The role of evidence in the consensus process. Results from a Canadian consensus exercise

As part of a consensus conference on cesarean birth, the ten-member consensus panel rated 224 clinical scenarios on their appropriateness for a cesarean section. Ratings were obtained before and immediately after the consensus conference. The level of agreement (consensus) among panelists was assessed separately for scenarios with good research evidence (evidence scenarios) and for those with conflicting, poor, or no evidence (nonevidence scenarios). For each scenario, consensus between panelists was measured as total agreement, partial agreement, or disagreement on the appropriateness of a cesarean section. Before the conference, total or partial agreement existed for a larger percentage of evidence than nonevidence scenarios (85% vs 30%), with the pattern reversed for disagreements (15% vs 70%). After the conference, possible improvement in the level of consensus actually occurred for 71% of the evidence and only 24% of the nonevidence scenarios. Thus, the consensus process, as structured here, was sensitive to the availability of good evidence and suggests that aspects of both expert and public processes can successfully be combined. However, an improvement could be made in the process by grading final recommendations according to the availability of rigorous research evidence.     

2004中国哮喘论坛专家共识

近年来支气管哮喘成为呼吸系统疾病中最为活跃的研究领域,借助于免疫学、分子生物学和基因技术的进展,对哮喘的发病机制在多个层面进行了深入的研究,作出了新的诠释,并形成了一些新的学说;通过贯彻执行《全球哮喘防治创议》(GINA)以及以GINA为蓝本的各个国家的哮喘诊治指南,哮喘的临床控制得到了极大的改观;各大医药公司研制成功的新型平喘药物、给药装置以及在此基础上提出的联合用药方案,使临床疗效提高,患者依从性改善。我国呼吸学界对哮喘的发病机制进行了广泛的研究,在临床实践中积累了丰富的经验。然而,在国际哮喘学界,中国的哮喘…     

An evidence-based approach to prescribing NSAIDs in musculoskeletal disease: a Canadian consensus. Canadian NSAID Consensus Participants.

OBJECTIVE. To make recommendations for the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) in primary care practice, particularly for patients at high risk for NSAID-induced complications. OPTIONS. The use of misoprostol to prevent gastrointestinal ulceration and other unwanted NSAIDs effects was considered. The role of cyclooxygenase-2 (COX-2) versus COX-1 inhibiting agents was also examined. OUTCOMES. Reduction of complications associated with long-term use of NSAIDs. EVIDENCE. Evidence was gathered in late 1995 from published research studies and reviews. Position papers were prepared by faculty and advisory board members and discussed at the Canadian NSAID Consensus Symposium in Cambridge, Ont., Jan. 26 and 27, 1996. VALUES. Recommendations were based on randomized, placebo-controlled clinical trials (level I evidence) and case-control studies (level II evidence) involving NSAID use when such evidence was available. When the scientific literature was incomplete or inconsistent in a particular area, recommendations reflect the consensus of the participants at the symposium (level III evidence). Physicians were recruited from across Canada for their expertise in rheumatology, gastroenterology, epidemiology, gerontology, family practice, and clinical and basic scientific research. BENEFITS, HARMS AND COSTS. Although a reduction in complications due to inappropriate NSAID use should reduce costs of additional investigations, admissions to hospital and time lost from work, definitive cost analysis studies are not yet available. RECOMMENDATIONS. Currently, no NSAID is available that lacks potential for serious toxicity; therefore, long-term use of NSAIDs should be avoided whenever possible, particularly in high-risk patients (e.g., those who are elderly, suffer from hypertension, congestive heart failure, renal or hepatic impairment or volume depletion, take certain concomitant medications or have a history of peptic ulcer disease) (level I evidence). If NSAIDs are to be used in patients with gastric or nephrotoxic risk factors, the lowest effective dose of NSAID should be used (level III evidence); NSAIDs that are weak COX-1 inhibitors may be preferred (level II evidence). In addition, concomitant administration of misoprostol is recommended in patients at increased risk for upper gastrointestinal complications (level I evidence). However, the clinical judgement of the practising clinician must always be part of any therapeutic decision. VALIDATION. These recommendations are based on the consensus of Canadian experts in rheumatology, gastroenterology and epidemiology, and have been subjected to external peer review.     

Report of the Canadian Hypertension Society's consensus conference on the management of mild hypertension.

Since the publication in 1977 of joint recommendations by the Canadian Cardiovascular Society, the Canadian Heart Foundation and the Ontario Council of Health on the detection and management of hypertension in Canada, several clinical trials on the efficacy of antihypertensive drug treatment in patients with mild hypertension have been undertaken. The Canadian Hypertension Society (CHS) felt that the results of these trials should be reviewed to determine whether existing recommendations on treatment should be changed. Three expert panels appointed by the CHS reviewed evidence on the clinical efficacy of antihypertensive therapy, the diagnosis of hypertension and the treatment of mild hypertension, and formulated recommendations on the care of mildly hypertensive patients in Canada. A consensus conference of biomedical scientists, practising physicians and government representatives reviewed and reached agreement on the panels' recommendations. The final recommendations of the conference are presented in this report.     

Clinical problem solving based on the 1999 Canadian recommendations for the management of hypertension

The 1999 Canadian Recommendations for the Management of Hypertension are notable for the trends that they represent with regard to the evolution of the management of hypertension. Diagnostically, the Recommendations endorse the greater use of non-office-based measures of blood pressure control and greater emphasis on the assessment of other atherosclerotic risk factors, both when considering prognosis in hypertension and in the choice of therapy. On the treatment side of the equation, lower targets for blood pressure control have been advocated in subgroups of hypertensive patients, particularly in those with diabetes and renal disease. In conjunction with the recently published recommendations on lifestyle management, there is a greater emphasis on lifestyle modification, both as initial and adjunctive therapy in hypertension. Implicit in the recommendations for therapy is the principle that for the vast majority of hypertensive patients treated pharmacologically, practitioners should not follow a stepped-care approach. Instead, therapy should be individualized, primarily based on consideration of concurrent diseases, both cardiovascular and noncardiovascular (Tables 1 and 2). Through the consensus process, there was a general appreciation of how far we have come in the development of evidence-based recommendations for hypertension management. However, there was also an increasing appreciation of how far we have to go in effectively translating these recommendations into better blood pressure control.