The relation between methods and recommendations in clinical practice guidelines for hypertension and hyperlipidemia

OBJECTIVE: To assess the association between methods used to develop clinical practice guidelines and the recommendations that are made. STUDY DESIGN: Systematic review of clinical practice guidelines for hypertension or hyperlipidemia. OUTCOMES MEASURED: Two people independently appraised guideline methods by using 8 criteria and the aggressiveness of recommendations for treatment thresholds, initial drug selection, and screening. RESULTS: We identified 33 guidelines. Only 6 fulfilled 5 or more of the 8 criteria. For 5 of the criteria, fewer than 50% of the guidelines fulfilled those criteria. There was wide variation in recommendations for treatment thresholds, drug selection, and cholesterol screening. Guidelines that did not fulfill the criteria tended to suggest more aggressive recommendations than did guidelines that met the criteria. For 6 of the 8 criteria, guidelines published by specialty societies were less likely to fulfill them compared with guidelines not published by specialty societies. CONCLUSIONS: Guideline developers who did not use rigorous methods tended to promote intervening more aggressively for hypertension and hyperlipidemia.     

Improving the use of research evidence in guideline development: 16. Evaluation

Background  

The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the last of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this.     

Improving the use of research evidence in guideline development: 8. Synthesis and presentation of evidence

Background  

The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the eighth of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this.     

Improving the use of research evidence in guideline development: 6. Determining which outcomes are important

Background  

The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the sixth of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this.     

SUPPORT Tools for evidence-informed health Policymaking (STP) 8: Deciding how much confidence to place in a systematic review

This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.The reliability of systematic reviews of the effects of health interventions is variable. Consequently, policymakers and others need to assess how much confidence can be placed in such evidence. The use of systematic and transparent processes to determine such decisions can help to prevent the introduction of errors and bias in these judgements. In this article, we suggest five questions that can be considered when deciding how much confidence to place in the findings of a systematic review of the effects of an intervention. These are: 1. Did the review explicitly address an appropriate policy or management question? 2. Were appropriate criteria used when considering studies for the review? 3. Was the search for relevant studies detailed and reasonably comprehensive? 4. Were assessments of the studies' relevance to the review topic and of their risk of bias reproducible? 5. Were the results similar from study to study?     

Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis

Background

Diabetes self-management education (DSME) can be delivered in many forms. Group based DSME is widespread due to being a cheaper method and the added advantages of having patient meet and discuss with each other. assess effects of group-based DSME compared to routine treatment on clinical, lifestyle and psychosocial outcomes in type-2 diabetes patients.

Methods

A systematic review with meta-analysis. Computerised bibliographic database were searched up to January 2008 for randomised controlled trials evaluating group-based DSME for adult type-2 diabetics versus routine treatment where the intervention had at least one session and =/>6?months follow-up. At least two reviewers independently extracted data and assessed study quality.

Results

In total 21 studies (26 publications, 2833 participants) were included. Of all the participants 4 out of 10 were male, baseline age was 60?years, BMI 31.6, HbA1c 8.23%, diabetes duration 8?years and 82% used medication. For the main clinical outcomes, HbA1c was significantly reduced at 6?months (0.44% points; P?=?0.0006, 13 studies, 1883 participants), 12?months (0.46% points; P?=?0.001, 11 studies, 1503 participants) and 2?years (0.87% points; P?<?0.00001, 3 studies, 397 participants) and fasting blood glucose levels were also significantly reduced at 12?months (1.26?mmol/l; P?<?0.00001, 5 studies, 690 participants) but not at 6?months. For the main lifestyle outcomes, diabetes knowledge was improved significantly at 6?months (SMD 0.83; P?=?0.00001, 6 studies, 768 participants), 12?months (SMD 0.85; P?<?0.00001, 5 studies, 955 participants) and 2?years (SMD 1.59; P?=?0.03, 2 studies, 355 participants) and self-management skills also improved significantly at 6?months (SMD 0.55; P?=?0.01, 4 studies, 534 participants). For the main psychosocial outcomes, there were significant improvement for empowerment/self-efficacy (SMD 0.28, P?=?0.01, 2 studies, 326 participants) after 6?months. For quality of life no conclusion could be drawn due to high heterogeneity. For the secondary outcomes there were significant improvements in patient satisfaction and body weight at 12?months for the intervention group. There were no differences between the groups in mortality rate, body mass index, blood pressure and lipid profile.

Conclusions

Group-based DSME in people with type 2 diabetes results in improvements in clinical, lifestyle and psychosocial outcomes.     

Study-design selection criteria in systematic reviews of effectiveness of health systems interventions and reforms: A meta-review

At present, there exists no widely agreed upon set of study-design selection criteria for systematic reviews of health systems research, except for those proposed by the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) review group (which comprises randomized controlled trials, controlled clinical trials, controlled before-after studies, and interrupted time series). We conducted a meta-review of the study-design selection criteria used in systematic reviews available in the McMaster University's Health Systems Evidence or the EPOC database. Of 414 systematic reviews, 13% did not indicate any study-design selection criteria. Of the 359 studies that described such criteria, 50% limited their synthesis to controlled trials and 68% to some or all of the designs defined by the EPOC criteria. Seven out of eight reviews identified at least one controlled trial that was relevant for the review topic. Seven percent of the reviews included either no or only one relevant primary study. Our meta-review reveals reviewers' preferences for restricting synthesis to controlled experiments or study designs that comply with the EPOC criteria. We discuss the advantages and disadvantages of the current practices regarding study-design selection in systematic reviews of health systems research as well as alternative approaches.     

The "Child Health Evidence Week" and GRADE grid may aid transparency in the deliberative process of guideline development

ObjectiveTo explore the evidence translation process during a 1-week national guideline development workshop (“Child Health Evidence Week”) in Kenya.Study Design and SettingNonparticipant observational study of the discussions of a multidisciplinary guideline development panel in Kenya. Discussions were aided by GRADE (Grading of Recommendations Assessment, Development, and Evaluation) grid.ResultsThree key thematic categories emerged: 1) “referral to other evidence to support or refute the proposed recommendations;” 2) “assessment of the presented research evidence;” and 3) “assessment of the local applicability of evidence.” The types of evidence cited included research evidence and anecdotal evidence based on clinician experiences. Assessment of the research evidence revealed important challenges in the translation of evidence into recommendations, including absence of evidence, low quality or inconclusive evidence, inadequate reporting of key features of the management under consideration, and differences in panelists’ interpretation of the research literature. A broad range of factors with potential to affect local applicability of evidence were discussed.ConclusionThe process of the “Child Health Evidence Week” combined with the GRADE grid may aid transparency in the deliberative process of guideline development, and provide a mechanism for comprehensive assessment, documentation, and reporting of multiple factors that influence the quality and applicability of guideline recommendations.