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The Quality of Clinical Practice Guidelines in Traditional Medicine In Choi et al. Implementation Science (2015) 10:104 DOI 10.1186/s13012-015-0294-1 Implementation Science RESEARCH Open Access The quality of clinical practice guidelines in traditional medicine in Korea: appraisal using the AGREE II instrument Tae-Young Choi1†, Jiae Choi1†, Ju Ah Lee1, Ji Hee Jun1, Bongki Park2 and Myeong Soo Lee1* Abstract Background: This study aimed to evaluate the quality of the current clinical practice guidelines (CPGs) in traditional medicine (TM) in South Korea using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to further enhance the CPG development. Methods: A search was performed for guidelines in Korea from inception until March 2014 in the major Korean guideline websites [the Korean Medical Guideline Information Centre (KoMGI), the Korean Guideline Clearing House (KGC)], PubMed and seven Korean electronic databases; the Association of Korean Oriental Medicine (AKOM) was also consulted. Five independent assessors rated the quality of each CPG using the AGREE II instrument and calculated the mean score of each AGREE item. The overall agreement amongst reviewers was evaluated using the intra-class correlation coefficient (ICC). Results: Initially, 17 CPGs were examined for TM in Korea, and only 8 CPGs satisfied the inclusion criteria. The mean scores for each AGREE II domain were as follows: (1) scope and purpose, 60.0 % (CIs, 45.05-74.94 %); (2) stakeholder involvement, 56.11 % (41.28-70.94 %); (3) rigour of development, 42.7 % (23.48-61.92 %); (4) clarity and presentation, 62.50 % (50.89-74.10 %); (5) applicability, 20.31 % (13.96-26.66 %); and (6) editorial independence, 44.58 % (10.78-78.38 %). All of the CPGs were rated as “recommended with provisos or modifications”. The ICC values for CPG appraisal using the AGREE II ranged from 0.230 to 0.993. Conclusions: To improve clinical practice and health outcomes, well-developed CPGs are needed. The quality of CPGs for TM in Korea has remained suboptimal according to the AGREE II instrument evaluation. Therefore, guideline developers in Korea should make more of an effort to ensure high-quality CPGs. Keywords: Clinical practice guideline (CPG), Korean traditional medicine, Appraisal of Guideline for Research and Evaluation (AGREE) II, Quality assessment, Evidence-based medicine (EBM) Background been gradually formalised and now consists of evidence- Clinical practice guidelines (CPGs) are systematically de- based guidelines [4]. Evidence-based CPGs ensure that the veloped statements to assist practitioner and patient de- document or recommendation has been created using an cisions about appropriate health care for specific clinical unbiased and transparent process of systematically review- circumstances [1, 2]. CPGs have the potential to influ- ing, appraising and using the best clinical research findings ence the care delivered by healthcare providers and the of the highest value to aid in the delivery of optimum clin- outcomes of patients [3]. Therefore, the quality of CPGs is ical care to patients. Evidence-based CPGs can be used to critically important. Whereas guidelines were initially based develop quality measures and to support referrals when on consensus amongst experts, guideline development has theyarequestionedbyinsurance companies; these CPGs also serve as education tools for patients. * Correspondence: [email protected] The Appraisal of Guidelines for Research and Evalu- †Equal contributors 1Medical Research Division, Korea Institute of Oriental Medicine, Daejeon ation (AGREE) instrument was published by a group of 305-811, South Korea Full list of author information is available at the end of the article © 2015 Choi et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Choi et al. Implementation Science (2015) 10:104 Page 2 of 10 international guideline developers and researchers [5]. Methods The purpose of the AGREE is to provide a framework Study design for assessing the quality of guidelines, provide a meth- This study conducted a review of CPGs using the odological strategy for the development of guidelines AGREE II instrument. and inform what information and how information ought to be reported in guidelines [6]. Many countries Review protocol have adopted the AGREE instrument to assess and valid- This study was performed in accordance with the guide- ate the quality of CPGs, including CPGs for the manage- lines from the preferred reporting items for systematic ment of particular diseases [7–10]. reviews and meta-analyses (PRISMA) [16]. In Korea, developing clinical