Development Of Care Guidelines Research Articles

Practice patterns in pediatric infectious encephalopathy in four centers in Africa.

Infectious encephalopathy (IE), including meningitis, infectious encephalitis, and cerebral abscess, remains prevalent and carries high mortality and morbidity in children, especially in low and middle income countries (LMIC). This study aims to describe the usual care and outcomes of pediatric IE in four LMIC hospitals in sub-Saharan Africa to support evidence-based care guideline development. This is a secondary analysis of the Prevalence of Acute Critical Neurological disease in children: A Global Epidemiological Assessment-Developing Countries study, a 4-week, prospective, observational study in children (1 week to 17 years) with IE presenting to referral hospitals in Ethiopia, Kenya, Rwanda, and Ghana. Data collection included diagnostic testing, interventions, and patient outcomes [e.g., mortality, Pediatric Cerebral and Overall Performance Category Scores (PCPC and POPC)]. Seventy-two children with IE were enrolled. Most patients were diagnosed with undifferentiated IE (78%, n = 56). Specific etiologies included cerebral malaria (10%, n = 7), viral encephalitis (4%, n = 3), tuberculosis (4%, n = 3), bacterial meningitis (3%, n = 2), and cerebral abscess (1%, n = 1). Fourteen patients (20%) had a head computed tomography performed. Thirty two (44%) children had a lumbar puncture but only 9 samples (28%) were sent for culture. Median time from diagnosis to antimicrobial therapy was 3 h (IQR 1-12 h). Half (51%, n = 33) of inpatients received intracranial pressure (ICP)-directed treatment but none underwent ICP monitoring. Mortality was 13% (n = 9). The percentage of children with a favorable cognitive score decreased from 95% (n = 62) prior to admission to 80% (n = 52) and 77% (n = 50) at discharge for PCPC and POPC respectively. IE led to considerable morbidity and mortality in this cohort, and evaluation and management varied across the care continuum. Resource limitations and diagnostic constraints may have affected diagnosis-directed therapy and other aspects of management. Further studies are needed to describe the epidemiology and management of IE in LMICs to inform future treatment protocols, the role of technological and human capacity building to support both basic monitoring and interventions, as well as creative new solutions to emergency and critical care in these settings.

Perspectives on high-quality interpersonal care among people obtaining abortions in Argentina

IntroductionLittle is known about how people who have abortions describe high-quality interpersonal care in Argentina. This qualitative study aimed to understand preferences and priorities in their interactions with providers.Study designWe conducted 24 in-depth interviews with people who obtained abortions at a comprehensive reproductive health clinic or with support from a feminist accompaniment group in Buenos Aires and Neuquén, Argentina. We iteratively coded transcripts using a thematic analysis approach based on interpersonal domains present in current quality of care frameworks.ResultsParticipants described high-quality abortion care as feeling acompañamiento and contención from their providers – terms that imply receiving kind, caring, compassionate and emotionally supportive care throughout their abortion. They described four key elements of interpersonal interactions: attentive communication from providers and accompaniers, clear and understandable information provision, non-judgmental support, and individualized options for pain management.ConclusionsPeople obtaining abortions in Argentina consistently identified receiving compassionate and supportive care throughout an abortion as a key aspect of care. The findings have implications for incorporating people’s perspectives in the development of care guidelines, training of providers, and monitoring and improving of services. This is particularly important as the government of Argentina prepares to expand legal access to abortion.

Value for Money in Social Care: The Role of Economic Evidence in the Guideline Development Process of the National Institute for Health and Care Excellence in England

In England, the National Institute for Health and Care Excellence (NICE) has been responsible for developing social care guidelines since 2012. Internationally, it is the first health technology assessment and guideline agency that specifically includes social care. As is the case for NICE’s clinical and public health guidance, social care guidelines comprise recommendations based on the best available evidence of effectiveness and cost-effectiveness. This paper provides an overview of how economic evidence is used within social care guideline development. Firstly, the paper describes the guideline development and quality assurance process, in addition to the roles and responsibilities of the technical team and guideline committee members. Secondly, the paper summarises how economic evidence is reviewed, generated, and used to inform recommendations, with examples given to highlight some of the challenges and opportunities that can be encountered. The paper culminates with proposals for the use of economic evidence in social care in England going forward and makes recommendations for further research in this area. The paper posits that guidelines are an important vehicle for supporting evidence-based practice in social care and that economic evidence is a critical kind of evidence to include. As economic evidence in social care becomes more widely available, it can be increasingly used to produce useful and accessible information for decision makers. Further research is needed to understand the impact of implementing economic evidence-based recommendations in social care practice.

