基于临床实践指南决策树的设计与思考

临床实践指南可以促进临床诊疗规范化,提高医疗服务质量。但是,指南在传播与实施过程中可能存在多种障碍因素,导致其对临床实践的规范性及患者结局的有效性并未完全体现。主要障碍在于非结构化的文本指南不便于临床医生查阅和使用,阻碍了指南在临床实践中的应用。因此,本文通过介绍决策树模型,阐述将文本化的指南转化为结构化决策树的方法,提出基于临床实践指南设计决策树的优点、难点及解决策略,为推动文本化临床实践指南的转化提供参考。     

中西医结合临床实践指南实施框架构建的思考

中西医结合临床实践指南作为医学实践的重要指导性文件,是发挥中西医各自优势,促进中西医结合的重要抓手。然而目前中西医结合指南的研究存在“重研制”而“轻实施”的问题,依据实施科学的理论框架,构建中西医结合临床实践指南实施框架和方法,有利于促进中西医结合指南的实施和中西医临床的融合与发展。本文通过梳理和分析知识-行动框架,对中西医结合指南实施框架的研发思路展开讨论和思考,以期为未来相关研究奠定基础。     

2019年期刊公开发表的中国临床实践指南文献调查与评价——传播与实施情况

  目的  分析2019年期刊公开发表的中国临床实践指南传播与实施情况,为推动我国临床实践指南的转化与落地提供建议。  方法  针对2019年期刊公开发表的中国临床实践指南传播与实施相关内容报告情况,以及指南多期刊、多版本、多语种发表情况进行分析。同时,分析2019年中国临床实践指南解读类文献的发表情况,进一步了解我国指南的传播与实施现状。  结果  2019年期刊公开发表的中国临床实践指南共226篇,仅5.8%(13/226)报告了传播与实施相关内容。共报告了12种传播与实施策略,其中通过学术会议及多媒体平台促进指南传播与实施被报告的次数最多,在8篇指南中均进行了报告。在传播与实施策略的应用方面,12.4%(28/226)的指南在多本期刊上公开发表,9.3%(21/226)的指南发表了不同版本,8.4%(19/226)的指南分别以中、英文语种进行发表。对2019年中国指南的解读类文献进行检索,共纳入48篇文献,分别对30篇(13.3%,30/226)指南进行了解读。指南与解读类文献发表的中位时间间隔为5.5个月。  结论  2019年期刊公开发表的中国临床实践指南中传播与实施的报告率及相关策略的应用率均较低,建议指南制订者在指南制订过程中应制订有针对性、形式多样的传播与实施策略,并在撰写时遵循相应的报告规范。     

临床实践指南实施性评价工具的研制和验证评价

目的开发临床实践指南的实施性评价工具并进行验证评价,以促进对指南的全面评价进而提高指南的推广与实施。方法课题组成立指南实施性评价工具制订小组,通过前期调研、访谈及相关文献的系统评价、两次专家共识会议,初步建立了指南实施性评价工具;再通过两轮德尔菲专家咨询,进一步判断该工具不同领域和条目的合理性;最终对指南实施性评价工具的表面效度和内容效度进行验证评价。结果最终确定的指南实施性评价工具包括可及性、沟通性、可执行性、易识别性和应用性5个领域,共计7个条目。两次德尔菲咨询的S-CVI值分别为0.91和0.93。按照均数<3.5,变异系数>15%且I-CVI<0.78的评价标准,两次咨询后不进行条目的删减,仅对工具内容进行适当修改。结论本研究建立了由临床相关专业医生和指南制订方法学专家共同担任评价者的指南实施性评价工具,为评价指南实施性提供标准和方法。本指南实施性评价工具的表面效度和内容效度均较好。我们将对这一工具的适用性进行下一步实证研究。     

加拿大安大略注册护士协会临床实践指南应用方法解析

临床实践指南与临床实践之间的差距阻碍着最佳证据的有效实施。加拿大安大略注册护士协会发布的《工具书:如何实施最佳实践指南》一书,其以知识转化模型为框架,分别从确定问题、适应当地文化背景、评估知识使用过程中的促进和阻碍因素、选择和调整干预措施和策略、监测知识应用情况和评估实施结果以及知识的持续性应用等方面,为促进证据的临床转化提供了系统的策略指导。该文通过对书中以上6个方面进行解析,进一步介绍指南的应用方法,以促进我国对临床实践指南的高效运用。     

