制定"肠外肠内营养临床指南"的方法学、推荐意见分级与通过程序

中华医学会肠外肠内营养学分会自2004年12月成立，即开始了合理规范应用肠外肠内营养学的有关工作。在中华医学会正副会长的指导下，2005年4月启动了“肠外肠内营养临床指南”（简称“指南”）制定的艰难工作。参与“指南”编写的52位专家来自多个学科，也包括部分基层医院医护人员；共组成8个编写组，分别完成“指南”（草案）相应部分的内容。     

中国新生儿营养支持临床应用指南

推荐意见强度分级 指南参考美国肠内肠外营养学会2000年指南,依据证据等级强度,将推荐意见分为A、B、C三个等级(表1).     

《临床诊疗指南-肠外肠内营养分册（2008版）》已出版发行

d由中华医学会编写的《临床诊疗指南-肠外肠内营养分册（2008版）》于2008年12月正式出版。本书是在《临床诊疗指南-肠外肠内营养分册（2006版）》基础上，由全国的有关专家和热心医护工作者经过多次会议讨论达成共识后，对2006版的补充和修正。     

慢性乙型肝炎防治指南(节选)

慢性乙型肝炎是我国常见的慢性传染病之一，严重危害人民健康。为进一步规范慢性乙型肝炎的预防、诊断和治疗，中华医学会肝病学分会和中华医学会感染病学分会组织国内有关专家，在参考国内外最新研究成果的基础上，按照循证医学的原则，制定了《慢性乙型肝炎防治指南》（简称《指南》）。其中推荐意见所依据的证据共分为3个级别5个等次，文中以括号内斜体罗马数字表示。     

血脂异常医学营养管理专家共识

血脂异常是动脉粥样硬化性心血管疾病的主要危险因素。医学营养干预是治疗血脂异常的基础措施, 对早期防治动脉粥样硬化性心血管疾病发生和降低该疾病负担具有重要的意义。本专家共识由中国健康管理协会临床营养与健康分会联合中国营养学会临床营养分会和《中华健康管理学杂志》编辑委员会的学者和专家对国内外关于血脂异常患者的膳食营养指南、共识及临床研究证据进行了全面的回顾、分析和总结, 结合我国国情而制定, 分别就血脂异常患者膳食模式、食物品种、营养补充剂、肠内肠外营养制剂以及常见疾病合并血脂异常注意事项等方面给出了具体推荐意见, 为医疗机构人员开展血脂异常医学营养管理提供重要参考。     

ESPEN指南——建议等级的科学背景

2006年9月14～17日中华医学会肠外肠内营养学分会在天津溏沽召开了2006年“指南”及“规范”工作会议。与会人员400多人。为了向未能参加会议的同道提供有关信息，本刊将分期转载会议内容。以下为部分主题报告的摘要，欢迎多提宝贵意见。[编者按]     

EASL慢性乙型肝炎临床管理指南

本指南的目的是对优化慢性乙型肝炎(CHB)管理的推荐意见进行更新.指南由临床实践指南专家组制定,并经欧洲肝病学会管理委员会批准.这些指南中的证据和推荐意见根据GRADE系统进行分级,因此推荐意见的力度反映了基础证据的质量.     

第9届《营养支持“临床路径-DRG＂与转化医学3T模式》暨《肠外肠内输注系统》论坛2014暨第二届《美国临床营养杂志（AJCN）-中华临床营养杂志（CJCN）作者工作坊》2014将于2014年4月于北京举行

由《中华临床营养杂志》和中华医学会肠外肠内营养学分会联合主办的第9届《营养支持“临床路径-DRG”与转化医学3T模式》暨《肠外肠内输注系统》论坛2014及其会前会第二届《美国临床营养杂志（AJCN）-中华临床营养杂志（CJCN）作者工作坊》2014定于2014年4月11日至13日在北京举行。会议邀请包括《美国临床营养杂志（AJCN）》主编Bier教授、丹麦哥本哈根大学医学院Kondrup教授、《中华临床营养杂志（CJCN）》名誉主编蒋朱明教授等国内外知名专家,分别就营养支持“临床路径-DRG”与转化医学3T模式、肠外肠内输注系统等主题进行报告和研讨。     

第四届全国“老年疾病营养支持的循证应用”学术研讨会暨肠外肠内营养学分会老年营养支持学组成立会议纪要

经中华医学会批准（国家级继续医学教育项目编号2011－04-13－053）,由中华医学会肠外肠内营养学分会主办,卫生部北京医院承办,卫生部北京老年医学研究所、北京医学会肠外肠内营养专业委员会、中华临床营养杂志和中华老年医学杂志协办的第四届全国“老年疾病营养支持的循证应用”学术研讨会暨中华医学会肠外肠内营养学分会老年营养支持学组成立会议于2011年4月22至24日在北京内蒙古大厦成功召开。     

