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Evaluation of CPG: The AGREE Tool

Describe a detailed description of the health questions covered by the guideline ?
 

Clinical practice guidelines are the statements that are systematically developed to assist practitioners, as well as, the patient in diagnosis, screening, health promotion, as well as, in decision-making related to health care in the specific clinical circumstances. Clinical practice guidelines are focused on offering the concise instructions related to the provision of the healthcare services. The most important and foremost benefit offered by clinical practice guidelines is the potential of these guidelines to improve the process or quality of the care, as well as, the patient outcomes (Wilmott, 2005). For successful implementation of these guidelines and their development appropriate methodologies, as well as, rigorous strategies are used. The quality of the clinical practice guidelines can be varied extremely and in a few cases, these guidelines often fall short or lack the implementation of basic standards. Hence, evaluation of the clinical practice guidelines is an important aspect and should meet the standard parameters (Grant, 2000).

Evaluation of CPG:  The Appraisal of Guidelines for Research & Evaluation (AGREE) Tool are the tool used for the evaluation of the clinical practice guidelines. This tool provides the set of various standardized questions, which are used as a guide for the evaluation of the methodology used in the development of the guidelines. AGREE tool is considered as an excellent tool that has been adopted extensively and is generally used and accepted in the assessment of the quality of the development of the guideline. The AGREE instrument besides assessing the process of developing the guidelines also assesses the extent of reporting the  process. AGREE tool includes 23 Likert scale items that are organized into 6 different domains. Every single domain is focused on capturing a separate dimension related to the quality of the guideline. Assessment of each guideline then assigns the standardized dimension scores that ranges from 0–100. Besides including the score, this tool also consists of sets of questions that is used to provide the assessment of the guideline’s overall quality globally, i.e., whether one would “strongly recommend this guideline for use in practice without modifications,” “recommend this guideline for use in practice on the condition of some alterations or with provisos,” or “not recommend this guideline (not suitable for use in practice).” 

Six domains of the AGREE tool: The following are the six different domains that are included in the AGREE tool, which are domain 1 is scope and purpose, domain 2 is stakeholder involvement, domain 3 is the rigor of development, domain 4 is clarity and presentation, domain 5  is applicability, and domain 6 is editorial independence. Overall assessment of the guidelines includes their overall rating of the guideline’s quality and whether there will further recommendation of these guidelines for use in the practice.

Six domains of the AGREE tool

Domain 1 of AGREE tool, which is the Scope and Purpose, is focused and concerned with the  aim of the guideline as a whole, the specific health questions, as well as, the target population. The three key points that are kept in mind using the domain 1 are: The overall objective or objectives of the mentioned guidelines are specifically described. There is a specific description of all the clinical questions that are covered by the guideline, and there is specific and complete description of the patients on whom the guidelines are supposed to apply.

Domain 2 of the AGREE tool is the Stakeholder Involvement, which focuses and concentrate on the extent of the development of the guidelines by the appropriate and concerned stakeholders, as well as, also represents the views and perspectives of its intended users. The main factors that are kept while studying the domain 2 is focusing that the group involved in the development of the guideline consists of individuals that are from all the desired and relevant professional groups. The complete views, as well as, the preferences of the patient have been sought. There is a clear description of the target users meant for the intended guidelines. The guidelines that are developed has been piloted between the target users (Silagy, 2002).

Domain 3 of AGREE tool is the Rigor of Development that is related to the process, which is  used and focused on gathering, as well as, synthesizing the evidence, the ways and methods used to formulate different recommendations, as well as, to update them. Follwing key factors are studied in the rigor development domain, focused on studying the systematic methods that were used for searching the evidence, there is a complete and clear description of the criteria used for selecting the evidence, clear description of the methods that are used in the formulation of the recommendations are mentioned, the consideration of all the health benefits, risks, as well as, side effects are clearly accounted while formulating the recommendations, an explicit link is mentioned between the recommendations formulations and the supporting evidence, the expert panel had externally reviewed the guideline prior to its publication, and there is a provision of the procedure required for updating the guideline (Graham, 2005). 


Domain 4, which is the Clarity of Presentation is the domain that deals with the structure, language, as well as, the format of the guideline. The things that are evaluated in this domain are the recommendations that used in the guidelines are specific, as well as, unambiguous, there is a clear representation of the various options that can be used for the management of the specified condition, the key recommendations used in the development are easily identifiable, and the guideline specified is supported by various tools for application (Arries, 2006).

Critical appraisal of CPGs

Domain 5 of the AGREE tool is Applicability that pertains to the common facilitators, as well as, barriers related to the implementation, various strategies related to the improvement of the uptake, and implications of the resources during the application of the guidelines. It focuses that there is clear and conscise discussion of all the potential organisational barriers that are present during the application of the guideline, there is consideration of all the potential cost implications that are or can occur during the application of the recommendations, the guideline is able to present the key review criteria that can be used for monitoring or audit purposes. The sixth domain, i.e. the editorial independence deals that the guideline formed is editorially independent and is not linked to the funding body, as well as, all the conflicts of interest related to the development of the guideline members are recorded (Brouwers, Kerkvliet, & Spithoff, 2016).

Critical appraisal of CPGs: In the era of an overwhelmingly growing and large medical literature, practitioners and providers often turn and refers to the clinical practice guidelines for the information related to the decisions they usually make with the patients. Hence, by systematically appraising the processes and evidences, as well as, by providing the means of transparent recommendations used for the practice, these guidelines will have the potential of improving both the health policy, as well as, the decision making. Therefore, the Appraisal of Guidelines for Research & Evaluation Instrument was formed to address all the issues related to the variability in the quality of the guideline (Dans & Dans, 2010).

