International Journal of Technology Assessment in Health Care


Analysis of the quality of clinical practice guidelines on established ischemic stroke

Ma Asunción Navarro Puertoa1, Iñaki Gutiérrez Ibarluzeaa2, Oscar Guzmán Ruiza3, Francisco Moniche Alvareza3, Rocío Gómez Herrerosa3, Ruth Engelhardt Pintiadoa3, Antonio Reyes Domingueza3 and Ignacio Marín Leóna4

a1 Valme University Hospital

a2 Osteba-Basque Office for HTA and Nursing University School Vitoria-Gasteiz

a3 Valme University Hospital

a4 Seville University and Valme University Hospital


Objectives: To catalogue and comparatively assess the quality of Clinical Practice Guidelines (CPG) for ischemic stroke taking into account format and development methodology.

Methods: We performed a comprehensive, systematic bibliographic search of CPGs addressing the management of ischemic stroke. We designed a sensitive strategy, using methodological filters in the following databases: Medline, IME and Lilacs, National Guidelines Clearinghouse, National electronic Library for Health, NICE, Guidelines International Network (GIN), Canadian Medical Association Infobase, development groups such as Scottish Intercollegiate Guidelines Network (SIGN), New Zealand Guidelines Group (NZGG), Agency for Healthcare Research and Quality (AHRQ), Ministry of Health Singapore, Institute for Clinical Systems Improvement (ICSI); and scientific societies: American Heart Association, American Medical Association, Royal College of Physicians London. We included all CPGs published in English, French, Italian, Portuguese, or Spanish from 1999 to 2005 and excluded those CPGs whose scope was primary prevention and rehabilitation from ischemic stroke. Four researchers independently assessed the structure and methodologies followed in drafting the CPGs using the Changing Professional Practice (CPP) and Appraisal of Guidelines Research & Evaluation (AGREE) instruments.

Results: We retrieved 117 documents; following application of exclusion criteria, twenty-seven CPGs were appraised. With regard to methodological quality (using the AGREE instrument), the domains that scored highest were “Scope and purpose” and “Clarity and presentation.” The lowest scoring domains were “Stakeholder involvement,” “Rigor of development,” and “Applicability.” Most guidelines received an overall score of “would not recommend” (77.8 percent). Finally, based on the CPP instrument, most of the CPGs evaluated were aimed at secondary care and did not provide updating procedures.

Conclusions: The overall quality of the CPGs published for ischemic stroke management did not have minimum methodological quality. Quality improvement has been observed in more recent CPGs and may be due to the publication of new tools such as the AGREE or CPP instruments, as well as international initiatives for CPG improvement.


Funded by the Junta de Andalucia (Andalusian Parliament) CTS306. The authors express their gratitude to Dr. Eduardo Briones Pérez de la Blanca for his inestimable comments of former versions of this document.