P118 Are Levels Of Evidence From Different Clinical Practice Guidelines Comparable? – Testing Of A Method For Standardization Of Different Evidence Grading Systems

Purpose: The American Academy of Orthopaedic Surgeons produces clinical practice guidelines for the treatment of orthopedic injuries. We examined the strength of the evidence underlying these recommendations in order to answer the following questions: (1) Have AAOS work groups improved guideline creation practices to locate evidence to generate strong recommendations? (2) Is there variability in the available evidence based on anatomic site or stage of care? (3) Has the level of evidence supporting improved over time? Methods: Twenty-two current guidelines of the Academy were examined which yielded 408 individual recommendations. These recommendations were assigned one of five strength of evidence ratings (strong, moderate, limited, inconclusive, consensus) by the guideline panel, based on the availability and quality of the supporting evidence. From these guidelines, we extracted all of the recommendations and their corresponding evidence ratings. We then classified the recommendations by stage of care, year, and anatomical site. Results: The distribution of the levels of evidence was as follows: 77 (18.9%) were based on consensus; 53 (13.0%) were inconclusive; 93 (22.8%) were based on limited evidence; 112 (27.5%) were based on moderate evidence; and 73 were based on (17.9%) strong evidence. Strong strength of evidence was found in 45.2% of the recommendations for preventive/screening/diagnostic care, 41.1% of nonsurgical treatment, 45.1% of surgical treatment, 51.1% of rehabilitation/postoperative treatment, and 45.5% of the recommendations that had mixed stages of care. Inconclusive strength of evidence was found to be prevalent from 2009–2013, but was eliminated starting in 2014. Conclusions: Only 73 (17.9%) recommendations generated by the Academy in its 22 clinical practice guidelines are based on a “strong” strength of evidence. More robust research is needed in orthopedics to bolster confidence in the recommendations in future guideline updates.

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Transitioning toward Evidence-Based Research in the Health Sciences for the XXI Century

Evidence-based Complementary and Alternative Medicine ◽

10.1093/ecam/nem123 ◽

2008 ◽

Vol 5 (2) ◽

pp. 123-128 ◽

Cited By ~ 6

Author(s):

Francesco Chiappelli ◽

Olivia S. Cajulis

Keyword(s):

Clinical Practice ◽

Clinical Practice Guidelines ◽

Practice Guidelines ◽

Research Evaluation ◽

Clinical Intervention ◽

Health Sciences ◽

Clinical Applications ◽

Evidence Based ◽

Levels Of Evidence ◽

Evidence Based Dentistry

This article discusses some of the misconceptions of evidence-based research in the health sciences. It proposes that since not all treatments in medicine and dentistry can be evidence-based, clinical applications of the evidence-based process should become a specialty. The case is particularly evident in dentistry. Therefore dentistry is taken in this article as a model for discussion. We propose that to approach dentistry from the viewpoint of the patient-oriented evidence that matters (POEM) is perfectly acceptable so far as we also engage in the process of research evaluation and appraisal in dentistry (READ). We distinguish between dentistry based on the evidence, and evidence-based dentistry. We argue that when invoking an evidence-based approach to dentistry or medicine, it is not sufficient to establish the ‘levels of evidence’, but rather that all evidence-based clinical intervention must undergo the stringent process of evidence-based research so that clinical practice guidelines be revised based on the best available evidence.

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Levels of Evidence Supporting the North American and European Perioperative Care Guidelines for Anesthesiologists between 2010 and 2020: A Systematic Review

Anesthesiology ◽

10.1097/aln.0000000000003808 ◽

2021 ◽

Author(s):

Andres Laserna ◽

Daniel A. Rubinger ◽

Julian E. Barahona-Correa ◽

Noah Wright ◽

Mark R. Williams ◽

...

Keyword(s):

