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Critical Appraisal of Guideline

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Critical Appraisal of Guideline

Critical Appraisal of Guideline
Appraisal Tool The tool chosen to appraise the guideline is called the AGREE II (http://www.agreetrust.org/). The purpose of the AGREE II is to examine the quality of guidelines through a step-by-step approach as to what and how information is presented in a guideline. The step-by-step approach is completed via twenty three steps which are categorized into 6 domains. Domain one addresses the overall scope and purpose of the guideline. Domain two is concerned with the stakeholders’ involvement and how the intended users view the guideline. Domain three pertains to the rigor of development of the guideline through eight steps which cover the method of evidence synthesis. Domain four deals with the clarity of the presentation throughout the guideline. Domain five is titled applicability, and it focuses on barriers and facilitators in applying the guideline. Domain six is titled editorial independence and evaluates whether the guideline is free from biases.
Guideline
The guideline chosen for appraisal is Diagnosis and management of headache in adults. A national clinical guideline (http://www.guideline.gov/content.aspx?id=13446#Section396).
Critique
Domain one: The guideline presents evidence-based recommendations for the diagnosis and management of headaches in adults. The health questions covered by the guideline are located in the annex of the ¬¬¬¬¬original guideline, and the target population, interventions, and outcomes are identified. The population targeted by this guideline is adults with primary and secondary headaches. The interventions include specific diagnosis and evaluation through symptoms and signs, along with management, treatments, and prevention. The major outcomes considered are as follows: headache frequency and severity, pain control, and quality of life.
Domain two: The individuals who authored the guidelines consist of general practitioners, neurologists, a psychologist, a physiotherapist, and an oral medicine consultant. Other relevant professionals that could have been included involve ophthalmologists, physical therapists, and endocrinologists. The views and preferences of adults with primary and secondary headaches, whom this guideline is intended for, are not available in the guideline. This guideline is meant for the following target users: advanced practice nurses, dentists, nurses, patients, pharmacists, physician assistants, and physicians.
Domain three: A hand-search of published literature of primary and secondary sources was performed as well as a systematic review of literature. Medline, Embase, CINAHL, PsycINFO, and the Cochrane Library were searched between the years of 2001 and 2007. Other guidelines and internet searches were also carried out. The criteria for selecting the evidence are not clearly described in the guideline. After careful searching, some exclusion criteria were uncovered, such as headaches caused by disorders like trigeminal neuralgia or meningitis. To maintain a consistency of results across studies, a variety of checklists were used. Two group members evaluated each study independently, then compared their results. An independent reviewer or an experienced member of the staff provided arbitration as needed.
The strengths and limitations of the body of evidence are not clearly described. No limitations were specifically found in the guideline. The methods used to assess the quality and strength of the evidence are weighted according to a rating scheme that is clearly identified in the guideline. The highest level is described as having a high quality meta-analysis, systematic reviews of randomized controlled trials, or randomized controlled trials with a very low risk of bias. The lowest level is described as being an expert opinion.
The method of expert consensus was used to formulate recommendations. Both subjective and objective grading is used to distinguish between strong and weak evidence. An objective assessment is used for design and quality of the evidence, but the subjective assessment is used for consistency, clinical relevance, and external validity of the entire body of evidence.
Health benefits, potential harm, and clinical impact have been considered in the formulation of the recommendations. The potential benefits are the appropriate diagnosis and management of headaches in adults. Potential harms include side effects from pharmacological interventions and fetal harm from ibuprofen in late pregnancy.
A link exists between the recommendations and the supporting evidence. The recommended best practice is based on the clinical experience of the group members who were involved in the development of the guideline.
The guideline has been internally and externally reviewed by peers during an open meeting which was held in 2007 in which 123 representatives from all key specialties attended. The guideline was also available for internet comments for those who could not attend the meeting. Prior to publication, all comments were addressed before the final draft of the guideline was published. This guideline will be reviewed in three years and updates will be posted intermittently before the three year mark.
Domain four: Specific and unambiguous major recommendations were made. Headaches are either primary or secondary headaches. Primary headaches include migraine, tension-type, and cluster headache. They do not have an underlying pathology. Secondary headaches have an underlying pathology and include infectious, neoplastic, vascular, or drug-induced origin. The patient’s history is most important for diagnosis, and it is used to classify the headache. The history is also used to catch “red flag” features of a headache which need specialized attention. Most misdiagnosed headaches result from an inadequate patient history.
Different options for management of primary and secondary headaches are clearly presented. Pharmacological interventions for acute migraine attacks and for prevention of migraines are presented. Treatments for tension-type headaches, trigeminal autonomic cephalalgias, and drug induced headaches are also provided in the guideline. Conditions such as pregnancy, contraception, menstruation, menopause, and lifestyle factors are specifically discussed. Various options of physical therapy and complementary therapy are clearly described. Specific recommendations are grouped together under bolded and underlined titles. This makes it easily identifiable.
Domain five: Barriers and facilitators for the application of this guideline were not found in this guideline, nor were they found in the companion documents or the original guideline. The guideline provides tools on how the recommendations can be put into practice. The implementation tools are as follows: audit criteria, chart documentation, checklists, forms, quick reference guides and physician guides. A quick reference guide can be found in the companion documents. A formal cost analysis was not conducted and published cost analyses were not reviewed. The guideline clearly presents auditing criteria key points in the guideline for primary care and secondary care. Primary care general practitioners are to screen for headaches caused by medication overuse. The number of educational leaflets given out is a key point for audit. Key auditing points for secondary care include the screening for all headache patients for thunderclap headaches.
Domain six: Financial disclosures and conflicts of interest are reported. All group members involved in the development of the guideline have made declarations of interest on this subject.
Outcomes
A patient’s history is of primary importance to evaluate a headache. Different types of headaches can be properly classified. Through the use of the headache diaries recommended, 82-percent of headaches were identified to be incorrectly diagnosed and were changed from tension-type headaches to migraine headaches. These strategies are aimed to correctly classify headaches for successful treatment, and to recognize “red flag” features for those who need immediate or specialized care.
Conclusion
The guideline provides criteria to classify headache disorders in adults. This guideline was developed by healthcare professionals to assist healthcare professionals and patients in the diagnosis and management of headaches. The correct classification of headache will lead to a more accurate treatment. The guideline addresses thirteen key questions through evidence-based research and recommendations. Hand searches and electronic searches were conducted to find and compile information for the development of this guideline. The organization of the guideline enhances its usefulness to both the patient and the health care provider. Various tools are provided to aid in the implementation of the recommendations such as the quick reference guide. Biases in relation to financial contribution have prevented in the development of this guideline.…...

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