• Ophthalmology Clinical Trials
• Glaucoma

• Ophthalmology Clinical Trials
• Ophthalmology
• Glaucoma

A study examining 3 separate clinical practice guidelines governing primary open-angle glaucoma found that all 3 sets of guidelines require improvements, stated Annie Wu, MD, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.

Glaucoma affects about 60.5 million people globally and is the second leading cause of blindness [Quigley HA, Broman AT. Br J Ophthalmol. 2006]. Although rigorous clinical practice guidelines are necessary for glaucoma, there are obstacles that can color the rigor of guidelines, including conflict of interest and quality of the evidence [Kung J et al. Arch Intern Med. 2012; Ransohoff DF et al. JAMA. 2013].

The present study evaluated the quality of guidelines for primary open-angle glaucoma published in recent years by the American Academy of Ophthalmology (AAO) [AAO Glaucoma Panel, Primary Open-Angle Glaucoma Preferred Practice Patterns, 2010], Canadian Ophthalmological Society (COS) [COS, Can J Ophthalmol. 2009], and the National Institute for Health and Care Excellence (NICE) [National Collaborating Center for Acute Care. Glaucoma: Diagnosis and management of chronic open-angle glaucoma and ocular hypertension. London (UK), 2009].

Four evaluators independently appraised each set of guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool [Brouwers M et al. CMAJ. 2010]. AGREE II contains 6 domains: Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence. The overall assessment score across all domains uses a 7-point scale; a score of 7 indicates 100% adherence to the particular guideline.

Application of AGREE II-produced scores ranged from 28% to 85% for the AAO guidelines, 51% to 96% for the COS guidelines, and 55% to 97% for the NICE guidelines. Scope and Purpose was the strongest domain for all 3 sets of guidelines. Clarity of Presentation was a strong domain for the COS and NICE guidelines. The weakest domains were Editorial Independence for all 3 guidelines, and Stakeholder Involvement for the AAO and COS guidelines.

Comparison of the AGREE II evaluation of the 3 guidelines revealed variability that sometimes could be considerable between the individual guideline domain scores; for example, scores for the Stakeholder Involvement domain varied from 28% for the AAO guidelines to 79% for the NICE guidelines (Table 1).

The overall assessment favored the NICE guidelines, followed by the COS and AAO guidelines. The results of the study have prompted several primary and additional recommendations.

Primary recommendations concerned clarifying stakeholder involvement, using a guideline development process that is transparent and rigorous, and acknowledging competing interests and their possible influence.

The researchers concluded that the use of the AGREE II assessment instrument revealed shortcomings in methodologies in all 3 association guidelines in the domains of Stakeholder Involvement, Rigor of Development, and Editorial Independence. This appraisal highlights the importance of regularly assessing clinical practice guidelines. Such a regular assessment, and the resulting improvements, will result in meaningful recommendations for clinical practice.

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