Clinical practice guidelines are meant to reduce the inappropriate kind of variations occurring in the clinical care setting, minimize the harm, produces the optimal outcomes related to the patient’s health, as well as, focuses on promoting the practices that are cost-effective practice. There is a use of a systematic process in the evidence-based guidelines to develop the policy based on the selection and the review of scientific evidence. In a clinical practice guideline, the development of the policy is defined in terms of recommendations. Recommendations are usually the components of the guideline that are intended for influencing the behavior of the practitioner and the patient. There is a high level of rigor used in support of an evidence-based guideline with the help of which there is the identification, appraisal, as well as, summarization of the guidelines. Moreover, there must be an explicit linkage in between the recommendations, as well as, the evidences that supports them (Long, 2001).

The recent development is seen in the use of various clinical practice guidelines that help and aid in the medical decision making. Though in the past, the use of narrative reviews or clinical position statements that were from professional societies were used by the clinicians in the decision making, the use of rigorously developed CPGs in the recent times can explicitly address the limitation with the use of a recommended course of action that is based on the systematic, as well as, the comprehensive grading and review of the evidence. Moreover, it is an explicit comparison between the benefits, as well as, the potential harms of the given treatment or test (Clutter, 2009). 

Nursing care provided for the patient having stroke is more effective when multidisciplinary members work in collaboration with each other. A working multidisciplinary group was formed including nurses for providing acute care, rehabilitation settings, and long term care to Mary Pierce. The foremost step was the development of an evidence-based and consistent approach for the assessment and management of the risk associated with the stroke (Rohde, Worrall, & Le Dorze, 2013). The main areas for assessment of the risk in Mary were risk of swallowing problems, communication deficits, skin breakdown, as well as, falling (Hill, 2008). Mary was screened for any kind of swallowing deficits prior to giving food, fluid, or oral medications. She was also screened for the presence of any kind of communication deficits with the help of a screening tool, which was valid and reliable (Politi, Wolin, & Légaré, 2013). Assessment in performing daily activities by Mary was being assessed by the trained clinician. She was screened for malnutrition and was given dietary plan to follow. Instructions related to dietary, lifestyle changes, and post-discharge cautions were provided.

Facilitators and barriers to the implementation of the clinical practice guidelines: Clinical practice guidelines are created to help the health professionals to apply research evidence into the practice, which can improve the outcomes of the stroke care and facilitates the implementation. However, CPGs are usually not implemented successfully in the clinical practice and lack of time or resource allocation are sometimes barriers. More research is required for exploring the factors that will influence the implementation of the clinical practices guidelines (Hadely, Power, & O’Halloran, 2014).

Conclusion

Use of updated and evidence-based clinical practice guidelines is an irremissible and  prerequisite for the better and high-quality management of various diseases. Recognizing the several  factors which can affect the compliance of the guidelines make it possible to focus and work towards the improvement of the adherence of the guidelines in the clinical practice. CPGs have the potential of improving process of care and the patient outcomes. But, their beneficial effects are possible on their successful implementation. There are various factors which can influence the CPGs implementation that can be understood by using different implementation frameworks, as well as, knowledge creation. Clinical settings can be moved towards definite use of evidence in one’s practice by local adaptation or adopting the existing guidelines. There must be a careful consideration of various available clinical guidelines during decision-making for the suitable outcome of the setting. The use of  rigorous, as well as, transparent process in the identification, appraisal, and adapting guidelines is very important as the clinical practice guidelines are the multiple interventions, as well as, the decisions that are made, which can affect both the providers and the patients. 

References

Arries, E. (2006). Practice standards for quality clinical decision-making in nursing. Curationis, 29(1).

Brouwers, M., Kerkvliet, K., & Spithoff, K. (2016). The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines. BMJ, i1152.

Clutter, P. (2009). Clinical Practice Guidelines: Key Resources to Guide Clinical Decision Making and Enhance Quality Health Care. Journal Of Emergency Nursing, 35(5), 460-461.

Dans, A. & Dans, L. (2010). Appraising a tool for guideline appraisal (the AGREE II instrument).Journal Of Clinical Epidemiology, 63(12), 1281-1282.

Graham, I. (2005). Evaluation and adaptation of clinical practice guidelines. Evidence-Based Nursing,8(3), 68-72.

Grant, J. (2000). Making use of guidelines in clinical practice. Family Practice, 17(2), 213-213.

Hadely, K., Power, E., & O’Halloran, R. (2014). Speech pathologists’ experiences with stroke clinical practice guidelines and the barriers and facilitators influencing their use: a national descriptive study. BMC Health Services Research, 14(1), 110.

Hammond, R. & Lennon, S. (2002). Development of National Clinical Guidelines for the Management of Stroke. Physiotherapy, 88(3), 177-178.

Hill, K. (2008). Australian Clinical Guidelines for Acute Stroke Management 2007. Int J Stroke, 3(2), 120-129.

Long, M. (2001). Clinical practice guidelines: when the tool becomes the rule. Journal Of Evaluation In Clinical Practice, 7(2), 191-199.

Politi, M., Wolin, K., & Légaré, F. (2013). Implementing Clinical Practice Guidelines About Health Promotion and Disease Prevention Through Shared Decision Making. J GEN INTERN MED,28(6), 838-844.

Rohde, A., Worrall, L., & Le Dorze, G. (2013). Systematic review of the quality of clinical guidelines for aphasia in stroke management. J Eval Clin Pract, 19(6), 994-1003.

Silagy, C. (2002). The effectiveness of local adaptation of nationally produced clinical practice guidelines. Family Practice, 19(3), 223-230.

Wilmott, R. (2005). Variation in use of clinical practice guidelines. The Journal Of Pediatrics, 147(3), A2.

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