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摘要: 指南改编不仅作为低收入国家或缺乏指南制订能力的国家获取高质量指南的有效途径, 也是中高收入国家或具备指南制订能力国家减少重复工作、充分整合现有资源的有效方法。本文就指南改编的现状、理论框架和面临的挑战进行了分析, 在此基础上提出我国指南改编应用的一些思考与建议。Abstract: Guideline adaptation is not only an effective approach for low-income countries lacking the ability to develop and obtain high-quality guidelines, but also for middle- and high-income countries or coun-tries with guideline-developing capacity, to reduce work of duplication and fully integrate the existing resources. Thus, the purpose of this paper is to analyze the current situation, the theoretical framework, and challenges, and then put forward some thoughts and suggestions on the application of adapting guidelines.
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Key words:
- clinical practice guideline /
- guideline adaptation /
- theoretical framework
利益冲突 无 -
表 1 8种不同指南改编理论框架比较
框架名称 委员会的
构成方法 更新 推荐意见的
形成外部评审 确定卫生问题 检索 步骤 2005年PGEAC框架[25] 由主要利益相关者组成的当地跨学科指南评价小组构成 (1)确定具体的临床问题
(2)检索现有指南
(3)评价现有指南
(4)改编现有指南是 专家共识 由本地从业人员、其他利益相关者和决策者进行审查和评价 基于疾病流行率、疾病负担、成本因素遴选临床问题 (1)PubMed数据库
(2)指南相关数据库
(3)指南制订机构官网10步 2009年SGR框架[26] 未报告 (1)检索现有指南
(2)评价现有指南
(3)改编现有指南(不同指南的推荐意见整理成标准化证据表)否 专家共识 由患者代表进行审查和试点测试 不适用 (1)MEDLINE数据库
(2)Cochrane Library数据库
(3)DARE数据库
(4)HASTAT数据库9步 2011年ADAPTE更新版框架[8, 10, 27-29] 由指导委员会和指南制订小组构成的双重委员会 (1)确定具体临床问题
(2)检索现有指南
(3)评价现有指南
(4)改编现有指南是 专家共识 咨询目标用户、相关认证机构和原指南制订者 指导委员会确定研究问题并按照PIPOH格式进行呈现 (1)Cochrane Library数据库
(2)指南相关数据库
(3)指南制订机构官网24步 2011年AAP框架[30] 由指导委员会、咨询委员会和指南制订小组构成 (1)确定具体临床问题
(2)检索现有指南
(3)评价现有指南
(4)改编现有指南(指南制订小组每月通过视频会议进行指南改编)是 专家共识 由临床专家、方法学家和未参与指南制订的指南潜在使用者进行审查 针对当地从业人员的知识空白进行调查,确定临床问题 未报告 3阶段11步 2012年CANIMPLEMENT框架[16-18] 由两个或两个以上的委员会(包括指导委员会及指南制订小组)构成 (1)与ADAPTE步骤相似
(2)指南制订小组的不同小组委员会同时完成了改编过程的某些步骤,注重改编指南的实施是 专家共识 由受推荐意见影响的利益相关者进行审查 指导委员会确定研究问题并按照PIPOH格式进行呈现 (1)MEDLINE数据库
(2)指南相关数据库
(3)指南制订机构网站
(4)谷歌搜索引擎等3阶段11步 2013年MAGIC框架[31-32] 由编辑委员会和指南各章的编辑构成 (1)遴选一部公认的采用GRADE分级标准的高质量指南
(2)遴选指南中与改编环境相关的推荐意见进行采用/改编是 编委会专家和方法学家采用或改编的推荐意见,小组就推荐意见的修改与原指南编辑进行协商 由所有相关的医学专业组织、当地卫生机构和原指南制订小组进行审查 当地卫生机构确定临床问题 不适用 5步 2015年AdaptedADAPTE框架[33] 由指导委员会和指南制订小组构成的双重委员会 以ADAPTE和CANIMPLEMENT框架为基础,修改形成新的框架 是 专家共识 与ADAPTE一致 指导委员会确定研究问题并按照PIPOH格式进行呈现 (1)PubMed数据库
(2)DynaMed数据库
(3)BMJ Best Practice数据库3阶段24步 2017年GRADEADOLOPMENT框架[34] 由McMaster大学的方法学小组和指南制订小组(多学科背景的当地专家及患者代表组成)构成 (1)确定具体临床问题
(2)确定具体问题的推荐意见
(3)选择使用GRADE分级标准指南并构建证据决策表不适用 证据决策表以及指南小组共识 否 当地卫生机构确定临床问题 不适用 8步 PGEAC:Practice Guideline Evaluation and Adaptation Cycle;SGR:Systematic Guideline Review;MAGIC:The Making GRADE the Irresistible Choice;AAP:The Alberta Ambassador Program Adaptation Process -
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