人工智能如何改变指南的未来

近年来,人工智能的快速发展和进步对医学领域的影响日益加深。科技部发布的人工智能指南明确提出要加大人工智能技术在医药卫生领域应用的支持力度。临床实践指南作为医疗实践的重要指导性文件,可以规范医务人员的诊疗行为,缩小最佳研究证据与当前实践之间的差距,具有重要意义和价值。如何利用人工智能技术加速指南的制订流程,提高其制订效率,创新其传播与实施模式,乃至改变指南的未来发展,已引起国内外学者的广泛关注。本文就人工智能在临床实践指南领域的应用现状和发展前景进行分析和讨论,并在此基础上提出促进人工智能与临床实践指南结合的思考与建议。     

实施科学中实施策略的介绍

实施科学是系统的研究方法,旨在能够促进研究结果和其他循证实践的证据运用到临床日常实践中,已经成为与科学研究高度相关的话题。随着“实施科学”理念的深入,相关理论和实践方法不断更新,研究者针对临床干预、以证据为基础的循证实践或新技术在临床实践运用的决定因素（包括障碍及促进因素）,建立了“实施策略”,以期促进创新措施的应用和推广。本文系统介绍实施策略的定义、选择以及相关的记录和报告,旨在为更好地开展实施研究提供参考。     

卫生技术评估的审慎评议：HTAi/ISPOR联合工作组的指南解读

国际卫生技术评估组织（HTAi）联合国际卫生经济学和成果研究专业协会（ISPOR）领导的工作组,在前期研究的基础上发表了设计和实施卫生技术评估的审慎评议实践报告指南与附属清单。鉴于目前国内缺乏运用卫生技术评估（HTA）审慎评议方法开展的相关实践与报告,因此本文对该指南和附属清单进行了详细解读,以期为我国HTA及其审慎评议的实践和报告提供参考依据,同时促进HTA方法的传播和应用,推动国内HTA审慎评议能力及体制机制的建设。     

推动证据向临床转化(五)证据临床转化研究中的文献质量评价

循证实践是对公开报道的研究进行组织、整理、评价、整合、分类、遴选和有效利用的过程,以促进证据向临床转化,促进护理实践水平的提高。在证据临床转化的四个阶段中,文献质量评价是证据准备阶段的关键环节。本文将详细介绍对指南、专家共识、系统评价和原始研究的文献质量评价的原则和方法,为研究者进一步梳理可用的证据,开展后续临床转化环节提供依据。     

《中成药治疗优势病种临床应用指南》实施性评价

目的 分析《中成药治疗优势病种临床应用指南》的实施性现况与质量。方法 纳入2019年2月—2022年8月公开发表的中成药治疗优势病种临床应用指南。使用指南实施性评价工具对纳入指南的实施性概况进行总结及评价。结果 本研究共纳入29部指南,总体实施性质量较高,13部指南的实施性质量属于高等级(44.8%),16部属于中等级(55.2%)。结论 《中成药治疗优势病种临床应用指南》实施性质量高于国内其他中医/中西医结合指南。指南实施性评价工具适用于中医药指南的评价,但中医药指南的实施性评价方法仍需综合考量中医药本身的特殊性。     

Practice guidelines for tumor marker use in the clinic

BACKGROUND: Increasing interest in implementing the practice of evidence-based medicine in oncology has encouraged the development of clinical guidelines, many of which include recommendations about the appropriate use of serum tumor markers. METHODS: Recent national and international guidelines relating to the use of tumor markers in germ cell, colorectal, breast, ovarian, prostate, lung, neuroendocrine, and thyroid cancers were identified from the scientific literature and other sources and tabulated. RESULTS: Guideline recommendations developed by national and international groups and relating to the use of tumor markers for specific cancers are reviewed and compared, considering the recommendations made for their use in screening, diagnosis, prognosis, and monitoring of therapy. Potential advantages and disadvantages of clinical guidelines, how best to implement them, and means of auditing their effectiveness are also considered. CONCLUSIONS: Excellent clinical guidelines, including recommendations for the most appropriate use of tumor markers, are already available for many cancers. Many questions relating to optimal use of these important tests remain to be answered, but current guidelines already contain much valuable information and advice. Further dissemination and implementation of the guidelines should encourage better use of tumor markers in clinical practice. Careful audit studies are also required to establish the impact of these guidelines on the practice of evidence-based medicine.     

