5
5/4
5/7
7/6
58
5/3
7/3
5/2
4/3
7/1
40
5/3
7/1
3/1
2/2
1/2
27
GUIDELINE ASSESSMENT
its publication
14. A procedure
for updating the
guideline is
provided
TOTAL
20
3/1
3/1
1/6
1/1
2/1
20
82
84
75
69
78
388
AGREE Table 4
DOMAIN 4CLARITY OF
PRESENTATION
Appraiser 1
Appraiser 2
Appraiser 3
Appraiser 4
Emily/Julie
Jay/Mary G
Jennifer/
Jody/Susan
TOTAL
Joan/Mary
H
DeAnne
15. The
recommendations
are specific and
unambiguous
16. The different
options for
management of
the health issue
are clearly
defined
17. Key
recommendations
are easily
identifiable
TOTAL
Appraiser
5
7/6
7/6
6/7
7/6
7/7
66
6/5
6/5
5/5
6/5
7/4
54
7/5
6/5
6/5
7/5
6/6
58
36
35
34
36
37
178
GUIDELINE ASSESSMENT
21
AGREE Table 5
DOMAIN 5APPLICABILITY
Appraiser 1
Appraiser 2
Appraiser 3
Appraiser 4
Appraiser 5
Emily/Julie
Jay/Mary G
Jennifer/
Jody/Susan
Joan/Mary
H
DeAnne
18. The guideline
describes
facilitators and
barriers to its
application
19. The guideline
provides advice
and/or tools on
how the
recommendations
can be put into
practice
20. The potential
resource
implications of
applying the
recommendations
have been
considered
21. The guideline
presents
monitoring
and/or auditing
criteria
TOTAL
TOTAL
6/5
6/5
5/3
6/6
6/5
53
4/3
2/3
2/3
4/3
1/4
29
4/4
3/4
4/5
4/4
1/6
39
2/4
2/5
2/7
2/2
1/4
31
32
30
31
31
28
152
GUIDELINE ASSESSMENT
22
AGREE Table 6
DOMAIN 6EDITORIAL
INDEPENDENCE
22. The views
of the funding
body have not
influenced the
content of the
guidelines
23. Competing
interests of
guideline
development
group
members have
been recorded
and addressed
TOTAL
Appraiser 1
Appraiser 2
Appraiser 3
Appraiser 4
Appraiser 5
TOTAL
Emily
Jay
Jennifer
Jody
Joan
Julie
Mary G.
DeAnne
Susan
Mary H.
7/7
7/7
7/7
7/7
7/7
70
7/7
7/7
7/7
7/7
7/5
68
28
28
28
28
26
138
AGREE TOTAL SCORES
DOMAIN
Scope and Purpose
Stakeholder Involvement
Rigour of Development
Clarity of Presentation
Applicability
Editorial Independence
SCORE OBTAINED (TOTAL)
201
140
388
178
152
138
PERCENTAGE (TOTAL)
95%
61%
64%
82%
47%
98%
GUIDELINE ASSESSMENT
Overall
guideline
assessment
23
AGREE Overall Guideline Assessment
Appraiser Appraiser Appraiser Appraiser
1
2
3
4
Jennifer/
Jody/Sue
Emily/Julie Jay/Mary
DeAnne
G.
5/4
NA/5
5/5
5/4
Rate the
overall
quality of
this
guideline.
I would
recommend
this guideline Julie/Emily
for use.
Yes
X/X
Yes, with
modifications
No
Jay/Mary G.
NA/X
Jennifer/
DeAnne
X/X
Appraiser
5
Joan/Mary
H.
6/4
TOTAL
43
Jody/Sue
Joan/Mary
H.
XX
X
X
GUIDELINE ASSESSMENT
Individual Contributions to this Paper
Joan Berkey
Rigor of Development, Level of Evidence
Emily Gast
Clarity & Presentation
Mary Groves
AGREE Tables and calculations
Mary Holstad
AGREE Tables and calculations, Title page
Jody Hosch
Application
Jay Jackson
Scope & Purpose, Stakeholder Involvement
Julie Johnson
AGREE Tables and calculations
Jennifer Lewis
Editorial Independence
Susan Rasmusson
Conclusion
DeAnne Savick
Guideline topic paper, Introduction, Reference page
24