陈耀龙;杨克虎;
CHEN Yao-long;YANG Ke-hu;Evidence Based Medicine Center of Lanzhou University,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation of Chinese GRADE Center;

• 1:兰州大学循证医学中心/兰州大学基础医学院甘肃省循证医学与临床转化重点实验室WHO指南实施与知识转化合作中心GRADE中国中心

摘要(Abstract)：

高质量的临床实践指南能够有效指导和规范医生的诊疗行为,提高医疗质量,降低医疗成本。随着指南数量的逐年增加以及涵盖领域的不断扩大,医务人员对指南的关注度也越来越高,因此掌握如何正确理解、制订和应用指南的方法至关重要。本文主要介绍临床实践指南的定义和发展、指南制订过程中存在的常见误区以及基于RIGHT报告标准对指南进行快速评价和实施的技巧。
High-quality clinical practice guidelines can effectively guide and regulate clinicians' decision on diagnosis and treatment,improve medical quality,and reduce costs. Since the number of guidelines increases each year and the coverage of guidelines continues to expand,guidelines get more attention from clinicians. It is important for clinicians to know how to understand,develop,and apply clinical guidelines correctly. This article gives a brief introduction of definition,development,and misconception of clinical practice guidelines,and discusses how to quickly evaluate and implement guidelines based on the RIGHT reporting checklist.

关键词(KeyWords)： 临床实践指南;循证医学;质量评价;报告规范
clinical practice guidelines;evidence based medicine;quality appraisal;reporting guidance

Abstract:

Keywords:

基金项目(Foundation): 国家自然科学基金(81503459)

作者(Authors): 陈耀龙;杨克虎;
CHEN Yao-long;YANG Ke-hu;Evidence Based Medicine Center of Lanzhou University,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province,WHO Collaborating Centre for Guideline Implementation and Knowledge Translation of Chinese GRADE Center;

