中国老年骨质疏松症诊疗指南（2018）

根据国内外循证医学指南制定标准化方法与步骤,组建多学科指南制定专家工作组,先后经过指南注册及指南计划书撰写、相关指南评价分析、临床问题遴选和确定、临床证据检索及评价、形成推荐意见等流程,经共识专家组3轮讨论,最终制定中国老年骨质疏松症诊疗指南(2018)。使用GRADE系统对证据体和推荐意见进行分级。同时考虑中国患者的偏好与价值观、干预措施的成本和利弊平衡为老年骨质疏松症的诊疗提供15条推荐意见。该指南涵盖了老年骨质疏松症的筛查、风险评估、诊断、基础措施、多种抗骨质疏松药物、疗效监测和评估等方面。本指南旨在为我国广大临床医生和患者提供科学依据。     

Evidence-based orthopaedics: a primer

Evidence-based medicine has evolved from the need of solving clinical problems. In contrast to the traditional paradigm of clinical practice, evidence-based medicine acknowledges that intuition, clinical experience, and pathophysiologic rationale are not sufficient for making the best clinical decisions. Although evidence-based medicine recognizes the importance of clinical experience, it includes the evaluation of evidence from clinical research and the integration of patients' values, preferences, and actions for best clinical decision-making. To optimize this process, evidence-based medicine advocates that a formal set of rules must accompany training and clinicians' common sense to interpret and apply evidence from clinical research results effectively. We describe the critical appraisal of studies related to prognosis and therapy or prevention building on an example relevant for the clinical orthopaedist. Based on the example, the authors describe how clinicians can apply measures of association and of intervention effects to their practice and patient care. The authors conclude with describing the appraisal of systematic reviews, their application to the development of practice guidelines, and the process of guideline development and recommendations.     

Review article: The role of practice guidelines and evidence-based medicine in perioperative patient safety

Purpose

The purpose of this narrative review is to discuss the impact of clinical practice guidelines on the outcomes of care and patient safety.

Principal findings

The care provided to patients has a high degree of variability, including some care that is discordant with available evidence. This inconsistency has implications for patient safety as some patients receive care that is unlikely beneficial yet may be harmful, while others are denied care that would clearly be helpful. The medical literature is expanding at an alarming rate; its quality and reliability is often poor; study methodology is frequently suboptimal, and reversal is common, even among frequently cited articles. For decades, specialty societies and other agencies have been providing clinical practice guidelines to assist physicians with the integration of evidence into clinical decision-making. Implementation of guidelines has been variable, and their goals are often not achieved due to failed uptake and application. The reasons for this shortcoming are complex and some explanations are valid. Many guidelines have not been evidence-based and many have been methodologically unsound. Physician autonomy likely also plays an important role in guideline uptake; an updated concept of autonomy that embraces appropriate guidelines is long overdue.

Conclusions

Under certain conditions, guidelines can add value to care and improve outcomes; they need to be evidence-based, methodologically sound, and appropriately applied to patients and clinical scenarios. Simply summarizing evidence in a guideline is an inadequate process. To achieve the benefit of guidelines, implementation strategies need to be robust.     

Implementing nursing practice guidelines: a complex undertaking.

Clinical practice guidelines have been proposed to significantly reduce the gap between available scientific evidence and clinical practice. Evidence-based guidelines are also being produced at an ever-increasing pace. However, guidelines do not implement themselves, and the research to support implementation does not provide straightforward answers. What works in one setting does not necessarily work in another. In short, guideline implementation and change of practice is complex and messy. The purpose of this article is to discuss the implementation of clinical practice guidelines using the Promoting Action on Research Implementation in Health Services framework. More specifically, 3 key components are highlighted: (1) the evidence base for guideline recommendations, (2) the clinical context where guidelines are to be implemented, and (3) the nature of facilitation needed to ensure a successful change process. An overview of the literature in the field is provided, and the authors' experiences are shared, and a few recommendations are tentatively provided.     

