AGREEing on Canadian cardiovascular clinical practice guidelines

The use of clinical practice guidelines (CPGs), particularly the routine implementation of evidence-based cardiovascular health maintenance and disease management recommendations, affords both expert and nonexpert practitioners the opportunity to achieve better, and at least theoretically similar, patient outcomes. However, health care practitioners are often stymied in their efforts to follow even well-researched and well-written CPGs as a consequence of contradictory information. The purposeful integration and harmonization of Canadian cardiovascular CPGs, regardless of their specific risk factor or clinical management focus, is critical to their widespread acceptance and implementation. This level of cooperation and coordination among CPG groups and organizations would help to ensure that their clinical practice roadmaps (ie, best practice recommendations) contain clear, concise and complementary, rather than contradictory, patient care information. Similarly, the application of specific tools intended to improve the quality of CPGs, such as the Appraisal of Guidelines for Research and Evaluation (AGREE) assessment tool, may also lead to improvements in CPG quality and potentially enhance their acceptance and implementation.     

Introducing the Canadian Thoracic Society Framework for Guideline Dissemination and Implementation,with Concurrent Evaluation

The Canadian Thoracic Society (CTS) is leveraging its strengths in guideline production to enable respiratory guideline implementation in Canada. The authors describe the new CTS Framework for Guideline Dissemination and Implementation, with Concurrent Evaluation, which has three spheres of action: guideline production, implementation infrastructure and knowledge translation (KT) methodological support. The Canadian Institutes of Health Research ‘Knowledge-to-Action’ process was adopted as the model of choice for conceptualizing KT interventions. Within the framework, new evidence for formatting guideline recommendations to enhance the intrinsic implementability of future guidelines were applied. Clinical assemblies will consider implementability early in the guideline production cycle when selecting clinical questions, and new practice guidelines will include a section dedicated to KT. The framework describes the development of a web-based repository and communication forum to inventory existing KT resources and to facilitate collaboration and communication among implementation stakeholders through an online discussion board. A national forum for presentation and peer-review of proposed KT projects is described. The framework outlines expert methodological support for KT planning, development and evaluation including a practical guide for implementers and a novel ‘Clinical Assembly – KT Action Team’, and in-kind logistical support and assistance in securing peer-reviewed funding.     

Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers,children and adults

BACKGROUND:

In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and/or gaps in the previous guidelines.

METHODS:

Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS/long-acting beta₂-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations.

RESULTS:

The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified.

CONCLUSIONS:

The present clinical practice guideline is the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee’s new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.     

Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers,children and adults: Executive summary

BACKGROUND:

In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and/or gaps in the previous guidelines.

METHODS:

Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS/long-acting beta₂-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations.

RESULTS:

The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified.

CONCLUSIONS:

The present document is an executive summary of the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee’s new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.     

Quality Appraisal of Clinical Practice Guidelines on Pancreatic Cancer: A PRISMA-Compliant Article

Clinical practice guidelines (CPGs) play an important role in health care. The guideline development process should be precise and rigorous to ensure that the results are reproducible and not vague. To determine the quality of guidelines, the Appraisal of Guidelines and Research and Evaluation (AGREE) instrument was developed and introduced.The objective of this study is to assess the methodological quality of CPGs on pancreatic cancer.Five databases (included MEDLINE and EMBASE) and guideline websites were searched till April, 2014. The methodological quality of the guidelines was assessed by 4 authors independently using the AGREE II instrument.From 2526 citations, 21 relevant guidelines were included. The overall agreement among reviewers was moderate (intraclass correlation coefficient = 0.86, 95% confidence interval 0.64–0.96). The mean scores were moderate for the domains “scope and purpose” and “clarity of presentation”; however, they were low for the domains “stakeholder involvement” (31.22), “rigor of development”, “applicability”, and “editorial independence”. These domain scores were lower when compared with international levels. There are 5 (23.81%) guidelines that described the systematic methods for searching. Moreover, only 5 (23.81%) guidelines reported that methodological expertise were included in the guideline developing teams.The quality and transparency of the development process and the consistency in the reporting of pancreatic cancer guidelines need to be improved. Many other methodological disadvantages were identified. In the future, pancreatic cancer CPGs should base on the best available evidence rigorously developed and reported. Greater efforts are needed to provide high-quality guidelines that serve as a useful and reliable tool for clinical decision making in this field.     