参考文献(References)：

• [1]Institute of Medicine.Clinical practice guidelines:directions for a new program[M].Washington DC:National Academy Press,1990:38.
• [2]詹思延.临床实践指南的制定应该科学、规范[J].中华儿科杂志,2009,47:163-166.
• [3]http://www.ncbi.nlm.nih.gov/mesh/?term=Practice+guidelines(2018-04-09).
• [4]Institute of Medicine.Clinical practice guidelines we can trust[M].Washington DC:The National Academies Press,2011:25-16.
• [5]Ye ZK,Chen YL,Chen K,et al.Therapeutic drug monitoring of vancomycin:a guideline of the Division of Therapeutic Drug Monitoring,Chinese Pharmacological Society[J].J Antimicrob Chemother,2016,71:3020-3025.
• [6]World Health Organization.Global recommendations on physical activity for health[EB/OL].2010.http://www.who.int/dietphysicalactivity/publications/9789241599979/en/.
• [7]中华人民共和国教育部.3-6岁儿童学习与发展指南[EB/OL].http://www.moe.edu.cn/srcsite/A06/s3327/201210/t20121009_143254.html.
• [8]Whelton PK,Carey RM,Aronow WS,et al.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APh A/ASH/ASPC/NMA/PCNA Guideline for the Prevention,Detection,Evaluation,and Management of High Blood Pressure in Adults:Executive Summary:A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[J].Hypertension,2018,71:1269-1324.
• [9]Munich RE.The 2017 Clinical Practice Guidelines for Hypertension New criteria but little change in current risk[EB/OL].https://www.munichre.com/site/marclife-mobile/get/documents_E-364826261/marclife/assset.marclife/Documents/Publications/New_blood_pressure_guidelines.pdf.
• [10]Brunstr9m M,Carlberg B.Association of Blood Pressure Lowering With Mortality and Cardiovascular Disease Across Blood Pressure Levels:A Systematic Review and Meta-analysis[J].JAMA Intern Med,2018,178:28-36.
• [11]南方周末.一夜“患”上高血压美国修改指南,中国恐增3亿病人[EB/OL].http://www.infzm.com/content/131098.
• [12]Qaseem A,Wilt TJ,Kansagara D,et al.Hemoglobin A1c Targets for Glycemic Control With Pharmacologic Therapy for Nonpregnant Adults With Type 2 Diabetes Mellitus:A Guidance Statement Update From the American College of Physicians[J].Ann Intern Med,2018,168:569-576..
• [13]Handelsman Y,Bloomgarden ZT,Grunberger G,et al.American Association of Clinical Endocrinologists and American College of Endocrinology—clinical practice guidelines for developing a diabetes mellitus comprehensive care plan—2015[J].Endocr Pract,2015,21:1-87.
• [14]American Diabetes Association.Standards of medical care in diabetes—2017[J].Diabetes Care,2017,40:S48-S56.
• [15]中华医学会糖尿病学分会.中国2型糖尿病防治指南(2013年版)[J].中华糖尿病杂志,2014,6:447-498.
• [16]Shubrook J.The pendulum is still in motion:the American College of Physicians provides recommendations for the Hb A1c target for adults with type 2 diabetes[EB/OL].2018.03.05.https://diabetes.medicinematters.com/glycemic-control/guidelines/editorial-board-commentary/15507890.
• [17]Leffert J.ACP recommends less intensive glycemic control targets for type 2 diabetes[EB/OL].https://www.healio.com/internalmedicine/diabetes/news/online/%7Ba2335 ed3-21d6-4262-b828-7528f285a5f9%7D/acp-recommends-less-intensiveglycemic-control-targets-for-type-2-diabetes?page=2.
• [18]中华医学会风湿病学分会.2016中国痛风诊疗指南[J].中华内科杂志,2016,55:892-899.
• [19]Qaseem A,Harris RP,Forciea MA,et al.Management of Acute and Recurrent Gout:A Clinical Practice Guideline From the American College of Physicians[J].Ann Intern Med,2017,166:58-68.
• [20]Chen Y,Wang C,Shang H,et al.Clinical practice guidelines in China[J].BMJ,2018,360:j5158.
• [21]Brouwers MC,Kho ME,Browman GP,et al.AGREEⅡ:advancing guideline development,reporting and evaluation in health care[J].CMAJ,2010,182:E839-E842.
• [22]Allegranzi B,Bischoff P,de Jonge S,et al.New WHO recommendations on preoperative measures for surgical site infection prevention:an evidence-based global perspective[J].Lancet Infect Dis,2016,16:e276-e287.
• [23]Busse JW,Craigie S,Juurlink DN,et al.Guideline for opioid therapy and chronic noncancer pain[J].CMAJ,2017,189:E659.
• [24]Lamontagne F,Fowler RA,Adhikari NK,et al.Evidencebased guidelines for supportive care of patients with Ebola virus disease[J].Lancet,2018,391:700-708.
• [25]彭晓霞.Meta-分析的方法学局限性及其适用领域[J].协和医学杂志,2017,8:381-386.
• [26]Wu T,Li Y,Bian Z,et al.Randomized trials published in some Chinese journals:how many are randomized?[J].Trials,2009,10:46.
• [27]Lund H,Brunnhuber K,Juhl C,et al.Towards evidence based research[J].BMJ,2016,355:i5440.
• [28]Zhao JG,Zeng XT,Wang J,et al.Association between calcium or vitamin D supplementation and fracture incidence in community-dwelling older adults:a systematic review and meta-analysis[J].JAMA,2017,318:2466-2482.
• [29]Antman EM,Lau J,Kupelnick B,et al.A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts.Treatments for myocardial infarction[J].JAMA,1992,268:240-248.
• [30]Nath S,Koziarz A,Badhiwala JH,et al.Atraumatic versus conventional lumbar puncture needles:a systematic review and meta-analysis[J].Lancet,2018,391:1197-1204.
• [31]Engelborghs S,Niemantsverdriet E,Struyfs H,et al.Consensus guidelines for lumbar puncture in patients with neurological dis-eases[J].Alzheimers Dement(Amst),2017,8:111.
• [32]国家食品药品监督管理总局.腰椎穿刺针(YY/T1148-2009)[EB/OL].http://www.sfda.gov.cn/WS01/CL0845/59355.html.
• [33]Moisset X,Ruet A,Brochet B,et al.Who performs lumbar puncture,how many do they perform,how and why?A retrospective study of 6,594 cases[J].Eur Neurol,2016,76:8-11.
• [34]Rouse B,Cipriani A,Shi Q,et al.Network meta-analysis for clinical practice guidelines:a case study on first-line medical therapies for primary open-angle glaucoma[J].Ann Intern Med,2016,164:674-682.
• [35]Psaty BM,Lumley T,Furberg CD,et al.Health outcomes associated with various antihypertensive therapies used as first-line agents:a network meta-analysis[J].JAMA,2003,289:2534-2544.
• [36]Stegenga H,Rogers G,Kandaswamy P,et al.International Network.Network meta-analyses in national clinical guidelines:a description and quality assessment[J].Electrophoresis,2000,21:2851-2858.
• [37]Chen Y,Yang K,Maru2ic'A,et al.A Reporting tool for practice guidelines in health care:the RIGHT statement[J].Ann Intern Med,2017,166:128-132.
• [38]陈耀龙,王小琴,王琪,等.遵循指南报告规范提升指南报告质量[J].中华内科杂志,2018,57:168-170.
• [39]Chen Y,Yang K,Maru2ic'A,et al.[A reporting tool for practice guidelines in health care:the RIGHT statement][J].Z Evid Fortbild Qual Gesundhwes,2017,127-128:3-10.
• [40]Chen Y,Yang K,Maru2ic'A,et al.[RIGHT statement:strumento per il reporting delle linee guida per la pratica clinica][J].Evidence,2017,9:1-9.
• [41]Enhancing the Quality and Transparency of Health Research[EB/OL].http://www.equator-network.org.
• [42]Shekelle PG,Ortiz E,Rhodes S,et al.Validity of the agency for healthcare research and quality clinical practice guidelines:how quickly do guidelines become outdated?[J].JAMA,2001,286:1461-1467.
• [43]International Practice Guideline Registry Platform[EB/OL].http://www.guidelines-registry.org.
• [44]Alonsocoello P,Oxman AD,Moberg J,et al.GRADE Evidence to Decision(Et D)frameworks:a systematic and transparent approach to making well informed healthcare choices.2:Clinical practice guidelines[J].BMJ,2016,353:i2089.
• [45]Mirnezami R,Nicholson J,Darzi A.Preparing for precision medicine[J].N Engl J Med,2012,366:489-491.
• [46]Zhang L,Wang H,Li Q,et al.Big data and medical research in China[J].BMJ,2018,360:j5910.
• [47]Sun X,Tan J,Tang L,et al.Real world evidence:experience and lessons from China[J].BMJ,2018,360:j5262.
• [48]Beam AL,Kohane IS.Translating artificial intelligence into clinical care[J].JAMA,2016,316:2368-2369.
• [49]Grimshaw JM,Russell IT.Effect of clinical guidelines on medical practice:a systematic review of rigorous evaluations[J].Lancet,1993,342:1317-1322.
• [50]刘凤林,秦净.从指南到实践:解析《中国普通外科围手术期血栓预防与管理指南》[J].协和医学杂志,2018,9:44-49.
• [51]肖波,周罗.癫痫最新临床诊疗指南:机遇与挑战并存[J].协和医学杂志,2017,8:122-126.