Research Article: Screening for osteoporosis: A systematic assessment of the quality and content of clinical practice guidelines, using the AGREE II instrument and the IOM Standards for Trustworthy Guidelines

Date Published: December 6, 2018

Publisher: Public Library of Science

Author(s): Lamia M. Hayawi, Ian D. Graham, Peter Tugwell, Said Yousef Abdelrazeq, Bart O. Williams.


Numerous clinical practice guidelines (CPGs) are published to guide management of osteoporosis. Little is known about their quality or how recommendations have changed over time.

To systematically assess the quality and content of the guidelines on screening for osteoporosis, using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool, and the Institute of Medicine (IOM) standards for trustworthy guidelines.

We conducted a systematic search for osteoporosis CPGs published between 2002–2016, using multiple databases and guideline websites. Two reviewers appraised the quality of eligible CPGs using the AGREE II. High quality CPGs were considered if they scored ≥ 60 in four or more domains including the domain for rigor of development. Non-parametric tests were used to test for the change of quality over time. One reviewer assessed the guidelines with IOM standards. We summarized the different evidence grading systems and extracted and compared the recommendations.

A total of 33 CPGs were identified. The mean scores for AGREE II differed by domain (range: 42% to 71%). CPGs scored higher on domains for clarity of presentation, scope and purpose, and rigor of development. CPGs scored lower on domains for stakeholder involvement, editorial independence and applicability. Assessment of CPGs by IOM standards showed that CPGs scored better on standards for systematic review, establishing evidence foundation and rating strength of recommendation, articulation of recommendation, and establishing transparency. While scored lower on standards for updating, external review, and the development group composition. There was no difference in AGREE II and IOM defined guidelines’ quality before and after the introduction of the two tools (P values >0.05). The IOM identified four more guidelines as high quality compared to the AGREE II. Examining these additional guidelines indicated that the two tools may give conflicting results especially for the rigor of development domain. Recommendations in certain areas showed substantial differences between guidelines.

Osteoporosis screening CPGs are of variable quality, and their recommendations often differ. Guideline quality as measured by AGREE II and IOM standards has not improved overtime. Guideline developers should work together to improve the quality and consistency of recommendations to improve the likelihood that their guidelines will be used in practice.

Partial Text

Osteoporosis is a disease characterised by low bone mass and deterioration of the bone tissue structure leading to increased bone fragility and liability to fractures [1]. These fractures usually result from low mechanical forces such as a fall from standing height or less, that usually don’t cause a fracture [2]. The most common sites of these fractures are in the spine, hip, and wrist [2]. Worldwide, osteoporosis leads to nearly 9 million fractures annually [1].

This systematic review followed the Cochrane Methodology [27], to identify, and select the CPGs and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to guide the reporting of this review [28]. Ethics approval was not required as this work was based on systematic literature review.

We systematically identified and assessed 33 guidelines for screening for osteoporosis published between 2002–2016 from 13 countries, using the AGREE II instrument and the IOM standards for trustworthiness, which are developed to appraise the quality of CPGs. Our findings reveal that there has been marked variability in the compliance to the criteria of the AGREE II tool and the IOM standards by these guidelines.

The AGREII and IOM defined quality of CPGs for screening of osteoporosis is variable, and there is a considerable room to improve the guideline development process in this field as well as the reporting of guideline development. Guideline developers should develop their guidelines paying attention to the criteria and standards included in the AGREE II instrument and the IOM standards for trustworthy guideline. The reporting of applicability considerations of the guideline and editorial independence areas appear week. The inclusion of patients, economists, and, knowledge translation experts as well as other stakeholders should be considered as a mean of improving the quality of guidelines and their likelihood of implementation. The lack of consensus on specific guideline recommendations for osteoporosis screening is problematic and creates confusion for clinicians and patients about what exactly is best practice.