Journal of evaluation in clinical practice
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We assessed the quality of a sample of clinical guidelines for thyroid nodules and thyroid cancers, using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. We also evaluated the reliability and validity of the AGREE instrument and summarized the key recommendations of the appraised guidelines. ⋯ We identified three clinical guidelines that obtained high overall assessment scores and were recommended for use in practice. Our findings have important implications for those developing clinical guidelines, especially as clarity and presentation significantly influenced the participants' assessment of the guidelines. The developers should ensure that the recommendations are presented clearly and unambiguously, and flowcharts, algorithms and other tools are developed to help the users in applying the recommendations into practice. The optimal number of appraisers for each guideline is four. Further work is needed to improve the 'applicability' domain of the AGREE.
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Meta Analysis
Clinical effectiveness in cardiovascular trials in relation to the importance to the patient of the end-points measured.
In order to increase the statistical power of a trial design, it is common practice for trialists to place a strong emphasis on end-points other than mortality. To assess the validity of this practice, the aim of this study was to investigate the relationship between the effectiveness of cardiovascular interventions in clinical trials and the importance to the patient of the end-point used to measure this effectiveness. ⋯ The proportion of interventions tested in the cardiovascular trials considered in this study that have a substantial beneficial effect relative to the control decreases as the end-point used to measure this effect becomes more important to the patient, that is, as the end-point severity increases from minor outcome to major outcome to death. Also, the analysis presented in this study strongly suggests that most of these interventions are likely to have close to no genuine effect on mortality relative to the control. Overall, this study substantially strengthens the empirical basis for the belief that the actions of trialists in choosing to study and heavily emphasize end-points other than mortality in cardiovascular trials and in particular end-points that are of only moderate or major importance to patients, may mislead practitioners and policy-makers about the overall effectiveness of the intervention concerned.
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Clinical judgment is a central element of the medical profession, essential for the performance of the doctor, and potentially generating information also for other clinicians and for scientists and health care managers. The recently renewed interest in clinical judgement is primarily engaged with its role in communication, diagnosis and decision making. Beyond this issue, the present article highlights the interrelations between clinical judgement, therapy assessment and medical professionalism. ⋯ Consequences of a methodological and logistical advancement of clinical judgment are discussed, both in regard to medical progress and to the renewal of the cognitive basis of the medical profession.
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This study focused on factors that most concern specialist societies when choosing an evidence grading system, such as methodological strengths and weaknesses, applicability and ease of use. The grading systems chosen were the Scottish Intercollegiate Guidelines Network (SIGN), the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the National Service Framework for long-term neurological conditions critical appraisal tool (NSF-LTC). ⋯ It is recommended that specialist societies consider the type of evidence they will be evaluating and the research experience of the appraisers before selecting a grading system. Additionally, appraisers should have training in appraising and grading evidence using the system to be employed.
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This paper examines the sources of practice variations and definitions of unwarranted variation, as derived from the literature. The literature suggests variables/factors related to patient health needs, doctor 'practice style' and environmental constraints/opportunities as sources of practice variations. However, this list is likely to be incomplete because of significant unexplained variation in each study. ⋯ Among those offered, more information is needed regarding the scientific basis for including the selected factors, and how to operationalize the framework provided a particular one is chosen. A clear and consistent framework for unwarranted variation, and a clear indication how each component factor could be measured and integrated can help investigators determine which variables should be included in their studies, such that the sources of unwarranted variations may be identified. A better understanding of the role of patient preference as a potential source of practice variations is also required.