Resident guideline development to standardize intensive care unit care delivery: a competency-based educational method

PURPOSE: We developed a system of resident-driven, evidence-based standardization of care in our trauma-surgical intensive care unit (TSICU). Our main purposes are to improve patient care and outcomes and to help the residents develop practical competency in practice-based learning and improvement and in systems-based practice. DEVELOPMENT OF THE ACTIVITY: Since October 2006, each rotating TSICU resident has chosen a topic to research the available evidence and has developed a guideline, which the resident then presents to the TSICU faculty and residents for discussion, amendments, and acceptance or reevaluation. EVALUATION COMPONENT: Evaluation of proposed guidelines is based on the quality of information presented in support of the recommendations. Ultimately, acceptance of a guideline requires consensus among the TSICU faculty. Immediate feedback is given to the presenting resident by the faculty. The residents evaluate the program via a Web-based evaluation tool. PROPOSED OUTCOME MEASURES: We have qualitative data from residents that indicate this experience is positive. We are developing a tool to use both qualitative and quantitative means to evaluate resident, faculty, and nursing staff satisfaction with the process. We will use our clinical database to evaluate whether improved patient outcomes have resulted from standardization of care. IMPLEMENTATION DATES AND EXPERIENCE TO DATE: We implemented this methodology in October 2006 and have thus far implemented 20 guidelines and 2 standardized order sets. CONCLUSION AND OR NEXT STEPS: We believe competency is achieved and demonstrated by actively participating in a process such as development of care guidelines. Researching and developing standardized guidelines for our TSICU seems to be an effective and practical way for residents to use multiple sources for practice-based learning and improvement. It also requires the resident to advocate for quality patient care and optimal patient care systems. We plan to use outcome and qualitative data to validate this method.     

A Fine Balance: Developing Clinical Practice Guidelines in Areas Where Evidence is Lacking

Over the last 15 years, numerous clinical practice guidelines have been developed by clinicians driven by national societies and funders of healthcare services. Writing and publication of guidelines have been refined such that a transparent and robust process has evolved. The main purpose of clinical practice guidelines is to provide healthcare professionals with evidence‐based recommendations to assist clinical decision‐making and reduce variability in clinical practice: this benefits patients and the healthcare system. When evidence is abundant and robust, guideline development is relatively straightforward. However, in areas where evidence is lacking, there is a tension between providing advice based on expert opinion while maintaining a clinical equipoise that will facilitate the design and execution of clinical trials, so that new information is gained, and that will ultimately inform care 1 . In this commentary, we explore these problems and suggest an alternative approach to the development of clinical guidance in areas where evidence is lacking.     

An updated overview of clinical guidelines for the management of non-specific low back pain in primary care

The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000. Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity. For chronic low back pain, consistent features included supervised exercises, cognitive behavioural therapy and multidisciplinary treatment. However, there are some discrepancies for recommendations regarding spinal manipulation and drug treatment for acute and chronic low back pain. The comparison of international clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations are generally similar. There are also some differences which may be due to a lack of strong evidence regarding these topics or due to differences in local health care systems. The implementation of these clinical guidelines remains a challenge for clinical practice and research.     

An independent AGREE evaluation of the Occupational Medicine Practice Guidelines.

BACKGROUND AND CONTEXT: A large number of practice guidelines are being produced by numerous organizations. Health-care professionals need to critically evaluate these practice guidelines to understand whether they are well constructed and representative of the preponderance of evidence. The guideline development process should be precise and rigorous to ensure that the results are reproducible and not vague. PURPOSE: To evaluate the quality of the second edition of the practice guidelines published by the American College of Occupational and Environmental Medicine (ACOEM Guidelines). STUDY DESIGN/SETTING: Four appraisers used the AGREE (Appraisal of Guidelines Research and Evaluation) guideline evaluation instrument to evaluate the ACOEM Guidelines. METHODS: The Guidelines were evaluated with the AGREE guideline evaluation instrument. The AGREE instrument has been widely adopted around the world, and the authors recommended that it be adopted as the standard of guideline construction process evaluation in the United States. The instrument standardizes the quantitative assessment of quality for a guideline's development process across six domains that include: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application, and editorial independence. Scores from four assessors were collected and interpreted. Additionally, each evaluator selected one of four global assessment choices: "strongly recommended for use in practice," "recommended for use with some modification or proviso," "not recommended as suitable for use in practice," or "unsure". RESULTS: The ACOEM Guidelines scored highest in the dimensions that evaluated reporting of the guideline's scope and purpose (79.63) as well as clarity and presentation (86.81). The guideline scored much lower in the remaining areas that included stakeholder involvement (46.06), rigor of development (26.59), application (31.48), and editorial independence (19.17). The global assessment was unanimous with all four evaluators assessing the guideline as recommend with proviso. CONCLUSIONS: Many of the Guidelines recommendations were consistent with current literature and guidelines; however, the AGREE assessment instrument evaluates the guideline development process and not the content. All the evaluators thought the content of the guidelines was substantially better than the documentation of the guideline construction process. The ACOEM Guidelines appear to have content consistent with their stated objectives, but the reporting of the guidelines construction process, particularly the rigor of recommendation development, is flawed, and the recommendations may not be valid owing to possible evidence selection deficiencies. The reader should consider these flaws and limitations when using the guideline. The reader should consider utilizing guidelines of higher quality when possible. Future guidelines should incorporate better reporting and give closer attention to guideline construction.     