呼吸机相关性肺炎诊断、预防和治疗指南的质量评价

目的 评价国内2013年颁布的呼吸机相关性肺炎诊断、预防和治疗指南(VAP指南)的质量,了解当前指南存在的问题,为今后更新该指南和开发其他循证指南提供方法学参考.方法 利用指南质量评价工具AGRE EⅡ评价指南质量.结果 VAP指南六个领域得分情况为:范围和目的79％,参与人员68％,制定的严谨性70％,表达的明晰性81％,应用性40％,编辑独立性0％.结论 国内2013年颁布的呼吸机相关性肺炎循证指南质量中等,仍需在指南报告规范和应用性、编辑独立性方面进一步加强.     

Methodological appraisal of guidelines. The AGREE instrument.

The increasingly important role of clinical practice guidelines as a support tool for clinical decision-making is shown by a growing number of publications in the literature. In fact, it is almost impossible to open a medical journal without coming across one or more guidelines on various subjects. Guidelines serve several objectives: 1) improvement in health care (increasing good and decreasing bad practices); 2) greater availability of and access to medical knowledge; and 3) promotion of cost-effective strategies. The recommended methodology for guideline design and development requires that the recommendations should be evidence-based, i.e., based on selected and critically appraised data, with the final inclusion of evidence that is valid, important and applicable, based on explicit pre-defined criteria. The methodological quality of guidelines varies substantially, raising credibility issues, with subsequent lack of results (in terms of changing medical practice). This has given rise to a series of recent publications on methodological rules for the design and writing of guidelines. This paper presents the first international instrument that can be used as a quality assurance tool for evidence-based clinical guidelines: the Appraisal of Guidelines Research and Evaluation (AGREE) instrument.     

Critical Appraisal of Guidelines for Antithrombotic Therapy in Atrial Fibrillation Post-Percutaneous Coronary Intervention

Objective:In our present study, our objective was to appraise guidelines on antithrombotic therapy in atrial fibrillation post-percutaneous coronary intervention and to explore the differences in treatment practices for better informed decision-making.Methods:We searched for English language guidelines published between January 2000 and December 2020 at MEDLINE, Embase and websites of guideline organizations. Guidelines with recommendations on antithrombotic regimens for patients with AF undergoing PCI were included. Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument was applied to assess guidelines. The reporting of conflicts of interest (COI) was evaluated separately by the RIGHT (Reporting Item for Practice Guidelines in Healthcare) checklist as supplementary items.Results:Sixteen guidelines were included, among which 13 (81.25%) were considered as ‘recommended’ and 1 (6.25%) as ‘unrecommended.’ The average scores of guidelines ranged from 55% to 88% (<60% as low quality, 60–70% as sufficient quality, and >70% as good quality). Among the 6 domains of AGREE II, scope and purpose (84%) and editorial independence(87%) were considered to be the fields in which CPGs performed best, evidenced by the highest mean AGREE II scores. The domains in which the reviewed CPGs received the lowest mean scores were stakeholder involvement (63%) and applicability (58%). The intraclass correlation coefficient scores were excellent in each domain. The overall quality of the selected CPGs was optimal, with the highest score in domain ‘scope and purpose’, and the lowest score in the domain ‘applicability.’ The reporting of COI was satisfactory.Conclusions:For the recommendations on antithrombotic strategies, guidelines with high AGREE II scores still exist discrepancy on the timing and selection. Current guidance documents on the treatment vary in methodological rigor and recommendations are not always consistent.     