血脂异常医学营养管理专家共识CSCD

血脂异常是动脉粥样硬化性心血管疾病的主要危险因素。医学营养干预是治疗血脂异常的基础措施,对早期防治动脉粥样硬化性心血管疾病发生和降低该疾病负担具有重要的意义。本专家共识由中国健康管理协会临床营养与健康分会联合中国营养学会临床营养分会和《中华健康管理学杂志》编辑委员会的学者和专家对国内外关于血脂异常患者的膳食营养指南、共识及临床研究证据进行了全面的回顾、分析和总结,结合我国国情而制定,分别就血脂异常患者膳食模式、食物品种、营养补充剂、肠内肠外营养制剂以及常见疾病合并血脂异常注意事项等方面给出了具体推荐意见,为医疗机构人员开展血脂异常医学营养管理提供重要参考。     

Guidelines,Guidelines, Guidelines

Over the past decade, clinical guidelines for nutrition therapy in the critically ill have been developed by different North American societies. To avoid target audience confusion and uncertainty, there is a need to undergo a review of the content of these guidelines. In this review, the authors compared the grading systems, the levels of evidence used, and the content of North American nutrition clinical guidelines. The 3 clinical guidelines that met their search criteria and hence were included in the comparison are the Canadian Clinical Practice Guidelines, the American Dietetics Association's evidence-based guideline for critical illness, and the Society of Critical Care Medicine and American Society of Parenteral and Enteral Nutrition's joint guideline. Through their comparison, the authors have shown that although there are several topics where there is a similar direction of recommendation across the 3 societies/organizations, there are stark contrasts among many of the recommendations. These major differences can be attributed to the admission of different populations, lower levels of evidence or expert opinion into the guideline production process, lack of clarity in the link between the evidence and the recommendation, and lack of uniformity in the reporting of levels of evidence and grades of recommendation. The authors have identified the need for the North American nutrition organizations to harmonize the development of future nutrition guidelines in a timely way, so that they remain current and up-to-date. Furthermore, guideline users need to be aware of the dissimilarities in these guidelines before applying the recommendations to their daily practice.     

儿童临床实践指南发展现状

目的对我国儿童临床实践指南的现况进行分析,为我国儿童临床实践指南的发展提供意见建议。方法计算机检索中国知网和万方数据库,根据纳入和排除标准,入选符合要求的儿童指南。采用文献研究对纳入指南进行分析研究,包括指南名称、发表年份、发表机构、制订方法、覆盖疾病等。结果根据纳入和排除标准,最终入选78部儿童指南,主要为中医、呼吸系统、常见病和营养类疾病(占73.08%)。在指南数量方面,2005年开始明显增加,在2016年达到高峰(20篇);制订机构较为杂乱,既有卫生健康行政部门,也有学协会所属的专业学组和单中心制订;在制订过程方面,89.74%的指南未在文中体现。结论从近期、中期和远期发展规划来看,近期,卫生健康行政部门应充分发挥致力于指南制订、评价和推广的专业学术组织和团体的专业优势和引领作用,配合儿科亚专业的行业组织规范化开展指南的制订、评价、应用和推广工作。同时,委托开发专业的指南注册和应用平台,制定注册和评审制度,规范循证过程,努力提升指南的数量和质量;中期规划来看,应该将临床实践中的指南应用纳入到医疗机构的质控要求中去,将临床诊疗的规范性嵌入到日常的诊疗中,逐步提高临床实践指南的规范使用率和应用水平;长期规划来看,应该开发海量级儿科临床规范与指南数据库,构建标准临床路径,推动我国儿童临床实践指南的高质量发展。     