Clinical guidelines in nursing, midwifery and the therapies: a systematic review

BACKGROUND: While nursing, midwifery and professions allied to medicine (PAMs) are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness in relation to these professions. We identified 18 evaluations of guidelines which met established quality for evaluations of interventions aimed at changing professional practice. This paper describes characteristics of guidelines evaluated and the effectiveness of different dissemination and implementation strategies used. METHODS: Guideline evaluations conducted since 1975 which used a randomized controlled trial, controlled before-and-after, or interrupted time-series design, were identified using a combination of database and hand searching. FINDINGS: It is mostly impossible to tell whether the guidelines evaluated were based on evidence. The most common method of guideline dissemination was the distribution of printed educational materials. Three studies compared different dissemination and/or implementation strategies: findings suggest educational interventions may be of value in the dissemination of guidelines and confer a benefit over passive dissemination.     

The guideline approach to chronic obstructive pulmonary disease: how effective?

Clinical practice guidelines are systematically developed to assist health care decisions in specific clinical circumstances. They first arose to improve quality of care by decreasing unexplained practice variation, controlling health care costs, fostering evidence-based decision-making, and accelerating the application of new advances in medical science to everyday practice. Unfortunately, multiple studies demonstrate incomplete and varied effectiveness of clinical practice guidelines in altering clinician behavior and improving patient outcomes. Efforts to enhance guideline effectiveness have focused on improving the methods for guideline development, diffusion, dissemination, and implementation. Despite evidence of limited effectiveness, more than 40 clinical practice guidelines pertaining to chronic obstructive pulmonary disease have been published since 1985. The present article reviews those guidelines, evidence for their effectiveness, and approaches to improve their implementation.     

Clinical review: Checklists - translating evidence into practice

Checklists are common tools used in many industries. Unfortunately, their adoption in the field of medicine has been limited to equipment operations or part of specific algorithms. Yet they have tremendous potential to improve patient outcomes by democratizing knowledge and helping ensure that all patients receive evidence-based best practices and safe high-quality care. Checklist adoption has been slowed by a variety of factors, including provider resistance, delays in knowledge dissemination and integration, limited methodology to guide development and maintenance, and lack of effective technical strategies to make them available and easy to use. In this article, we explore some of the principles and possible strategies to further develop and encourage the implementation of checklists into medical practice. We describe different types of checklists using examples and explore the benefits they offer to improve care. We suggest methods to create checklists and offer suggestions for how we might apply them, using some examples from our own experience, and finally, offer some possible directions for future research.     

循证针灸临床实践指南方法学研究初探

目的探讨循证针灸临床实践指南制定方法,为撰写循证针灸临床实践指南提供方法学经验。方法根据中医针灸学学科及文献特点,遵循循证医学原理与方法,介绍循证针灸临床实践指南具体撰写流程和方法,并在文中突出分析了针灸临床实践指南与其他临床指南方法学研究异同点,以撰写抑郁症循证针灸临床实践指南为例,重点分析文献检索、证据等级、文献质量评估标准和推荐强度形成方法等内容。结果初步形成循证针灸临床实践指南方法学研究建议。结论应用合理、优化的指南制定方法学研究成果,可以制定高质量的循证针灸临床实践指南。     

Are the 2010 guidelines on cardiopulmonary resuscitation lost in translation? A call for increased focus on implementation science

Despite significant resources spent on rigorous evidence review and resuscitation guideline development, an important gap remains in our understanding of effective strategies and tools for implementing resuscitation guidelines. The lack of evidence about effective guideline implementation for resuscitation is likely reducing the impact of the incredible amount of work that goes into the production of such guidelines. This commentary draws attention to knowledge translation learnings from other content areas and within the area of resuscitation science to support a call for increased attention and innovation in implementation science as an equally important investment for the future of resuscitation medicine.     

2019年期刊公开发表的中国临床实践指南现状评价

调查2019年国内外期刊公开发表的中国临床实践指南现状,分别从制订人员、利益冲突、引文、证据质量和推荐强度分级、方法学质量与报告质量、研究空白、传播与实施7个方面进行分析,旨在为我国指南制订者、使用者和评价者提供参考。