Knowledge, attitudes, and practice about bronchiectasis among general practitioners in four African cities

Objectives: The survey was to determine Knowledge, attitude, and practices around bronchiectasis, as a starting point for the development of guidelines for care in African Countries. Materials and Methods: This survey was administered to non-specialist physicians in urban health centers in Burkina Faso, Uganda, South Africa, and Ethiopia. Data were anonymized and analyzed at an individual level by country and health-care setting. Results: A total of 388 participants were recruited from Ouagadougou (75/388, 19.3%), Kampala (85/388, 21.9%), Johannesburg (74/388, 19.3%), and Addis Ababa (154/388, 39.6%). Median age was 30 years, and 66% were male, with a median of 3-year medical experience. Knowledge about the definition, clinical presentation, and diagnosis of disease was good. However, guidelines for local practice were largely absent. Wide variation was reported in diagnostic and management practices. Physicians recognized the need for guidelines and further training. Conclusion: This study highlighted the lack of local guidelines for bronchiectasis care in these settings and marked variation in approaches to investigation, diagnosis, and management within and between sites. Context-appropriate guidelines for bronchiectasis care in Sub-Saharan Africa are needed. These must be informed by local epidemiology, should reflect locally available resources and comorbidities including tuberculosis-disease, and should be codeveloped with local practitioners.

Variation in management of pediatric post-traumatic urine leaks

High-grade pediatric renal trauma may be associated with a urine leak and appropriate management remains unclear. Data on patients with a traumatic renal injury were retrieved from the trauma registry and data warehouse of a pediatric level 1 trauma center over a 15-year period. Demographics, diagnoses, imaging, interventions performed, and follow-up information on patients with a urine leak were analyzed. 187 renal injuries were identified and 32 (17%) were high grade. There were 21 (11%) diagnoses of urine leak, comprising the study population. Leaks were identified 0-10day post-injury. All patients underwent initial computerized tomography (CT); however, 10 (48%) lacked excretory-phase imaging, leading to repeat CT. Ten patients (48%) did not undergo an intervention for their leak, and 11 (52%) underwent at least one, most commonly stent placement (10). Comparing non-intervention and intervention groups: Injury Severity Score (ISS) and initial Shock Index - Pediatric Adjusted (SIPA) were similar, but there was variation in antibiotic prophylaxis (60% vs 100%), average number of imaging studies performed (6.4 vs 8.1) and average length of hospital stay in days (7.7 vs 8.6). Traumatic urine leaks are unusual, and half require no intervention. Management is variable and the development of care guidelines could decrease variation. Given their infrequency a multi-institutional study is required to generate sufficient patient volume.

Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluidand electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.

Clinical Care Recommendations for Cardiologists Treating Adults With Myotonic Dystrophy.

Myotonic dystrophy is an inherited systemic disorder affecting skeletal muscle and the heart. Genetic testing for myotonic dystrophy is diagnostic and identifies those at risk for cardiac complications. The 2 major genetic forms of myotonic dystrophy, type 1 and type 2, differ in genetic etiology yet share clinical features. The cardiac management of myotonic dystrophy should include surveillance for arrhythmias and left ventricular dysfunction, both of which occur in progressive manner and contribute to morbidity and mortality. To promote the development of care guidelines for myotonic dystrophy, the Myotonic Foundation solicited the input of care experts and organized the drafting of these recommendations. As a rare disorder, large scale clinical trial data to guide the management of myotonic dystrophy are largely lacking. The following recommendations represent expert consensus opinion from those with experience in the management of myotonic dystrophy, in part supported by literature‐based evidence where available.

