Grading quality of evidence and strength of recommendations in clinical practice guidelines part 3 of 3. The GRADE approach to developing recommendations

This is the third and last article in the series about the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to grading the quality of evidence and the strength of recommendations in clinical practice guidelines and its application in the field of allergy. We describe the factors that influence the strength of recommendations about the use of diagnostic, preventive and therapeutic interventions: the balance of desirable and undesirable consequences, the quality of a body of evidence related to a decision, patients' values and preferences, and considerations of resource use. We provide examples from two recently developed guidelines in the field of allergy that applied the GRADE approach. The main advantages of this approach are the focus on patient important outcomes, explicit consideration of patients' values and preferences, the systematic approach to collecting the evidence, the clear separation of the concepts of quality of evidence and strength of recommendations, and transparent reporting of the decision process. The focus on transparency facilitates understanding and implementation and should empower patients, clinicians and other health care professionals to make informed choices.     

Practice Involves More Than Treatment: How Can Evidence‐Based Assessment Catch Up to Evidence‐Based Treatment?

[Clin Psychol Sci Prac 18: 173–177, 2011] Given the excellent work being conducted in the area of evidence‐based treatments (EBTs), it is important to consider whether other forms of evidence‐based practice are receiving concomitant attention. While significant progress has been made in the last five years to generate reviews of evidence‐based assessment (EBA) practices, this work lags behind efforts to identify EBTs. This commentary describes available data on assessment practices in clinical care settings, discusses the importance of and current status of EBA, and considers how the next generation of EBA reviews might move beyond consideration of psychometric properties to the inclusion of “effectiveness” parameters.     

Grading quality of evidence and strength of recommendations in clinical practice guidelines

The GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach provides guidance to grading the quality of underlying evidence and the strength of recommendations in health care. The GRADE system's conceptual underpinnings allow for a detailed stepwise process that defines what role the quality of the available evidence plays in the development of health care recommendations. The merit of GRADE is not that it eliminates judgments or disagreements about evidence and recommendations, but rather that it makes them transparent. This first article in a three-part series describes the GRADE framework in relation to grading the quality of evidence about interventions based on examples from the field of allergy and asthma. In the GRADE system, the quality of evidence reflects the extent to which a guideline panel's confidence in an estimate of the effect is adequate to support a particular recommendation. The system classifies quality of evidence as high, moderate, low, or very low according to factors that include the study methodology, consistency and precision of the results, and directness of the evidence.     

The impact of evidence‐based decision making in transfusion practice and potential impact on litigation

Transfusion practices throughout the world have developed mostly empirically since the late 1940s, with little or no published studies to validate them. In the past 20 years, possibly fuelled in part by increasing numbers of lawsuits related to transfusion medicine, there has been a concerted effort to improve the evidence base, such as through prospective, well‐controlled randomized clinical trials (RCT) and by consensus conferences. These efforts have resulted in a number of peer‐reviewed publications that are elucidating the scientific basis for use of red blood cells (RBC) and other blood components. The term ‘evidence‐based medicine’ or ‘EBM’ was coined by Guyatt in 1991 [ 1 ], introduced widely in 1992 [ 2 ] and defined broadly in 1996 by Sackett et al. [ 3 ] as ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research’. A more recent updated definition has recognized that the goal of providing EBM includes patient needs and is restated as the ‘integration of best research evidence with clinical expertise and patient values’[ 4 ]. Since the recognition of this principle, the focus of every medical specialty, including transfusion medicine, has been to discern from the huge number of articles published each year, which are the ‘best practices’ that are supported by scientific data [ 5 - 8 ]. Despite the widespread endorsement of the concept of EBM and its incorporation into medical education [ 9 , 10 ], advocates and sceptics continue to express contrary positions regarding its value [ 11 - 16 ]. Resistance to ‘cook‐book’ medicine persists. In the background of this drive towards EBM during the past 20 years, there have been relatively few instances in which the legal systems of various countries have experienced actual litigations related to transfusion harm, so the utility of EBM in cases related to transfusion practices has not yet been determined. However, the courts have had a chance to view EBM in other medical situations. The status of EBM in litigation in general will be discussed later in this article.     

A comparison of client preferences for intervention empirical support versus common therapy variables

Client preferences have been identified as an essential part of evidence‐based practice in psychology. Further, client preferences have been found to play an important role in determining premature termination and therapy outcomes. However, our current understanding of this client variable is limited because of the methodologies that have previously been used to assess these preferences. In this study, 57 adult clients from a university‐based psychology department clinic completed an instrument weighing preferences for intervention specific empirical support against preferences for 4 other common factor variables. These clients were found to discount a significant amount of intervention empirical support to ensure the following: (a) a satisfactory therapeutic relationship could be developed, (b) their therapist would be empathetic and accepting, (c) their therapist would have a greater level of experience, and (d) they, as clients, would do more of the talking during sessions. These findings suggest that clients prefer treatment decisions to be based on variables other than intervention empirical support alone. Recommendations are made for assessing and including client preferences to provide more individually tailored interventions. © 2010 Wiley Periodicals, Inc. J Clin Psychol 66:1–15, 2010.     

