High methodologic quality but poor applicability: assessment of the AAOS guidelines using the AGREE II instrument

Clin Orthop Relat Res. 2014 Jun;472(6):1982-8. doi: 10.1007/s11999-014-3530-0. Epub 2014 Feb 25.


Background: The American Academy of Orthopaedic Surgeons (AAOS) is a globally recognized leader in musculoskeletal and orthopaedic education. Clinical guidelines are one important focus of the AAOS' educational efforts. Although their recommendations sometimes generate controversy, a critical appraisal of the overall quality of these guidelines has not, to our knowledge, been reported.

Questions/purposes: We wished to assess the overall quality of the AAOS guidelines using the AGREE II (Advancing Guideline Development, Reporting and Evaluation in Health Care) instrument.

Methods: All 14 guidelines available on the AAOS website as of August 2, 2013 were evaluated. Appraisal was performed by three reviewers, independently, using the AGREE II instrument. This is an internationally recognized and validated assessment tool for evaluating guideline quality. Interrater reliability was calculated and descriptive statistics were performed. Strong interrater reliability was shown using a Spearman's Rho test (correlation coefficient ≥ 0.95).

Results: The overall results for AGREE II domains across all 14 guidelines were: scope and purpose (median score, 95%), stakeholder involvement (median score, 83%), rigor of development (median score, 94%), clarity of presentation (median score, 92%), applicability (median score, 48%), and editorial independence (median score, 79%).

Conclusions: This study showed that the overall quality of the AAOS guidelines is high, however their applicability was found to be poor. The value of guidelines that have a high quality but that are difficult for clinicians to implement is questionable. Numerous suggestions have been proposed to improve applicability including; health economist involvement in guideline production, implementation of pilot studies and audit to monitor uptake of the guidelines and clinician feedback sessions and barrier analysis studies. Future AAOS guidelines should consider and implement steps that can improve their applicability.

Publication types

  • Comparative Study
  • Evaluation Study

MeSH terms

  • Guideline Adherence / standards*
  • Humans
  • Orthopedic Procedures / standards*
  • Orthopedics / standards*
  • Policy Making
  • Practice Guidelines as Topic / standards*
  • Practice Patterns, Physicians' / standards
  • Quality Improvement / standards
  • Quality Indicators, Health Care / standards*
  • Societies, Medical / standards*