practice guidelines began approximately 10 years ago and resulted in increased Literature search interest in the development of CPGs in the healthcare The CPG searches were conducted in March 2014 in major community [11]. The Korean Medical Guideline Infor- Korean guideline websites [the KoMGI and the KGC]. mation Centre (KoMGi) [12], which opened in 2008, is a PubMed was searched as an international database, and very useful nationwide dissemination tool of CPGs for KoreaMed, the Korea Institute of Science and Technology health professionals. The Korean guideline clearing- Information (KISTI), DBpia, the Korea National Assembly house (KGC) includes approximately 80 CPGs that have Library, the Korean Studies Information Service System been developed by 40 Western Medical Associations in (KISS) and the Oriental Medicine Advanced Searching Korea. Although Western medicine has established Integrated System (OASIS) were searched as domestic quality evaluations of CPGs using the AGREE, the ef- databases. forts to evaluate CPGs in Korea were not sufficient [13]. Other sources such as contact with the AKOM and South Korea has maintained a dual healthcare delivery the Society of Korean Medicine were utilised to receive system that incorporates both traditional Korean and information on CPGs; additionally, the reference lists of Western medicine. Traditional medicine (TM) in Korea all the obtained papers were searched. Hard copies of all remains in the beginning stage of development, and the the articles were obtained and read in full. The search use of CPGs is limited. Currently, only 17 CPGs are terms were (clinical or practice or diagnosis or treatment or available regarding TM (Table 1). The CPGs are mixed therapy or medication or drug or operation or prevention with training manuals and textbook-like publications, or management) and (guideline* or recommendation or and the aim of the CPGs is very unclear. The CPGs for consensus) and (traditional medicine or Korean medicine). TM have mostly been developed by the members of the The strategy of Korean search terms is shown in Additional Association of Korean Oriental Medicine (AKOM). file 1. Data regarding details such as development groups, Compared to Western medicine, the clinical diagnosis financial source, development year and update status were and treatment in TM is less consistent, and the stan- collected for each document identified as a CPG (Table 1). dards are poorer. In our previous study, which was a survey of Korean medical doctors concerning their per- ceptions of the development of CPGs for TM via e-mail, Inclusion and exclusion criteria the results suggested the need to develop CPGs and to The included CPGs in this study were original reports pub- establish evidence in clinical practice and provide health- lished in Korea that described TM interventions and pro- care standards in TM [14]. It is necessary to evaluate the vided sufficient methodological details based on evidence. assessments of CPGs before developing these guidelines. The inclusion criteria were as follows: (1) Korean lan- In other words, a thorough understanding and investiga- guage CPGs, which were produced by mainland Korea tion of the current status of CPGs is essential for quality organisations, and (2) based on a systematic review of management of CPGs in TM [15]. However, little is relevant research evidence. To determine whether the known about the quality of CPGs for TM. Therefore, the guidelines were evidence-based, we investigated whether assessment of CPGs for TM is urgently required. To the they reported a search strategy, quality and data extrac- best of our knowledge, no study has investigated the tion that classified the evidence quality and graded the evaluation of CPGs of TM based on the AGREE instru- strength of the recommendation. If the CPGs had up- ment, although CPG development is regularly researched dates, only the most recent version was assessed. in Korea. CPGs were excluded if they met any of the following Considering these needs, this study aimed to investi- criteria: systematic reviews, narrative reviews, primary gate the current state of CPGs for TM through evaluat- studies, critical pathways, training manuals for medical ing the quality of evidence-based guidelines in TM using doctors, textbook-like publications, guidelines for pa- the AGREE II instrument and to identify their quality to tients, editorials, translations of foreign guidelines, sec- further enhance CPG development. ondary or multiple publications and short summaries. Choi et al. Implementation Science (2015)
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