Utilization of incontinence clinical practice guidelines.

Clinical practice guidelines (CPGs) are evidence-based recommendations for best practice and have been developed with the assumption they will be embraced by practitioners; a further assumption is that clinical practice guidelines will improve the delivery of care. In this article, we provide a working definition of evidence-based practice, discuss the strengths and limitations of CPGs, describe the implementation of CPGs in the context of urinary incontinence, and consider the steps that the WOCN has taken to initiate evidence-based practice. Current issues are presented along with initiatives that have resulted in clinical practice guidelines on incontinence from the United States, United Kingdom, and Canada. On the basis of the current literature, it is concluded that clinical practice guidelines can play an important role in WOCN practice and that the implementation of guidelines may improve clinical practice. However, guidelines are only as valid as the evidence on which they are based and may not take into account gender or cultural differences or the effect that comorbid conditions can have on treatment outcomes. Finally, guidelines must follow a comprehensive approach that involves management and staff and includes education, facilitation, evaluation, feedback, and an understanding of change strategies.     

Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition

BackgroundThe latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine.MethodsThe Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, “body of evidence” and “benefit and harm balance” were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members.ResultsNine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature.ConclusionsThe 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.     

Evidence-based medicine in prostate cancer: where do we stand in 2006?

PURPOSE OF REVIEW: A majority of medical decisions relating to the diagnosis, prognosis, and therapy of prostate cancer are based on low levels of evidence. This article reviews the recommendations of currently available evidence-based practice guidelines that relate to the management of patients with newly diagnosed prostate cancer. The article further introduces a selection of recent studies that are relevant to the evidence-based patient care. RECENT FINDINGS: Updated clinical practice guidelines on the management of prostate-cancer patients provide an evidence-based summary of the literature and have recently been made available through the National Cancer Center Network and the European Urological Association. In addition, several recent high-quality studies have made major contributions to our knowledge of the natural history and therapy of prostate cancer. SUMMARY: The efforts of professional associations to generate evidence-based guidelines are reflective of an increased awareness that the care of prostate cancer should--to the greatest possible extent--be evidence-based. Practicing urologists should seek to become involved in the evidence-based medicine process by supporting the accrual to high-quality clinical trials, demanding the highest standards to the timely and unbiased dissemination of research findings and ultimately, strive to apply the best available evidence to the care of individual patients.     

The quality of clinical practice guidelines in hand therapy.

Clinical practice guidelines (CPGs) should consist of treatment recommendations that assist hand therapists in providing high-quality cost-effective care to specific patients based on the highest level of available evidence. This requires CPGs to be developed using a rigorous process based on evidence, appraisal of both original studies and expert opinion, and a process for multiple reviewers to evaluate the draft CPG. This study identified CPGs relevant to hand therapy and then evaluated their quality using the AGREE quality assessment tool. The majority of guidelines were not evidence-based and were of extremely low quality. Two guidelines were produced using a rigorous process that emphasized comparative clinical trials. These were able to provide only a single treatment recommendation, that ultrasound is effective for calcific tendinitis of the shoulder. Hand therapists need to move away from opinion- or clinic-based protocols and toward more evidence-based treatment guidelines. However, the value of treatment guidelines must be tested, not assumed, regardless of the development process.     

Translation of benign prostatic hyperplasia guidelines into clinical practice

PURPOSE OF REVIEW: The aim of this article is to describe the current position of clinical practice guidelines for benign prostatic hyperplasia in daily management and identify the potential barriers that may hinder the implementation of guidelines into clinical practice. RECENT FINDINGS: Recent studies have attempted to compare and grade benign prostatic hyperplasia clinical practice guidelines using appraisal instruments underlining the issues of quality and updates of guidelines. Surveys have evaluated the adoption of guidelines from the urological community and recent studies have made major contributions to our knowledge of the translation of evidence to daily practice. SUMMARY: Numerous clinical practice guidelines (both national and international) for benign prostatic hyperplasia exist. High methodological quality clinical practice guidelines are likely to be the most beneficial to patients and strength of recommendations depends on available evidence. Efforts to implement guidelines are not always successful and a considerable variation especially in diagnostic assessment of benign prostatic hyperplasia has been reported. Difficulties in translation of benign prostatic hyperplasia guidelines into clinical practice are related to lack of knowledge but also to differences in routine practices, beliefs, cost, availability, and reimbursement policy. Bridging the implementation gap represents a challenging task for clinical practice guideline supporters.     