Enhancing cancer care guideline development and implementation using formal guideline adaptation: methodology description

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

International evidence-based guideline for the assessment and management of polycystic ovary syndrome–Lifestyle management and models of care Guideline Development Group

International evidence-based guideline for the assessment and management of polycystic ovary syndrome–Lifestyle management and models of care Guideline Development Group

Falls and resulting fractures in Myotonic Dystrophy: Results from a multinational retrospective survey

Myotonic Dystrophy type 1 multisystem involvement leads to functional impairment with an increased risk of falling. This multinational study estimates the prevalence of falls and fall-associated fractures. A web-based survey among disease-specific registries (Germany, UK and The Netherlands) was carried out among DM1 ambulant adults with a total of 573 responses retrieved. Results provided a risk ratio estimation of 30%–72% for falls and of 11%–17% for associated fractures. There was no significant difference for falls between male and female, but there was for fall-related fractures with a higher prevalence in women. Balance and leg weakness were the most commonly reported causes for falling. This study is based on a voluntary retrospective survey with naturally inherent limitations; however, the sample size allows for robust comparisons. The estimated risk of falls in this cohort with a mean age of 46 years compares to a previous estimation for a healthy population of over 65 years of age. These results suggest a premature-ageing DM1 phenotype with an increased risk of falling depending on age and disease severity that, so far, might have been underestimated. This may have clinical implications for the development of care guidelines and when testing new interventions in this population.

Explore the Effectiveness of Outpatient Surgery in Pre-school Children’s Fear

Objective: Children are susceptible to sentiment because their physiology, psychology, comprehension and language expression has not yet matured. Therefore, when they have to undergo an operation there will be resistance because of fear of the unknown. Methods: This study was conducted from September 2015 to March 2016. Pre-school children who underwent outpatient surgeries were the subjects of the study. The research methods were actual observation and questionnaire survey. The “Pre-school Children’s Preoperative Fear Response Observation Record” was used as the survey tool. Mann-Whitney U Test was used to compare the children’s responsive behaviors before and after intervention. Results: A total of 11 subjects were included in the study. Only 13.3% of pre-school children were willing to cooperate, while 67.8% of pre-school children feel fear before the operation. In order to reduce their fear, this study used clinical care teaching, development of care guidelines for pre-school preoperative fear, the layout of surgery waiting area for outpatient and operating room, providing touch medical equipment and selective medical treatment, use of modeling balloons, use of games in tablets and stickers as a care auxiliary as intervention. Using these, they not only were willing to cooperate but also have reduced their fear. The degree of coordination increased from 13.3% to 76.7%, the extent of fear cut down from 67.8% to 10.3%, and 98% of the family members were satisfied. Conclusion: Throughout the operation, professional nursing care that also focuses on the children’s emotion by establishing good relationship were established. Through teamwork, the group provided the pre-school children with a wide range of care, thereby reducing the preschool children's preoperative fear and family members became more satisfied. Keywords: Outpatient Surgery, Pre-school Children, Children’s Fear

An Integrated Genomics and Clinical Resource for Data-Driven Health Services Policy and Practice Decisionmaking

