Importance of Evidence Grading for Guideline Implementation: The Example of Asthma

University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
The Annals of Family Medicine (Impact Factor: 4.57). 07/2009; 7(4):364-9. DOI: 10.1370/afm.995
Source: PubMed

ABSTRACT The goal of evidence-based clinical guidelines is to improve the value of health care by recommending treatments with favorable benefit/harm ratios. Achieving this goal requires use of evidence-grading systems that explicitly address strength of evidence in terms of external validity (generalizability), internal validity, and patient-oriented outcomes. To be clinically useful, guidelines should also incorporate patient preferences, particularly when evidence is weak. The National Heart, Lung and Blood Institute recently published Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3). This special report addresses the extent to which current guidelines adhere to the principles enunciated above by using EPR-3 as the prime example. EPR-3 used an unconventional evidence-grading system that emphasized precision and consistency (statistical significance, large sample sizes, and/or consistency of results) at the expense of patient-oriented outcomes and generalizability (applicability to the general population). EPR-3 did not report information on numbers needed to treat or numbers needed to harm, which are useful in eliciting patient preferences via shared decision making. Asthma guidelines (and others) are limited by lack of a generalizable research base, 3 awed evidence grading, and lack of attention to patient preferences. An evidence-grading system based on applicable populations, patient-oriented outcomes, and shared decision making might improve physician and patient guideline adherence and improve asthma outcomes.

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    ABSTRACT: Background and Objective Despite the availability of clinical practice guidelines (CPGs) for therapeutic drug monitoring (TDM) of vancomycin, vancomycin serum concentrations still do not reach therapeutic concentrations in many patients. Thus, we sought to systematically review the quality and consistency of recommendations for an international cohort of CPGs regarding vancomycin TDM. Methods PubMed, Embase, guidelines' websites and Google were searched for CPGs for vancomycin TDM. Two independent assessors rated the quality of each CPG using the Appraisal of Guidelines for Research & Evaluation II (AGREEII) instrument and data were independently extracted. Results Twelve guidelines were evaluated and the overall quality of guidelines for vancomycin TDM was moderate. The highest score was recorded in the domain of clarity of presentation, and the lowest score was recorded in the domain of rigor of development and stakeholder involvement. The specific recommendations for vancomycin TDM were moderately consistent and guidelines varied in trough concentration monitoring, frequency of TDM, and serum concentration targets. Conclusion The overall guideline quality for vancomycin TDM was not optimal and effort is needed to improve guideline quality, especially in the domain of rigor of development and stakeholder involvement.
    PLoS ONE 06/2014; 9(6):e99044. DOI:10.1371/journal.pone.0099044 · 3.53 Impact Factor
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    The Annals of Family Medicine 11/2009; DOI:10.1370/afm.1069 · 4.57 Impact Factor
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    The Annals of Family Medicine 07/2009; 7(4). DOI:10.1370/afm.1019 · 4.57 Impact Factor

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May 19, 2014