Evidence-based clinical practice guidelines for prostate cancer: the need for a unified approach

PURPOSE OF REVIEW: Clinical practice guidelines are being increasingly recognized as critically important to an evidence-based practice. This article reviews the different approaches used by leading urological organizations to the development of prostate cancer guidelines. It further introduces the recommendations of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group as a unified approach to guideline development. RECENT FINDINGS: Clinical guidelines on the management of prostate cancer demonstrate major methodological differences. Most notably, considerable discrepancies with regards to the systems used to grade the quality of the evidence and the strength of recommendation exist. The GRADE approach classifies the quality of evidence as high, moderate, low or very low, according to factors that include study design and execution, and the consistency of the results. It subsequently classifies recommendations as strong or weak, according to the balance between benefits and downsides and the degree of confidence in estimates of the downsides. SUMMARY: There is an urgent need to standardize processes used to develop clinical guidelines for the management of patients with prostate cancer by leading urological organizations. Adoption of the GRADE approach would offer considerable rewards in terms of efficiency, guideline credibility and optimal clinical decision-making.     

2018年美国关节置换术使用氨甲环酸的临床实践指南解读

2018年美国髋关节和膝关节外科医师协会(AAHKS),美国骨科医师协会(AAOS),髋关节学会(THS),膝关节学会(TKS)及美国局部麻醉与疼痛医学学会(ASRA)共同协作,针对氨甲环酸(TXA)在全关节置换术(TJA)中应用的有效性和安全性进行了循证研究,就氨甲环酸给药的方式、剂量和时机以及在血栓形成高风险患者中的使用等提出了推荐意见,并根据证据支持强度对推荐意见进行了分级。本文对该指南进行解读,旨在为中国的骨科医务工作者、患者、医疗管理人员和指南制定者提供参考。     

2016年美国临床肿瘤学会《潜在可治愈胰腺癌临床实践指南》解读

胰腺癌由于恶性程度高、预后极差,即便在当今医学技术高速发展的时代,胰腺癌的治疗仍然形势严峻。近日,美国临床肿瘤学会针对潜在可治愈胰腺癌病人颁布了相应的临床实践指南。指南中的各项建议大多源于大规模循证性系统回顾与分析,并由多学科专家组讨论通过,且给出其推荐强度及证据质量,旨在围绕病人诊治过程中影响疾病转归的关键问题给予循证性建议,以期改善病人预后。     

An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update)

Background contextThe evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spinal stenosis by the North American Spine Society (NASS) provides evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spinal stenosis. The guideline is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spinal stenosis as reflected in the highest quality clinical literature available on this subject as of July 2010. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.PurposeProvide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with degenerative lumbar spinal stenosis.Study designSystematic review and evidence-based clinical guideline.MethodsThis report is from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. The original guideline, published in 2006, was carefully reviewed. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated by a minimum of three physician reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.ResultsSixteen key clinical questions were assessed, addressing issues of natural history, diagnosis, and treatment of degenerative lumbar spinal stenosis. The answers are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.ConclusionsA clinical guideline for degenerative lumbar spinal stenosis has been updated using the techniques of evidence-based medicine and using the best available clinical evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, will be available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

膀胱灌注全流程管理的最佳证据总结

目的 检索、评价和总结膀胱灌注全流程最佳证据，为临床实施膀胱灌注护理实践提供循证依据。方法 依据“6S”证据模型，检索有关中英文数据库、指南网站及专业学会网站，纳入2017年1月至2022年12月涉及膀胱灌注流程护理与管理的所有证据，包括临床实践指南、系统评价、证据总结、临床决策、专家共识及随机临床对照试验。由2名硕士研究生对最终纳入文献所提取的证据进行标准化整合及汇总。结果 共纳入文献8篇，其中指南4篇，专家共识2篇，随机临床对照试验研究2篇。总结了28条最佳证据，包括药物配制、职业暴露防护、灌注流程管理、灌注后排泄管理、不良反应与并发症管理、延续性护理管理6个方面。结论 膀胱灌注全流程管理的最佳证据可为临床护理实践提供循证依据，应用证据时，应结合实际情况选择性地制定切实可行的管理方案。