title: A critical appraisal of the quality of critical care pharmacotherapy clinical practice guidelines and their strength of recommendations.
abstract: OBJECTIVE
  Clinical practice guideline (CPG) quality assessment is important before applying their recommendations. Determining whether recommendation strength is consistent with supporting quality of evidence is also essential. We aimed to determine quality of critical care pharmacotherapy CPGs and to assess whether high quality evidence supports strong pharmacotherapy recommendations.
  
  
  METHODS
  MEDLINE (1966-February 2008), EMBASE (1980-February 2008), National Guideline Clearinghouse (February 2008) and personal files were searched to identify CPGs. Four appraisers evaluated each guideline using the appraisal of guidelines, research and evaluation (AGREE) instrument. AGREE assesses 23 items in six domains that include scope/purpose, stakeholder involvement, rigor of development, clarity, applicability and editorial independence. Standardized domain scores (0-100%) were determined to decide whether to recommend a guideline for use. One appraiser extracted strong pharmacotherapy recommendations and supporting evidence quality.
  
  
  RESULTS
  Twenty-four CPGs were included. Standardized domain scores were clarity [69% (95% confidence interval (CI) 62-76%)], scope/purpose [62% (95% CI 55-68%)], rigor of development [51% (95% CI 42-60%)], editorial independence [39% (95% CI 26-52%)], stakeholder involvement [32% (95% CI 26-37%)] and applicability [19% (95% CI 12-26%)]. The proportion of guidelines that could be strongly recommended, recommended with alterations and not recommended was 25, 37.5 and 37.5%, respectively. High quality evidence supported 36% of strong pharmacotherapy recommendations.
  
  
  CONCLUSIONS
  Variation in AGREE domain scores explain why one-third of critical care pharmacotherapy CPGs cannot be recommended. Only one-third of strong pharmacotherapy recommendations were supported by high quality evidence. We recommend appraisal of guideline quality and the caliber of supporting evidence prior to applying recommendations.
authors.affiliation: Department of Pharmacy, Capital District Health Authority, College of Pharmacy, Dalhousie University, c/o Rm 2043 Victoria Building, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada. sean.gorman@dal.ca.
authors.forename: Sean K
authors.initials: SK
authors.lastname: Gorman
authors.affiliation: Department of Pharmacy, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
authors.forename: Michelle Ho
authors.initials: MH
authors.lastname: Chung
authors.affiliation: Pharmacy Department, Interior Health Authority, Faculty of Pharmaceutical Sciences, University of British Columbia, 200-1835 Gordon Drive, Kelowna, BC, V1Y 3H5, Canada.
authors.forename: Richard S
authors.initials: RS
authors.lastname: Slavik
authors.affiliation: Department of Pharmacy, Capital District Health Authority, College of Pharmacy, Dalhousie University, c/o Rm 2043 Victoria Building, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada.|Department of Emergency Medicine, Dalhousie University, Halifax Infirmary, Suite 355 (Room 345), 1796 Summer Street, Halifax, NS, B3H 3A7, Canada.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Zed
authors.affiliation: College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar.
authors.forename: Kerry
authors.initials: K
authors.lastname: Wilbur
authors.affiliation: Intensive Care Unit, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.|Faculty of Medicine, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada.
authors.forename: Vinay K
authors.initials: VK
authors.lastname: Dhingra
mesh_terms: D003422:Critical Care / Q000592:standards*; D004358:Drug Therapy / Q000592:standards*; D006801:Humans; D017410:Practice Guidelines as Topic