Grading quality of evidence and strength of recommendations in clinical practice guidelines: Part 2 of 3. The GRADE approach to grading quality of evidence about diagnostic tests and strategies

The GRADE approach to grading the quality of evidence and strength of recommendations provides a comprehensive and transparent approach for developing clinical recommendations about using diagnostic tests or diagnostic strategies. Although grading the quality of evidence and strength of recommendations about using tests shares the logic of grading recommendations for treatment, it presents unique challenges. Guideline panels and clinicians should be alert to these special challenges when using the evidence about the accuracy of tests as the basis for clinical decisions. In the GRADE system, valid diagnostic accuracy studies can provide high quality evidence of test accuracy. However, such studies often provide only low quality evidence for the development of recommendations about diagnostic testing, as test accuracy is a surrogate for patient-important outcomes at best. Inferring from data on accuracy that using a test improves outcomes that are important to patients requires availability of an effective treatment, improved patients' wellbeing through prognostic information, or – by excluding an ominous diagnosis – reduction of anxiety and the opportunity for earlier search for an alternative diagnosis for which beneficial treatment can be available. Assessing the directness of evidence supporting the use of a diagnostic test requires judgments about the relationship between test results and patient-important consequences. Well-designed and conducted studies of allergy tests in parallel with efforts to evaluate allergy treatments critically will encourage improved guideline development for allergic diseases.     

Developing pathways to assist parents to exit the child protection system in Australia

The prevalence of child abuse and neglect is an international concern that justifies the existence of child protection systems. An important first principle for all such statutory child protection systems is to ensure that the system itself does no further harm. It can be argued that there are specific circumstances within which well‐meaning services have the potential to do harm: specifically, processes and actions that disempower parents by reducing their autonomy and capacity for positive action. Exploring the circumstances in which reduced parental autonomy impacts negatively on families is an important first step in developing procedures for working with families that not only avoid harm but are orientated to produce meaningful change. Two evidence‐based programs are described that together have the potential to assist child protection practitioners to develop a collaborative helping partnership with families, clarify goals for change and support parents to achieve meaningful improvement in their family functioning. The programs described are both manualised and have empirical support for their effectiveness. The potential benefits for both families and practitioners working within child protection agencies in the two programs are described.     

Flype: Software for enabling personalized medicine

The advent of next generation DNA sequencing (NGS) has revolutionized clinical medicine by enabling wide‐spread testing for genomic anomalies and polymorphisms. With that explosion in testing, however, come several informatics challenges including managing large amounts of data, interpreting the results and providing clinical decision support. We present Flype, a web‐based bioinformatics platform built by a small group of bioinformaticians working in a community hospital setting, to address these challenges by allowing us to: (a) securely accept data from a variety of sources, (b) send orders to a variety of destinations, (c) perform secondary analysis and annotation of NGS data, (d) provide a central repository for all genomic variants, (e) assist with tertiary analysis and clinical interpretation, (f) send signed out data to our EHR as both PDF and discrete data elements, (g) allow population frequency analysis and (h) update variant annotation when literature knowledge evolves. We discuss the multiple use cases Flype supports such as (a) in‐house NGS tests, (b) in‐house pharmacogenomics (PGX) tests, (c) dramatic scale‐up of genomic testing using an external lab, (d) consumer genomics using two external partners, and (e) a variety of reporting tools. The source code for Flype is available upon request to the authors.     

The prevalence of os acromiale: A systematic review and meta‐analysis

Os acromiale (OA) results from a failure of consolidation between the ossification centers of the acromial epiphysis. Its prevalence and its interactions with ancestry, gender, laterality, and side have been variously reported in the literature. The aims of this review are to provide an accurate estimate of OA prevalence and to investigate its association with other variables in an attempt to comprehend its etiology. Twenty‐three studies met the inclusion criteria. The results of meta‐analyses of large‐sample studies revealed: (a) a crude overall prevalence of 7.0%, (b) a crude cadaveric prevalence of 7.6%, (c) a crude archeological (skeletal) prevalence of 5.6%, (d) a crude radiological prevalence of 4.2%, (e) a true anatomical prevalence of 9.6%, (f) a significantly higher frequency in persons of black ancestry than in persons of white, Native American and Middle Eastern ancestries (OR ≈ 3), (g) significantly higher unilateral and bilateral frequencies in black ancestry (OR of 2 and 4, respectively), (h) nonsignificant interactions of OA frequency with gender and side. The commonest type of OA was the meso‐acromion type (76.6%). Degenerative changes were present in 66.6% of OAs. The results of this evidence‐based anatomical review support a genetic basis for OA rather than the mechanical trauma‐induction hypothesis. Clin. Anat. 610–621, 2014. © 2013 Wiley Periodicals, Inc.     

Prediction and Postdiction in Clinical Decision Making

An article on "Post Hoc Reasoning in Possible Cases of Child Sexual Abuse: Symptoms of Inconclusive Origin" by Sbraga and O'Donohue (2003 , this issue) illustrates some general guidelines for clinical decision making. Most important in this regard is the fact that psychological assessment data are considerably more dependable for describing what people are like than for predicting how they are likely to behave or postdicting what they are likely to have done or experienced. This commentary reviews the nature of this difference in dependability and some related considerations involving nomothetic and idio-graphic appraisal, heterogeneity and nonspecificity of group characteristics, and markers and probabilities for identifying conditions. Awareness of these considerations can help clinicians and other psychological decision makers avoid unwarranted certainty in offering opinions about the likely occurrence of past or future events.     

如何获取循证医学证据

循证医学是以证据为基础的临床医学,它是最好的证据、医生的临床实践和病人价值三者之间的结合。笔者在文中就循证医学证据的获取作了系统的介绍,旨在为医务工作者的循证医学实践提供帮助。