医疗体制改革形势下实施临床路径的思考

从我国现行的医疗服务模式的不足入手，结合临床路径的概念、产生、优点等，阐述我国医院实施临床路径的必要性与可行性。     

Assessment of Clinical Guidelines for Continuation Treatment in Major Depression

ObjectiveThe primary objective of this study was to assess the appropriateness of the existing Dutch clinical guidelines for the treatment of depression from a health-economic perspective. The existing guidelines recommend continuation treatment for a period up to 9 months.MethodsThe assessment was based on a Markov model using decision-analytic techniques. For this analysis we defined six mutually exclusive states defined by the existence of depression and type of treatment. The outcomes for the model were defined as: time without depression (TWD), quality-adjusted life years (QALYs), direct medical costs, and cost of lost productivity. The primary perspective of the study was that of the third-party payer, while the secondary perspective was that of the society in 1999. The probabilities of clinical events and therapeutic choices as well as the utilities were based on published literature. The medical resource use related to each state was abstracted from published literature and expert opinion. The associated 1999 unit costs of the used medical resources were derived from official Dutch tariff lists of allowable reimbursements. Indirect costs in this model were based on lost productivity only.ResultsThe results of the primary analysis showed that the use of the guidelines is not cost-effective. Continuation treatment for a period of 9 months increases the total direct medical costs (NLG 1276 vs. NLG 474), decreases the costs resulting from lost productivity (NLG 304 vs. NLG 909), increases total costs (NLG 1580 vs. NLG 1383) and increases TWD (96.9% vs. 86.4%). However, continuation treatment does not change the utility outcomes (0.60 vs. 0.61 QALYs) for both treatment strategies. Hence continuation treatment is not cost-effective from either a third-party payer perspective or a societal perspective. A scenario analysis showed that an extension of the continuation treatment to maintenance treatment might result in a favorable cost-effectiveness outcome of the treatment guideline.ConclusionIn conclusion, based on the assumptions used in the model, the current Dutch treatment guidelines for depression are only appropriate from a health-economic perspective if continuation treatment is extended to maintenance treatment.     

Methodology of Clinical Nutrition Guidelines for Adult Cancer Patients

Background: Malnutrition delays recovery from cancer treatment and can lead to additional serious complications. Clinical guidelines for the management of malnutrition in cancer patients are essential tools for optimizing nutritional care; therefore, their methodological quality is of great importance. This review assesses the methodological quality of international clinical guidelines for the management of malnutrition in adult cancer patients. Methods: Guidelines were identified through searches in multiple electronic databases; afterward, they were systematically reviewed with the AGREE instrument, which is one method of evaluating the methodological quality of guidelines. Results: The methodological quality of the guidelines reviewed varied greatly. The highest scores were observed in the domains “scope and purpose” and “clarity and presentation,” while the lowest scores were awarded in the domains “editorial independence,” “stakeholder involvement,” and “applicability.” Furthermore, there was consensus on the indication for parenteral nutrition and nutrition screening. However, there was a lack of consensus on how nutritional therapy should be provided. No improvement was observed in methodological quality of the more recent guidelines compared to the older ones. Conclusions: The methodological quality of clinical guidelines on malnutrition for cancer patients and the way they are reported need to be improved. To achieve this, developers should utilize available guideline assessment tools, such as the AGREE instrument, when writing or updating guidelines on this topic.     

Main messages for primary care from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice

In 2016, a new version of the European Guidelines on Cardiovascular Prevention was released, representing a partnership between the European Association for Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology (ESC) and nine European societies, including Wonca-Europe. The ESC guidelines underscore the importance of a lifetime approach to cardiovascular (CV) risk since both CV risk and prevention are dynamic and continuous as patients’ age and/or accumulate co-morbidities. Healthy people of all ages should be encouraged to adopt a healthy lifestyle, as well as improved lifestyle and reduced risk factor levels are paramount in patients at increased risk of developing cardiovascular disease (CVD) and in those with established CVD. Healthcare professionals, and especially general practitioners, play an important role in helping patients achieve this and should set a personal example of healthy lifestyle behaviour. The ESC guidelines are based on ‘to do’ and ‘not to do’ messages. Of note, what remains uncertain is stated at the end of each dedicated chapter, confirming that guidelines are not absolute rules, and should be interpreted in the light of the healthcare worker’s knowledge and experience, patient preferences and the local social, cultural and economic situation.     

Economic Evaluation of National Patient Blood Management Clinical Guidelines in Cardiac Surgery

ObjectivesTo the best of our knowledge, no published clinical guidelines have ever undergone an economic evaluation to determine whether their implementation represented an efficient allocation of resources. Here, we perform an economic evaluation of national clinical guidelines designed to reduce unnecessary blood transfusions before, during, and after surgery published in 2012 by Australia’s sole public blood provider, the National Blood Authority (NBA).MethodsWe performed a cost analysis from the government perspective, comparing the NBA’s cost of implementing their perioperative patient blood management guidelines with the estimated resource savings in the years after publication. The impact on blood products, patient outcomes, and medication use were estimated for cardiac surgeries only using a large national registry. We adopted conservative counterfactual positions over a base-case 3-year time horizon with outcomes predicted from an interrupted time-series model controlling for differences in patient characteristics and hospitals.ResultsThe estimated indexed cost of implementing the guidelines of A$1.5 million (2018-2019 financial year prices) was outweighed by the predicted blood products resource saving alone of A$5.1 million (95% confidence interval A$1.4 million-A$8.8 million) including savings of A$2.4 million, A$1.6 million, and A$1.2 million from reduced red blood cell, platelet, and fresh frozen plasma use, respectively. Estimated differences in patient outcomes were highly uncertain and estimated differences in medication were financially insignificant.ConclusionsInsofar as they led to a reduction in red blood cell, platelet, and fresh frozen plasma use during cardiac surgery, implementing the perioperative patient blood management guidelines represented an efficient use of the NBA’s resources.