ABSTRACTObjectivesBiomedical understanding of cancer is evolving rapidly. Post-genomics cancer research is also being taken up in prevention, screening, treatment, and survivor programs to better identify and manage the risks and sequelae of cancer. In order to translate these findings into effective and efficient healthcare throughout the cancer care trajectory, risk stratification is needed, based on a comprehensive set of genetic, clinical, sociodemographic, and health system factors, to deliver targeted, sustainable care within specific health systems. ApproachData linkage of records can be conducted using unique person-specific provincial Personal Health Numbers for all British Columbia (BC) residents. ResultsAt the BC Cancer Agency we have linked person-based, longitudinal registry, clinical, and health administrative records for the approximately 32 thousand breast cancer patients diagnosed to BC residents from 1989-2011, and followed to end 2013, in order to assess mortality/survival, morbidity, healthcare utilization, access and quality of care, and predictors of these outcomes, throughout the cancer care trajectory. For approximately 1000 of these patients, we have collected biological samples (either blood or saliva) from which DNA was extracted, and questionnaire-based information on education; ethnicity; health, medical and reproductive history; family history of cancer; lifestyle characteristics; as well as lifetime occupational and residential histories. Tissue microarrays are being created from the tumour blocks. Genotyping is also being performed. For approximately 720 patients, data is available on ten genetically-distinct molecular subgroups with different survival rates, including a high-risk, estrogen-receptor-positive 11q13/14 cis-acting subgroup and a favourable prognosis subgroup without somatic copy number aberrations. Linkage of these datasets is pending. ConclusionThis resource can be made available for ongoing research into patient and healthcare (including utilization, quality, and sustainability of care provision) outcomes. A strength of this resource is the detailed clinical and treatment information available for the majority of patients. Among oncologists and other cancer specialists, this work will raise awareness of issues; identify treatment toxicities; contribute to clinical decision-making; inform survivor care guideline development; and encourage research into treatment alternatives. Among family physicians and other care providers, this work will raise awareness of risks of late complications among their patients; identify high-risk survivors; and support targeted risk-based care in primary care. Among policymakers and program managers, findings will identify resource issues; and support cost-effective models of care. And, among cancer patients, this work will raise awareness of the implications of genomics on their long-term care.

Policies on Conflicts of Interest in Health Care Guideline Development: A Cross-Sectional Analysis.

ObjectiveTo assess whether organisations that develop health care guidelines have conflict of interest (COI) policies and to review the content of the available COI policies.MethodsSurvey and content analysis of COI policies available in English, French, Spanish, and Italian conducted between September 2014 and June 2015. A 24-item data abstraction instrument was created on the basis of guideline development standards.ResultsThe survey identified 29 organisations from 19 countries that met the inclusion criteria. From these organisations, 19 policies were eligible for inclusion in the content analysis. Over one-third of the policies (7/19, 37%) did not report or did not clearly report whether disclosure was a prerequisite for membership of the guideline panel. Strategies for the prevention of COI such as divestment were mentioned by only two organisations. Only 21% of policies (4/19) used criteria to determine whether an interest constitutes a COI and to assess the severity of the risk imposed.ConclusionsThe finding that some organisations, in contradiction of widely available standards, still do not have COI policies publicly available is concerning. Also troubling were the findings that some policies did not clearly report critical steps in obtaining, managing and communicating disclosure of relationships of interest. This in addition to the variability encountered in content and accessibility of COI policies may cause confusion and distrust among guideline users. It is in the interest of guideline users and developers to design an agreed-upon, comprehensive, clear, and accessible COI policy.

New WHO antenatal care model—quality worth paying for?

The 2016 WHO guidelines on antenatal care 1 were published earlier this month and are widely welcomed because they are not only academically robust, but also relevant to end-users and patients. The guidelines cover antenatal care for normal pregnancies and have adopted a woman-centred, holistic approach to care. They cover nutritional interventions, maternal and fetal assessment, preventive measures, interventions for common physiological pregnancy symptoms, and health systems interventions to improve the use and quality of antenatal care. The guidelines address antenatal evidence-based practices that improve outcomes and detail how these practices should be delivered. In addition to standard antenatal medical advice, the 49 recommendations include guidance on psychological support, nutrition, and domestic violence screening. Each recommendation is backed up with an evidence review, generally based upon systematic reviews conducted by the Cochrane Collaboration. But even with the most rigorous analyses of the evidence, there are conflicting opinions as to how to deal with some of the results, and what to recommend when there is very limited evidence to support or reject common practice. The WHO antenatal care Guideline Development Group (GDG) is to be congratulated for putting into practice the old adage that “no evidence of benefit is not the same as evidence of no benefit”. So in symphysis-fundal height measurement, for example, where there is limited evidence for its benefit, they do not discard it but recommend that clinicians continue whatever is their current practice.

The prevalence of self-reported lower limb and foot health problems experienced by participants with systemic lupus erythematosus: Results of a UK national survey.

