Evidence-basing for quality improvement; bringing clinical practice guidelines closer to their promise of improving care practices

Marjolein Moleman, Sonja Jerak-Zuiderent, Hester van de Bovenkamp, Roland Bal, Teun Zuiderent-Jerak*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

9 Citations (Scopus)
42 Downloads (Pure)


Background: Clinical practice guidelines (CPGs) have become central to efforts to change clinical practice and improve the quality of health care. Despite growing attention for rigorous development methodologies, it remains unclear what contribution CPGs make to quality improvement. Aim: This mixed methods study examines guideline quality in relation to the availability of certain types of evidence and reflects on the implications of CPGs' promise to improve the quality of care practices. Methods: The quality of 62 CPGs was assessed with the Appraisal of Guidelines, Research, and Evaluation (AGREE) instrument. Findings were discussed in 19 follow-up interviews to examine how different quality aspects were considered during development. Results: The AGREE assessment showed that while some quality criteria were met, CPGs have limited coverage of domains such as stakeholder involvement and applicability, which generally lack a ‘strong’ evidence base (e.g., randomized controlled trials [RCT]). Qualitative findings uncovered barriers that impede the consolidation of evidence-based guideline development and quality improvement including guideline scoping based on the patient-intervention-comparison-outcome (PICO) question format and a lack of clinical experts involved in evidence appraisal. Developers used workarounds to include quality considerations that lack a strong base of RCT evidence, which often ended up in separate documents or appendices. Conclusion: Findings suggest that CPGs mostly fail to integrate different epistemologies needed to inform the quality improvement of clinical practice. To bring CPGs closer to their promise, guideline scoping should maintain a focus on the most pertinent quality issues that point developers toward the most fitting knowledge for the question at hand, stretching beyond the PICO format. To address questions that lack a strong evidence base, developers actually need to appeal to other sources of knowledge, such as quality improvement, expert opinion, and best practices. Further research is needed to develop methods for the robust inclusion of other types of knowledge.

Original languageEnglish
Pages (from-to)1003-1026
Number of pages24
JournalJournal of Evaluation in Clinical Practice
Issue number6
Early online date28 Jan 2022
Publication statusPublished - Dec 2022

Bibliographical note

Funding Information:
The authors are grateful for contributions in study design and data collection by Siok Swan Tan, Leona Hakkaart‐van Roijen, and Werner Brouwer. We also greatly appreciate the time spent by guidance developers and guideline development experts to participate in this study. Finally, we would like to thank the Dutch Council for Quality of Health care, especially Dunja Dreesens en Jannes van Everdingen, for support in the design of this study. This study was funded by the Dutch Council for Quality of Health care, The Hague, The Netherlands.

Publisher Copyright:
© 2022 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.


Dive into the research topics of 'Evidence-basing for quality improvement; bringing clinical practice guidelines closer to their promise of improving care practices'. Together they form a unique fingerprint.

Cite this