Evidence summaries and recommendations from the international evidence‐based guideline for the assessment and management of polycystic ovary syndrome: Lifestyle management

Lifestyle is fundamental in chronic disease prevention and management, and it has been recommended as a first‐line treatment in the Australian polycystic ovary syndrome (PCOS) guideline 2011. The first international evidence‐based guideline on PCOS was developed in 2018, which expanded the scope and evidence in the Australian guideline. This paper summarizes the lifestyle recommendations and evidence summaries from the guideline. International multidisciplinary guideline development groups delivered the International Evidence‐based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2018. The process followed the Appraisal of Guidelines for Research and Evaluation II and The Grading of Recommendations, Assessment, Development and Evaluation framework. Extensive communication and meetings addressed six prioritized clinical questions through five reviews. Evidence‐based recommendations were formulated before consensus voting within the panel. Evidence shows the benefits of multicomponent lifestyle intervention, efficacy of exercise and weight gain prevention with no specific diet recommended. Lifestyle management is the first‐line management in the intervention hierarchy in PCOS. Multicomponent lifestyle intervention including diet, exercise and behavioural strategies is central to PCOS management with a focus on weight and healthy lifestyle behaviours. The translation programme optimizes reach and dissemination for health professionals and consumers.     

A Framework for Crafting Clinical Practice Guidelines that are Relevant to the Care and Management of People with Multimorbidity

Many patients of all ages have multiple conditions, yet clinicians often lack explicit guidance on how to approach clinical decision-making for such people. Most recommendations from clinical practice guidelines (CPGs) focus on the management of single diseases, and may be harmful or impractical for patients with multimorbidity. A major barrier to the development of guidance for people with multimorbidity stems from the fact that the evidence underlying CPGs derives from studies predominantly focused on the management of a single disease. In this paper, the investigators from the Improving Guidelines for Multimorbid Patients Study Group present consensus-based recommendations for guideline developers to make guidelines more useful for the care of people with multimorbidity. In an iterative process informed by review of key literature and experience, we drafted a list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes. The recommended approaches address consideration of coexisting conditions at all major steps in CPG development, from nominating and scoping the topic, commissioning the work group, refining key questions, ranking importance of outcomes, conducting systematic reviews, assessing quality of evidence and applicability, summarizing benefits and harms, to formulating recommendations and grading their strength. The list of issues and recommendations was reviewed and refined iteratively by stakeholders. This framework acknowledges the challenges faced by CPG developers who must make complex judgments in the absence of high-quality or direct evidence. These recommendations require validation through implementation, evaluation and refinement.     

Clinical guidelines: a must for rheumatology?

Clinical guidelines are sets of recommendations, backed by medical evidence, to aid physicians in patient-care decisions. There has been a proliferation of practice guideline development in all fields of medicine, including rheumatology. This chapter will discuss the need for guidelines in rheumatology, the methodology of guideline development, validation and implementation, the various guidelines published in rheumatology, and the role of the rheumatologist in guideline development. Clinical guidelines can serve to inform practitioners of the latest medical evidence and minimize harmful practice variation. Guidelines must rely on good evidence to be credible to the medical community, yet there are still many barriers to guideline acceptance by practitioners. The theories behind guideline development and validation are well described, although not always practised. Guideline dissemination and implementation methods are still being explored. It remains unclear how best to implement guidelines and convince physicians to accept and incorporate evidence-based recommendations into their practice.     

