Date of Award

January 2018

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Arjun Venkatesh


Clinical practice guidelines (CPGs) have been published by the American College of Emergency Physicians (ACEP) since 1990 to advance the delivery of emergency medical care. These guidelines have raised controversy, and recent research shows that they are largely based on lower classes of evidence and expert opinion despite Institute of Medicine recommendations. The rigor of development and overall quality of these guidelines have not yet been assessed. Thus, we performed a systematic review and meta-analysis to evaluate the quality of ACEP Clinical Policies using a recognized, validated appraisal instrument: Appraisal of Guideline for Research & Evaluation (AGREE II).

The AGREE II instrument contains 23 appraisal items (scored on a 1 - 7 scale) in six quality domains and two overall assessments. The domains are Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence. Appraisals were performed independently and in random order by five trained appraisers. Primary outcomes were AGREE II ratings for each item, domain, and Overall Assessment. Domain and Overall Assessment ratings were standardized for analyses. Secondary analyses examined associations between AGREE II ratings and date of publication, strength of underlying evidence, and strength of recommendations. Additional analysis examined relationships between domain and Overall Assessment ratings.

Twenty guidelines published from October 2008 to November 2017 were included. Of the six domains, Scope and Purpose scored highest and varied least (mean 90%, coefficient of variation (CV) 0.03), while Applicability scored lowest and varied most (mean 35%, CV 0.16). The four remaining domains had mean scores of 53% - 78% and CVs of 0.3 - 0.14. The mean Overall Assessment rating was 69% (CV 0.13) and was not associated with CPG publication date, strength of underlying evidence, or strength of recommendations. Statistically significant relationships were found between Overall Assessment ratings and two domains (Rigor of Development and Clarity of Presentation).

Based on validated criteria, ACEP Clinical Policies have identifiable areas of strength and weakness. The overall CPG quality did not improve over time and is not explained by the quality of underlying evidence. ACEP Clinical Policies can be improved by including patient representation in the guideline development process and addressing factors that influence the application of these guidelines in clinical practice.


This is an Open Access Thesis.

Open Access

This Article is Open Access