Objective The main aim of this survey was to determine the frequency of self-reported lower limb or foot and ankle complications experienced by participants with systemic lupus erythematosus (SLE). A secondary aim was to determine the frequency of treatments that have been received or that participants with SLE may like to receive if offered. Method A quantitative, cross-sectional, self-reported survey design was utilized. The developed survey was checked for face and content validity prior to patient partner cognitive debriefing in order to ensure usability, understanding of the process of completion and of the questions posed. The full protocol for survey development has been published previously. Results This is the first comprehensive national UK survey of lower limb and foot health problems reported by participants with SLE. A high prevalence of vascular, dermatological and musculoskeletal complications was reported by survey respondents. Additionally, whilst the relative prevalence of sensory loss was low, a quarter of people reported having had a fall related to changes in foot sensation demonstrating a previously unknown rate and cause of falls. Conclusion Complications related to vascular, dermatological and musculoskeletal health are identified as particularly prevalent in participants with SLE. Further, there is a suggestion that the provision of interventions to maintain lower limb health is highly varied and lacks national standardization, despite there being a strong indication of participant reported need. The findings of this work can be used to inform care guideline development in addition to identifying areas for future research.

Nursing home nurses conceptualize how to care for residents with cardiac vulnerability.

With ageing, older people face cardiovascular problems as the major cause of disability and death. Although immediate medical attention is a major factor in determining outcomes of cardiac problems, lack of personnel (i.e. registered nurse, certified nursing assistant and home care aide) in nursing homes without residing doctor limits the awareness of such problems, thus making it difficult to initiate timely and appropriate intervention. The aim of this study was to conceptualize critical care for nursing home residents with cardiac vulnerability and develop practical knowledge in nursing practice. Conventional content analysis was performed on date from interviews with 30 nurses from 10 nursing homes in South Korea between July and November 2010. The analysis revealed three major cardiac problems resulting from residents' cardiac vulnerability: angina, myocardial infarction (MI) and cardiogenic shock. Through content analysis, we extracted 6 themes and 21 subthemes for nurses' conceptualization of critical care for nursing home residents with cardiac vulnerability. In nursing homes without a residing doctor, nurses assessed the physical, functional and cognitive conditions along with the responses and symptoms of residents when emergency situations related to the cardiac problems occurred. Moreover, with a lack of infrastructures of a hospital, nurses provided critical care to the elderly by using personal practice strategies based on their personal experience in facilities along with practical knowledge of nurses while following the management principles of emergencies. We found that nurses conceptualized critical nursing care for cardiac problems at nursing homes, which are different from those of general hospitals. The results of this study will provide basis for the development of care guidelines and educational materials that can be used by novice nurses or nursing students.

Screening High-Risk Populations for Lung Cancer: Guideline Recommendations

The aim of this practice guideline was to develop evidence-based recommendations for screening high-risk populations for lung cancer. The guideline was developed using the methods of Cancer Care Ontario's Program in Evidence-Based Care. The core methodology of the Program in Evidence-Based Care's guideline development process is systematic review. A systematic review had recently been completed by a collaboration of the American Cancer Society, the American College of Chest Physicians, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. The evidence from that systematic review formed the basis of the recommendations, which were reviewed, and amended where necessary, by clinical experts in the fields of medical and radiation oncology, radiology, lung disease, and population health. The systematic review included eight randomized controlled trials and 13 single-arm studies evaluating screening with low-dose computed tomography (LDCT) in patients at risk for lung cancer. One large randomized trial reported a statistically significant reduction in lung cancer mortality with LDCT at 6 years compared with chest radiography. The practice guideline recommendations generally align with the parameters of the National Lung Screening Study. Deviations were described and justified by the guideline working group. The recommendations support screening persons at high-risk for lung cancer with advice for determining a positive result on LDCT, appropriate follow-up, and optimal screening interval. The benefits of screening high-risk populations for lung cancer with LDCT outweigh the harms if screening is implemented in a strictly controlled manner.

