Is the AGREE II framework the appropriate tool to evaluate global urolithiasis guidelines?
Zou and colleagues have penned an interesting manuscript in which they evaluated existing urolithiasis clinical practice guidelines (CPGs) using the Appraisal of Guidelines for Research & Evaluation (AGREE II) Instrument (1). AGREE II is a well-regarded, internationally recognized tool, primarily developed by a Canadian consortium in 2009, that assesses the quality of guideline development and reporting. It has been used in various urologic contexts, including the evaluation of guidelines for benign prostatic hyperplasia, erectile dysfunction, and urinary stomas, with at least 15 applications thus far. In this study, the authors identified 19 urolithiasis CPGs, written in either Chinese or English, through a systematic review spanning the past 13 years. These guidelines were then analyzed using AGREE II and only 5 guidelines were deemed “strongly recommended” due to their quality.
It is worth noting that all Chinese guidelines were eventually excluded due to a lack of evidence-based recommendations. This raises concerns about the criteria used and potential Western biases in AGREE II that might lead to other non-Western guidelines failing in a similar way. Since the study only assessed guidelines in English or Chinese, we wonder if other non-Western guidelines would also fail and whether AGREE II is the best tool to assess all guidelines, regardless of origin. Furthermore, this study raises significant concerns about the number of subpar-quality guidelines being used for clinical decision-making without evidence-based guidance. Importantly, the authors emphasized the need for standardization in guideline development, with an increasing number of urological organizations leading this call.
We are eager to understand AGREE II’s results concerning the remainder of non-English urolithiasis guidelines and, again, its consistency with respect to country of origin, development group, and even types of urolithiasis. Beyond this, though, we should globally step back and assess whether the predominantly Western AGREE II framework is even the appropriate lens through which the rigor and quality of non-Western guidelines should be viewed.
While evidence-based methodologies are usually preferred over expert opinion, it is vital to account for variations in global practice patterns and technological resources. The paucity of “recommended” guidelines highlights the potential benefit of international collaboration among endourologists to develop comprehensive and far-reaching evidence-based guidelines to avoid issues stemming from inappropriate local guideline development.
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology. The article did not undergo external peer review.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-23-411/coif). DAW reports that he received consulting fees from Boston Scientific. The other authors have no conflicts of interest to declare.
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References
- Zou B, Zhou Y, He Z, et al. A critical appraisal of urolithiasis clinical practice guidelines using the AGREE II instrument. Transl Androl Urol 2023;12:977-88. [Crossref] [PubMed]