Clinical Practice ◽

Relative Risk ◽

Risk Ratio ◽

Clinical Practice Guidelines ◽

Practice Guidelines ◽

Risk Of Bias ◽

Relative Risk Ratio ◽

Level Of Evidence ◽

Levels Of Evidence ◽

Versus Level

Background Although there are thousands of published recommendations in anesthesiology clinical practice guidelines, the extent to which these are supported by high levels of evidence is not known. This study hypothesized that most recommendations in clinical practice guidelines are supported by a low level of evidence. Methods A registered (Prospero CRD42020202932) systematic review was conducted of anesthesia evidence-based recommendations from the major North American and European anesthesiology societies between January 2010 and September 2020 in PubMed and EMBASE. The level of evidence A, B, or C and the strength of recommendation (strong or weak) for each recommendation was mapped using the American College of Cardiology/American Heart Association classification system or the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The outcome of interest was the proportion of recommendations supported by levels of evidence A, B, and C. Changes in the level of evidence over time were examined. Risk of bias was assessed using Appraisal of Guidelines for Research and Evaluation (AGREE) II. Results In total, 60 guidelines comprising 2,280 recommendations were reviewed. Level of evidence A supported 16% (363 of 2,280) of total recommendations and 19% (288 of 1,506) of strong recommendations. Level of evidence C supported 51% (1,160 of 2,280) of all recommendations and 50% (756 of 1,506) of strong recommendations. Of all the guidelines, 73% (44 of 60) had a low risk of bias. The proportion of recommendations supported by level of evidence A versus level of evidence C (relative risk ratio, 0.93; 95% CI, 0.18 to 4.74; P = 0.933) or level of evidence B versus level of evidence C (relative risk ratio, 1.63; 95% CI, 0.72 to 3.72; P = 0.243) did not increase in guidelines that were revised. Year of publication was also not associated with increases in the proportion of recommendations supported by level of evidence A (relative risk ratio, 1.07; 95% CI, 0.93 to 1.23; P = 0.340) or level of evidence B (relative risk ratio, 1.05; 95% CI, 0.96 to 1.15; P = 0.283) compared to level of evidence C. Conclusions Half of the recommendations in anesthesiology clinical practice guidelines are based on a low level of evidence, and this did not change over time. These findings highlight the need for additional efforts to increase the quality of evidence used to guide decision-making in anesthesiology. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Perceptions and attitudes of clinicians in Spain toward clinical practice guidelines and grading systems: a protocol for a qualitative study and a national survey

BMC Health Services Research ◽

10.1186/1472-6963-10-328 ◽

2010 ◽

Vol 10 (1) ◽

Cited By ~ 6

Author(s):

Anna Kotzeva ◽

Ivan Solà ◽

José Miguel Carrasco ◽

Petra Díaz del Campo ◽

Francisco Javier Gracia ◽

...

Keyword(s):

Clinical Practice ◽

Qualitative Study ◽

National Survey ◽

Clinical Practice Guidelines ◽

Practice Guidelines ◽

Perceptions And Attitudes ◽

Grading Systems

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High Flow Oxygen Therapy and the Pressure to Feed Infants With Acute Respiratory Illness

Perspectives of the ASHA Special Interest Groups ◽

10.1044/2020_persp-19-00158 ◽

2020 ◽

Vol 5 (4) ◽

pp. 1006-1010

Author(s):

Jennifer Raminick ◽

Hema Desai

Keyword(s):

Clinical Practice ◽

Clinical Practice Guidelines ◽

Practice Guidelines ◽

Oxygen Therapy ◽

Respiratory Illness ◽

High Flow ◽

Oral Feeding ◽

Respiratory Support ◽

Acute Respiratory Illness ◽

High Flow Oxygen

Purpose Infants hospitalized for an acute respiratory illness often require the use of noninvasive respiratory support during the initial stage to improve their breathing. High flow oxygen therapy (HFOT) is becoming a more popular means of noninvasive respiratory support, often used to treat respiratory syncytial virus/bronchiolitis. These infants present with tachypnea and coughing, resulting in difficulties in coordinating sucking and swallowing. However, they are often allowed to feed orally despite having high respiratory rate, increased work of breathing and on HFOT, placing them at risk for aspiration. Feeding therapists who work with these infants have raised concerns that HFOT creates an additional risk factor for swallowing dysfunction, especially with infants who have compromised airways or other comorbidities. There is emerging literature concluding changes in pharyngeal pressures with HFOT, as well as aspiration in preterm neonates who are on nasal continuous positive airway pressure. However, there is no existing research exploring the effect of HFOT on swallowing in infants with acute respiratory illness. This discussion will present findings from literature on HFOT, oral feeding in the acutely ill infant population, and present clinical practice guidelines for safe feeding during critical care admission for acute respiratory illness. Conclusion Guidelines for safety of oral feeds for infants with acute respiratory illness on HFOT do not exist. However, providers and parents continue to want to provide oral feeds despite clinical signs of respiratory distress and coughing. To address this challenge, we initiated a process change to use clinical bedside evaluation and a “cross-systems approach” to provide recommendations for safer oral feeds while on HFOT as the infant is recovering from illness. Use of standardized feeding evaluation and protocol have improved consistency of practice within our department. However, further research is still necessary to develop clinical practice guidelines for safe oral feeding for infants on HFOT.

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