Standards of care in neuromuscular fields

There is general consensus that consensus guidelines for care standards are an important tool to provide both healthcare professionals and the patient community with up to date information about all aspects of best practices in a specific disease area. The specific development of care guidelines for neuromuscular diseases poses a number of challenges. All neuromuscular diseases are rare and many show a broad spectrum of clinical and genetic heterogeneity. A paucity of randomized controlled trials for most conditions means that best-practice care guidelines are often non-existent or poorly developed. Where they exist, healthcare professionals may be unaware of them. In many cases the lack of care guidelines contributes to a lack of clinical trial activity, as the implementation of care guidelines is also a prerequisite for a reliable comparison of outcome measures in clinical trials, especially in the neuromuscular disease field, where trials are normally multi-centric and international. Over the past years there have been various collaborative efforts to achieve trial readiness for a number of neuromuscular diseases by establishing care guidelines, patient registries and networks of care and trial sites. For some of the most common neuromuscular diseases like spinal muscular atrophy (SMA) and Duchenne muscular dystrophy (DMD) there are now international care guidelines for healthcare professionals and patients and families. Key factors that have helped to establish these care guidelines were the involvement of patient organizations, translational research networks, and health agencies and combining existing evidence with consensus among a large number of experts in different care areas. Once care guidelines have been established, it is important to disseminate them to the stakeholder community through clinics, meetings, journal and website publications, media interviews, patient registries and professional training courses. It is also crucial to keep care guidelines updated and to take new therapeutic developments and health research outcomes into account. Once care guidelines have been agreed and disseminated, it then becomes important to monitor their implementation and to assess whether they do indeed have a positive impact on health. This is particularly important for guidelines that are based on expert opinions that lack higher levels of evidence. Finally, we need to better understand why, despite agreed upon care guidelines for various neuromuscular diseases, many patients do not receive the treatment they describe.

Resident Guideline Development to Standardize Intensive Care Unit Care Delivery: A Competency-Based Educational Method

We developed a system of resident-driven, evidence-based standardization of care in our trauma-surgical intensive care unit (TSICU). Our main purposes are to improve patient care and outcomes and to help the residents develop practical competency in practice-based learning and improvement and in systems-based practice. Since October 2006, each rotating TSICU resident has chosen a topic to research the available evidence and has developed a guideline, which the resident then presents to the TSICU faculty and residents for discussion, amendments, and acceptance or reevaluation. Evaluation of proposed guidelines is based on the quality of information presented in support of the recommendations. Ultimately, acceptance of a guideline requires consensus among the TSICU faculty. Immediate feedback is given to the presenting resident by the faculty. The residents evaluate the program via a Web-based evaluation tool. We have qualitative data from residents that indicate this experience is positive. We are developing a tool to use both qualitative and quantitative means to evaluate resident, faculty, and nursing staff satisfaction with the process. We will use our clinical database to evaluate whether improved patient outcomes have resulted from standardization of care. We implemented this methodology in October 2006 and have thus far implemented 20 guidelines and 2 standardized order sets. CONCLUSION AND OR NEXT STEPS: We believe competency is achieved and demonstrated by actively participating in a process such as development of care guidelines. Researching and developing standardized guidelines for our TSICU seems to be an effective and practical way for residents to use multiple sources for practice-based learning and improvement. It also requires the resident to advocate for quality patient care and optimal patient care systems. We plan to use outcome and qualitative data to validate this method.

Guías de práctica clínica en atención primaria: Una evaluación crítica

There are doubts about the real usefulness of clinical guidelines to induce changes in practice, specially in primary health care. Those guidelines with inconsistent recommendations can even be misleading.To assess the quality of Chilean primary health care guidelines and to identify factors associated with high quality guidelines.Chilean primary care guidelines published and disseminated using any strategy 1999 and 2004 were analyzed. Each selected guideline was assessed independently by two evaluators using the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument following standardized instructions. Descriptive statistics for each dimension of the AGREE instrument were calculated for each guideline.A total of 33 guidelines were retrieved. Fifteen were located using a manual search and 18 from electronic sources. Twenty four did not match our definition of guidelines, therefore only nine were included in the final assessment. There were important differences in the scores obtained by each guideline in different dimensions, with relevant methodological shortcomings. However, no significant differences in scores were found when guidelines were compared by year of elaboration.Our results suggest that previous efforts in primary health care guideline development were misdirected and that important changes are necessary to generate high quality guidelines.