Quality assessment of conventional and traditional oriental medicine clinical practice guidelines for knee osteoarthritis using AGREE II instrument

Introduction:Knee osteoarthritis is a degenerative disease and its prevalence tends to increase. Clinical practice guidelines (CPGs) are evidence-based recommendations for treatment that help policymakers, practitioners, and patients make more appropriate and efficient decisions during the course of management. This study aimed to evaluate the quality of knee osteoarthritis CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.Method:The retrieval engines and websites were utilized from January 2010 to December 2020. The search words were “Clinical practice guideline” OR “Critical practice guideline” OR “guideline∗” AND “Osteoarthritis.” The quality of the CPGs was independently examined by four appraisers using the AGREE II instrument. Consequently, the selected CPGs were graded as Classes A, B, and C according to the level of recommendation.Result:In this study, 13 CPGs for knee osteoarthritis were selected and evaluated qualitatively using the AGREE II instrument. The overall quality percentage score was as follows: clarity of presentation, 72.6%, scope and purpose, 62.6%, rigor of development, 54.2%, stakeholder investment, 50.5%, editorial independence, 46.5%, applicability, 22.5%.Conclusion:Auxiliary materials for the treatment process of knee OA should be supplemented in future revised versions for quality improvement of knee OA CPGs. Also, more evidence should be accumulated to support the recommendation of traditional oriental medical treatments in the clinical field. From the perspective of integrative medicine, along with conventional pharmacological treatment, exercise, weight loss, and acupuncture can be combined together in clinical situations.     

International Primary Care Respiratory Group (IPCRG) Guidelines: dissemination and implementation--a proposed course of action.

There is growing evidence that good implementation of evidence-based guidelines can result in improvement in health outcomes. This paper on Dissemination and Implementation constitutes the final paper of the IPCRG Guidelines on the management of chronic respiratory diseases in primary care. It highlights the historical development of these guidelines following the formation of the International Primary Care Airways Group (IPAG) in 2001 together with its dissemination and implementation subgroup, and the subsequent transfer of this dissemination and implementation role to the IPCRG. It covers the main factors within the IPCRG workplan, including the issues of governance, launch, dissemination, implementation, and evaluation.     

Guidelines for the diagnosis and treatment of Helicobacter pylori infection in Korea, 2013 revised edition

The Korean College of Helicobacter and Upper Gastrointestinal Research first developed guidelines for the diagnosis and treatment of Helicobacter pylori (H. pylori) infection in 1998, and revised guidelines were proposed in 2009 by the same group. Although the revised guidelines were based on a comprehensive review of published articles and the consensus of expert opinions, the revised guidelines were not developed using an evidence‐based process. The new guidelines presented in this study include specific changes regarding indication and treatment of H. pylori infection in Korea, and were developed through the adaptation process using an evidence‐based approach. After systematic review of the literature, six guidelines were selected using the Appraisal of Guidelines for Research and Evaluation (AGREE) II process. A total of 21 statements were proposed with the grading system and revised using the modified Delphi method. After the guideline revisions, 11 statements about indication of test and treatment, four statements about diagnosis, and four statements about treatment of H. pylori infection were developed. The revised guidelines were reviewed by external experts before receiving official endorsement from the Korean College of Helicobacter and Upper Gastrointestinal Research, and disseminated to physicians and other medical professionals for use in clinical practice in Korea. The guidelines will continue to be updated and revised periodically.     

Guidelines for chronic obstructive pulmonary disease treatment and issues of implementation

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Treatment advances over the last decade, although limited, have precipitated the development of clinical practice guidelines, with the aim of improving the quality of care received by patients through fostering evidence-based decision making and accelerating the application of new advances to everyday practice. Of the COPD guidelines that have been developed, those developed through the Global Initiative for Chronic Obstructive Lung Disease (GOLD), initially a joint activity between the U.S. National Heart, Lung, and Blood Institute and the World Health Organization, and the National Institute of Clinical Excellence (NICE) in the United Kingdom have both published their methods for evaluation of evidence. These comprehensive guidelines cover all aspects of the disease, with the aim of providing the basis for local care pathways. The guideline development process includes evaluation of the evidence, development of the guideline, and dissemination of the findings. Efforts to enhance guideline effectiveness have focused on improving the methods and approaches to implementation, which requires an appreciation of the issues that stop translation of guideline definitions of best practice into improved patient care. A variety of questions remain unanswered in the clinical management of COPD, including the definition of outcome measures that move beyond lung function, the potential application of multidimensional grading systems that assess respiratory and systemic expressions of COPD and that could possibly better categorize and predict outcome in these patients, and the impact of new clinical trial findings. Large ongoing outcome studies may also have an effect on defining best practice within future guideline recommendations.     

