We thank Dr. Fervers and colleagues and Dr. Palda and associates for their comments on ACP's guidance statement. We concur that the AGREE instrument is not comprehensive enough to capture such issues as those raised by Dr. Fervers and colleagues. In our article, we acknowledged the limitations of the AGREE instrument, such as the inability to capture guideline development processes that lie outside the guideline document. Because of these limitations, ACP developed additional criteria, listed in Table 1 of the guidance statement, that address such concerns as translation of evidence into recommendations. However, we agree with Dr. Fervers and colleagues that our criteria did not account for organizational and cultural differences between different countries, and we hope for a new and improved evaluation instrument that can account for the shortcomings the writers pointed out in their letters.

The concern related to the use of aggregate scores versus individual domain scores is valid. We included a table in the article showing scores for each individual question to give the reader an idea of how guidelines fared against each other. In addition, we evaluated each guideline and summarized their strengths and weaknesses in ways that were not necessarily based on the AGREE instrument.

We also considered the issue of using 2 raters. In addition to the 2 raters, other members of the committee also reviewed selected parts of the guidelines. However, we agree that more reviewers are helpful, and we are investigating ways to increase the number of reviewers for assessments with the AGREE instrument.