To the Editor: The National Heart Foundation of Australia believes the study by Vitry and Zhang on the quality of Australian clinical guidelines1 is useful and raises two important questions:

• Are guidelines approved by the National Health and Medical Research Council (NHMRC) of a superior quality, as the study suggests? and,

• Why doesn’t Australia have a robust, focused approach to the funding, development and implementation of clinical guidelines?

Vitry and Zhang assessed various guidelines using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. This instrument, developed by an international collaborative process,2,3 defines “quality” by two definitions: potential for bias; and content validity. The process to determine validity, however, does not test a guideline’s potential to change practice or improve health outcomes. This limitation needs to be acknowledged to avoid over-interpretation of the AGREE instrument’s ability to assess quality.

Vitry and Zhang acknowledge that the AGREE instrument is not able to distinguish between “actual poor process” and “poor reporting of the methods”, recognising that some criteria for assessment involve a subjective appraisal with definitions of “effectiveness” still open to debate.

Including resources developed essentially as a practice tool or quick-reference guide4 with those that received full NHMRC support5 in this study diminishes the usefulness of its conclusions from using the AGREE instrument to evaluate clinical guidelines. It’s a pity that this important study of clinical guidelines failed to account for the range of activities and resources that support the implementation of individual guidelines, including companion patient resources.

These shortcomings, however, should not diminish a further key message from this study: Australia needs to abandon its laissez-faire approach to guidelines. The National Heart Foundation of Australia goes further and calls for a strong and robust national framework for the funding, prioritisation, development and implementation of guidelines.

There is, as yet, no such centralised or strategic approach to guidelines development, no national register or central database for guidelines, and a poor and uncoordinated approach to guideline implementation and evaluation.

In contrast, the United Kingdom has adopted a comprehensive approach through the National Institute for Health and Clinical Excellence (www.nice.org.uk), the United States has its National Guideline Clearinghouse (http://www.guideline.gov), while New Zealand has its government-funded Guidelines Group (http://www.nzgg. org.nz).

The Australian Government should adopt a similar approach as part of its national health reform agenda to ensure that the best possible guidelines are developed, that they are regularly updated, that developers are well resourced to undertake this increasingly complex task and that implementation and evaluation is rigorous.

The NHMRC and its National Institute of Clinical Studies (http://www.nhmrc.gov.au/nics) are obvious candidates to take this work forward, but they will need additional federal resources to enable them to do so.