AGREE II Instrument

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Development of the AGREE-REX


The AGREE II has advanced the practice guideline enterprise. However, while rigorous development methods and explicit reporting are required, they do not guarantee optimal recommendations for the targeted users nor optimal implementation of the recommendations. The clinical credibility of practice guideline recommendations is understudied; yet, this concept is critical in order to optimize the capacity of PGs to improve health and health systems.


The objective of the AGREE-REX project is to develop a useful, reliable, and valid knowledge resource to complement the AGREE II, which will guide the development, reporting, and evaluation of the clinical credibility and implementability of practice guideline recommendations.

AGREE-REX Development Methods

As part of a previous project, the AGREE research team conducted a realist review of the literature to identify intrinsic factors of practice guidelines that affect their implementability. Factors identified in the realist review were organized into a model called the GUIDE-M. The content and structure of the draft AGREE-REX was based on one domain of the GUIDE-M, called the Deliberations and Contextualization domain.

Two study were conducted:

  1. Validity Study – Participants reviewed the content of the tool and indicated their agreement with the inclusion of domains, items, and the overall structure of the tool.
  2. Reliability and Usability Study – Participants applied the tool to a practice guideline to capture how the tool rated the clinical credibility and implementability of the document. Participants were then required to indicate their agreement with the usability of the tool.

The participants in the studies included international practice guideline developers, guideline users, and researchers. Feedback received from these studies was used to refine the tool and create a final version of the AGREE-REX.

Funding: Canadian Institutes of Health Research (CIHR #125987).
Research Team: AGREE-REX Research Team