Table 1.

Examples of guideline excerpts purposefully designed to represent high- and low-quality content

AGREE Item	High	Low
Domain 1: Scope and purpose
3. The patients to whom the guideline is meant to apply are specifically described.	This recommendation applies to adult patients (> 18 years) with single or multiple radiographically confirmed bone metastases of any histology corresponding to painful areas in previously non-irradiated areas without pathologic fractures or spinal cord/cauda equine compression. It does not apply to the management of malignant primary bone tumour.	This recommendation applies to patients with bone metastases. It does not apply to the management of malignant primary bone tumour.
Domain 2: Stakeholder involvement
6. The target users of the guideline are clearly defined.	This provincial guideline was initiated to summarize the evidence and to provide recommendations on the preferred standard radiotherapy fractionation schedule for the treatment of painful bone metastases. The intended audience for this radiotherapy guideline includes radiation oncologists and physicians who may refer patients for radiotherapy.	This provincial guideline was initiated to summarize the evidence and to provide recommendations on the preferred standard radiotherapy fractionation schedule for the treatment of painful bone metastases. This radiotherapy guideline was primarily intended for clinicians.
Domain 3: Rigour of development
8. Systematic methods were used to search for evidence.	A search of MEDLINE, EMBASE, and the Cochrane Library (2002, Issue 4) was conducted to find randomized trials published between January 1998 and December 2002 using MeSH headings (radiotherapy, radiotherapy dosage, dose fractionation, bone neoplasms/sc [Secondary], explode Clinical Trials, clinical trial [publication type]), text words (bon; osseous, metasta; radiotherapy, irradiation, radiation, pain, analgesi; trial, and study) without language restrictions. Proceedings of the meetings of ASTRO (2001– 2002) and the Canadian Association of Radiation Oncologists (2000), as well as reference lists of papers and review articles, were scanned for additional citations. Please see Appendix A for a detailed listing of the search strategy.	The Canadian Medical Association Infobase (http://www.cma.ca/cpgs/index.asp), the National Guidelines Clearinghouse (http://www.guideline.gov/index.asp) were searched for existing evidence-based practice guidelines prior to the development of this guideline report. A search of MEDLINE, EMBASE, and the Cochrane Library was conducted to find trials without language restrictions for this guideline. Terms specific to radiotherapy and metastatic disease were used. Proceedings of the meetings of ASTRO and the Canadian Association of Radiation Oncologists, as well as reference lists of papers and review articles, were scanned for additional citations. The search strategy is available upon request from the authors.
Domain 4: Clarity of presentation
15. The recommendations are specific and unambiguous.	For patients where the treatment objective is pain relief, a single 8 Gy treatment, prescribed to the appropriate target volume, is recommended as the standard dose-fractionation schedule for the treatment of symptomatic and uncomplicated bone metastases. There is insufficient evidence at this time to make a dose-fractionation recommendation for other treatment indications, such as long term disease control for patients with solitary bone metastasis, prevention/treatment of cord compression, prevention/treatment of pathological fractures, and treatment of soft tissue masses associated with bony disease.	A single treatment, prescribed to the appropriate volume, is recommended as the standard dose-fractionation schedule for the treatment of symptomatic and uncomplicated bone metastases. There is insufficient evidence at this time to make a dose-fractionation recommendation for other treatment indications.
Domain 5: Applicability
19. The potential organizational barriers in applying the recommendations have been discussed.	Based on written feedback from the external review, the radiation oncologists identified the need for a province-wide electronic medical record to identify areas where previous radiation occurred. Otherwise, no additional barriers impacting the implementation of the guideline were identified.	Appendix A outlines a list of policy considerations for implementation of this guideline.
Domain 6: Editorial independence
23. Conflicts of interest of guideline development members have been recorded.	Members of the Supportive Care Guidelines Group disclosed potential conflict of interest information on standardized forms, addressing economic and academic conflicts (Appendix). The Supportive Care Guidelines Group Chair reviewed all reported conflicts in light of this guideline topic. One group member, who reported research funding from a pharmaceutical company producing anti-emetics, was excused from the development of recommendations. No other group members had conflicts of interest which precluded participation in the development of this guideline.	Members of the Supportive Care Guidelines Group disclosed potential conflicts of interest information. One group member, who disclosed pharmaceutical funding, was excused from the development of recommendations.