Pan-Canadian REspiratory STandards INitiative for Electronic Health Records (PRESTINE): 2011 National Forum Proceedings

In a novel knowledge translation initiative, the Government of Ontario’s Asthma Plan of Action funded the development of an Asthma Care Map to enable adherence with the Canadian Asthma Consensus Guidelines developed under the auspices of the Canadian Thoracic Society (CTS). Following its successful evaluation within the Primary Care Asthma Pilot Project, respiratory clinicians from the Asthma Research Unit, Queen’s University (Kingston, Ontario) are leading an initiative to incorporate standardized Asthma Care Map data elements into electronic health records in primary care in Ontario. Acknowledging that the issue of data standards affects all respiratory conditions, and all provinces and territories, the Government of Ontario approached the CTS Respiratory Guidelines Committee. At its meeting in September 2010, the CTS Respiratory Guidelines Committee agreed that developing and standardizing respiratory data elements for electronic health records are strategically important. In follow-up to that commitment, representatives from the CTS, the Lung Association, the Government of Ontario, the National Lung Health Framework and Canada Health Infoway came together to form a planning committee. The planning committee proposed a phased approach to inform stakeholders about the issue, and engage them in the development, implementation and evaluation of a standardized dataset. An environmental scan was completed in July 2011, which identified data definitions and standards currently available for clinical variables that are likely to be included in electronic medical records in primary care for diagnosis, management and patient education related to asthma and COPD. The scan, sponsored by the Government of Ontario, includes compliance with clinical nomenclatures such as SNOMED-CT^® and LOINC^®. To help launch and create momentum for this initiative, a national forum was convened on October 2 and 3, 2011, in Toronto, Ontario. The forum was designed to bring together key stakeholders across the spectrum of respiratory care, including clinicians, researchers, health informaticists and administrators to explore and recommend a potential scope, approach and governance structure for this important project. The Pan-Canadian REspiratory STandards INitiative for Electronic Health Records (PRESTINE) goal is to recommend respiratory data elements and standards for use in electronic medical records across Canada that meet the needs of providers, administrators, researchers and policy makers to facilitate evidence-based clinical care, monitoring, surveillance, benchmarking and policy development. The focus initially is expected to include asthma, chronic obstructive pulmonary disease and pulmonary function standards elements that are applicable to many respiratory conditions. The present article summarizes the process and findings of the forum deliberations.     

Guidelines for the management of pregnant women with obesity: A systematic review

Multiple clinical practice guidelines (CPGs) have been established for pregnant women with obesity. The quality and consistency of recommendations remain unknown. The objective of this study is to conduct a systematic review to synthesize and appraise evidence from CPGs, available worldwide, for pregnant women affected by obesity. An experienced information specialist performed a rigorous search of the literature, searching MEDLINE, Embase, grey literature, and guideline registries to locate CPGs that reported on pregnancy care relating to obesity. CPGs related to antenatal care of pregnant women with obesity (pre‐pregnancy body mass index [BMI] ≥ 30 kg/m²) in low‐risk (eg, care provider = family physician or midwife) or high‐risk settings (eg, obstetrician or maternal fetal medicine) were included. CPGs were appraised for quality with independent data collection by two raters. Information was categorized into five domains: preconception care. care during pregnancy, diet and exercise during pregnancy, care immediately before, during, and after delivery, and postpartum care. The literature search yielded 2614 unique citations. Following screening of abstracts and full texts, 32 CPGs were included, with quality ranging between 0 and 100 on the AGREE II tool. The strongest evidence related to nutritional advice, exercise, and pregnancy risk counselling. Guidance was limited for timing of screening tests, antenatal visits and delivery, ideal postpartum care, and management of adverse pregnancy outcomes. Most guidelines in this population are not evidence based. Research is needed to bridge knowledge gaps pertaining to fetal antenatal surveillance, management of adverse outcomes and postpartum care, and enhance consistency across CPGs.     

