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Assessment of the Scope and Quality of Clinical Practice Guidelines in Lung Cancer^*

^* From the Departments of Medicine (Drs. Harpole, Kelley, Schreiber, and McCrory) and Surgery (Dr. Toloza) and Center for Clinical Health Policy Research (Ms. Kolimaga), Duke University Medical Center, Durham, NC.

Correspondence to: Linda H. Harpole, MD, MPH, Duke Center for Clinical Health Policy Research, 2200 W Main St, Suite 220, Durham, NC 27705; e-mail: harpo003{at}mc.duke.edu

Study objectives: To provide an evidence-based background for developing the American College of Chest Physicians (ACCP) lung cancer guidelines, a systematic review of the literature was performed to identify published lung cancer guidelines and evaluate their quality.

Design, setting, and participants: A systematic search was performed for relevant literature from MEDLINE, Cancerlit, CINAHL, HealthStar, the Cochrane Library, and the National Guidelines Clearinghouse published from January 1989 to July 2001.

Measurement and results: From 369 citations, 51 relevant guidelines were identified. Each guideline was evaluated by at least four reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument and was coded for clinical topics covered. The recommendations included in each guideline also were abstracted. Of the 51 guidelines evaluated, 27 (53%) were evidence-based. Clinical topics identified by the ACCP for their guideline effort each were represented by at least one existing guideline. Of the 880 clinical recommendations abstracted from the guidelines, only 253 (29%) were evidence-based. The AGREE instrument rates guidelines along six domains. As a group, the guidelines performed well in the scope and purpose domain, with only six guidelines (12%) scoring < 50%. For the remaining domains, however, the guidelines did not perform as well, as follows: for stakeholder involvement, 41 guidelines (80%) scored < 50%; for rigor of development, 29 guidelines (57%) scored < 50%; for clarity and presentation, 17 guidelines (33%) scored < 50%; for applicability, 46 guidelines (90%) scored < 50%; and for editorial independence, 47 guidelines (92%) scored < 50%. After considering the domain scores, the reviewers recommended only 19 of the guidelines (37%).

Conclusions: All major clinical lung cancer topics are covered by at least one guideline, but no single guideline addresses all areas. Furthermore, although existing guidelines may accurately reflect clinical practice, most performed poorly when evaluated for quality. Future guideline efforts that address each item of the AGREE instrument would add substantially to the literature.

Key Words: evidence-based medicine • lung neoplasms • practice guidelines

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