Pan-canadian cardiovascular data definitions and quality indicators: a status update

After the 2009 publication of Building a Heart Healthy Canada, the Canadian Cardiovascular Society was commissioned to address a long-standing information gap related to the compatibility and comparability of data on the quality of cardiovascular care in Canada. Through collaboration between the Canadian Institute for Health Information, the Institute for Clinical Evaluative Sciences, the Public Health Agency of Canada, and 5 regional cardiovascular registries, 2 committees were tasked with developing standardized cardiovascular data definitions and quality indicators. The work culminated in national consensus on the definitions of 55 patient, disease, and therapeutic variables (core and optional) to facilitate cardiovascular care comparisons within and across Canada. Supplemental data definition chapters were then developed on acute coronary syndrome and coronary angiography/revascularization, with chapters on heart failure and atrial fibrillation electrophysiology to follow. This foundational work led to a critical appraisal of cardiac quality indicator development initiatives via the Appraisal of Guidelines for Research and Evaluation II (AGREE II) Quality Indicator tool, followed by the development of quality indicator catalogues on heart failure and atrial fibrillation. These indicators will be embedded within the clinical practice guidelines of the Canadian Cardiovascular Society, facilitating national comparisons across Canada on cardiovascular disease incidence, prevalence, patterns and quality of care, and clinical outcomes. This methodology-achieving national stakeholder consensus on a standardized process for the development and selection of cardiovascular quality indicators-illustrates the capacity to reach agreement by drawing on expertise and research across diverse organizational mandates and agendas, potentially contributing to improved cardiovascular care and outcomes for patients.     

Critical appraisal of clinical practice guidelines targeting chronic obstructive pulmonary disease

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is so prevalent that the endorsement of management strategies by professional organizations issuing clinical practice guidelines (CPGs) will likely influence the clinical and financial resources allocated to this condition. OBJECTIVES: To examine the content of and to critically appraise the CPGs targeting COPD. METHODS: We identified, through a MEDLINE search (from January 1990 to May 1999) and contacts with experts and professional organizations, the CPGs for the overall management of COPD. We assessed the guidelines according to an index of quality measuring 3 dimensions: the rigor of development, the context and content, and the extent to which the dissemination and implementation have been addressed. The recommendations were also examined and compared. RESULTS: Of the 15 CPGs we included, none was based on a systematic review of the literature. Two were independently reviewed before their release, 1 included strategies for dissemination and implementation, and 1 estimated the economic implications associated with its recommendations. The recommendations were often difficult to interpret (reviewers' agreement: kappa median, 0.41). When unanimity existed regarding the benefits of a given management modality (such as respiratory rehabilitation), discrepancies were often identified in the application of the recommendation. CONCLUSIONS: The methodological quality of CPGs targeting COPD is limited, and there are disparities among many of their recommendations. Despite there being several CPGs worldwide, there is a need for an evidence-based summary of the literature to serve as a resource for those who provide health care to individuals with COPD.     

临床实践指南实施关键环节方法分析

自2011年美国医学研究所公布临床实践指南(Clinical Practice Guidelines,CPGs)新定义之后,近年来是临床实践指南走向高质量、高标准化的关键时期。国内学者陆续发表关于临床实践指南制订的方法学的系列文章,并逐步注重临床实践指南的转化。本研究着重从指南实施的现状、内涵、关键步骤等进行分析,希望为临床医疗质量改进实践者提供一定的参考。