The shortage of health workforce in rural and remote areas has been commonly concerned by every country around the word. It is one of world health issues, challenging the aspirations of achieving equity. In this regard, WHO developed the Global Policy Recommendations to improve the accessibility of the health workforce in rural and remote areas through improved retention. This article focuses on the key steps of the policy guideline developed from evidence-based medicine methodology and from angle of guideline development, mainly about background, issues, evidence retrieval and selection, quality grading of evidence, and the forming of recommendation plan, in order to further explore how to correctly understand, obtain, evaluate and apply currently available research evidence, and how to use the GRADE system to make scientific and feasible recommendations in the decision-making process, emphasizing the importance of evidence and the GRADE system in the evidence-based health decision-making.
ObjectiveTo provide an overview of systematic reviews on the efficacy and safety of massage for the treatment of cervical spondylotic radiculopathy.MethodsCNKI, WanFang Data, VIP, CBM, PubMed, The Cochrane Library and EMbase databases were electronically searched to collect the systematic reviews on the efficacy and safety of massage for the treatment of cervical spondylotic radiculopathy from inception to December 30th, 2018. Two reviewers independently screened the literature and extracted the data, applied the AMSTAR2 scale to evaluate its methodological quality, and GRADE to evaluate the quality of the evidence.ResultsA total of 7 systematic reviews/meta-analysis were included. The AMSTAR2 scale evaluation showed that the quality of the included studies was extremely low. The GRADE evidence grading results showed that the quality of the VAS score outcome index of the two literatures was intermediate, and the quality of the OASCSR outcome index of one literature was intermediate. The quality of the remaining outcome indicators reported is low or very low.ConclusionThe available evidence shows that the efficacy and safety of manual treatment of cervical spondylotic radiculopathy is acceptable, but the overall methodological quality of the systematic review is extremely low, and the quality level of evidence is generally low. The future clinical trials and systematic reviews should be strictly followed. The scientific research design of the medical science provides high-quality evidence and provides reference for clinical practice.
ObjectiveTo systematically review the research issues related to evidence quality grading methods for public health decision making. MethodsPubMed, Web of Science, CNKI, WanFang Data, CBM and VIP databases were electronically searched to collect studies related to the application of evidence quality grading methods for public health decision making from inception to December 2022. The questions were constructed according to the SPIDER model. The quality of the included literature was evaluated by using the CASP checklist, and a three-level interpretation analysis of the questions on the application of quality rating methods for public health decision making was conducted using the thematic synthesis method to establish a pool of question entries. ResultsA total of 14 papers were included, covering seven countries. GRADE was the commonly used method for grading the quality of evidence. CASP evaluation results showed eight high quality studies, four medium quality studies and two low quality studies. The thematic synthesis method summarized 13 question entries in 7 categories. ConclusionThe existing methodology for grading the quality of evidence for public health decision making suffers from the diversity of evidence sources and the underestimation of the level of evidence from complex intervention studies.
ObjectivesTo evaluate the quality of methodology and evidence of the exiting systematic reviews (SRs) of acupuncture therapy for post-stroke spastic paralysis.MethodsCNKI, CBM, The Cochrane Library, PubMed and EMbase databases were electronically searched to collect SRs of acupuncture therapy for post-stroke spastic paralysis from inception to December 16th, 2018. Two reviewers independently screened literature, extracted data, and evaluated the quality of methodology and evidence by AMSTAR 2 scale and GRADE system.ResultsA total of 7 SRs were included. The results showed that acupuncture therapy had obvious advantages in treating post-stroke spastic paralysis without obvious adverse reactions. The results of AMSTAR 2 scale showed that the failure of key items 2 and 7 resulted in extremely low methodological quality. The results of GRADE system showed that 46.15% of which were low-level evidence quality, 42.31% were medium, 11.54% were extremely low, and no evidence quality were high.ConclusionsCurrent evidence shows that acupuncture and moxibustion therapy is effective in treating spastic paralysis after stroke, however, the quality of the SRs is low. The studies are required to be standardized and combined with the characteristics of TCM to obtain high quality evidence in the future.
Objectives To evaluate the methodological bias and the reliability of the conclusions of systematic reviews on acupuncture for polycystic ovary syndrome. Methods We comprehensively searched PubMed, EMbase, The Cochrane Library, CBM, CNKI and WanFang Data to collect systematic reviews on acupuncture for polycystic ovary syndrome from the establishment time of databases to January 5th, 2018. The AMSTAR tool was applied for methodological quality assessment of included studies and the GRADE system was applied for evidence quality assessment of included outcomes of systematic reviews. Results A total of 11 systematic reviews were included. The results of assessment using AMSTAR showed that, among the 11 items, most problems occurred in Item 5 " Were there any lists of research articles included and excluded”, followed by Item 1" Was an‘a prior’design provided?”and Item 11" Were potential conflict of interest included?”. GRADE grading results showed that quality of evidence for the outcome measure were" low”or" very low”. Conclusions Current acupuncture treatment of polycystic ovary syndrome has a certain effect, however, the quality of evidence is low. Thus, physicians should apply the evidence to make decision on acupuncture for polycystic ovary syndrome with caution in clinical practice and consider the actual situation, combined with the patient’s value preferences and economic factors.
ObjectiveTo evaluate the methodological bias and the reliability of the conclusions of systematic reviews (SRs) about traditional Chinese medicine for essential hypertension. MethodsWe comprehensively searched PubMed, EMbase, The Cochrane library (Issue 4, 2014), CBM, CNKI and WanFang Data to collect SRs of traditional Chinese medicine for essential hypertension from the establishment time of databases to April 30th, 2014. The AMSTAR tool was applied for methodological quality assessment of included studies, and the GRADE system was applied for evidence quality assessment of included outcomes of SRs. ResultsA total of 12 SRs involving 31 outcomes were included, of which 11 SRs focused on the comparison of therapeutic effects between traditional Chinese medicine combined with western medicine and western medicine alone. Nine SRs adopted Jadad tool to assess methodological quality of included original studies. The results of assessment using AMSTAR showed that, among 11 items, there were the most problems concerning Item 1 "Was an 'a prior' design provided?" (none of the 12 SRs provided it); followed by Item 11 "Were potential conflict of interest included?" (nine SRs didn't described it), and Item 6 "Were the characteristics of included studies provided" (six SRs didn't provided it). The results of grading showed that, 29 outcomes were graded as "low" or "very low" quality. The main factors contributed to downgrading evidence quality were limitations (31 outcomes), followed by imprecision (12 outcomes), and inconsistency (13 outcomes). ConclusionCurrently, the methodological quality of SRs about traditional Chinese medicine for essential hypertension was poor on the whole, with low quality of evidence as well as lack of enough attention to the end outcomes of patients with essential hypertension. Thus, physicians should apply the evidence to make decision about traditional Chinese medicine for essential hypertension with caution in clinical practice.
Objective To evaluate the effectiveness and safety of Endostar combined with chemotherapy for non-small cell lung cancer (NSCLC). Methods Randomized controlled trials (RCTs) on Endostar combined with chemotherapy for NSCLC were searched in The Cochrane Library, MEDLINE, EMbase, VIP, CNKI, CBMdisc and other electronic databases. The quality of RCTs meeting inclusion criteria was evaluated and the data were extracted; meta-analyses were performed with RevMan 5.1 software, and then the GRADE System was used to rate the level of evidence and strength of recommendation. Results Among the 18 RCTs involving 1 825 cases included, 1 816 cases met the inclusion criteria. Meta-analyses showed that: compared with the single chemotherapy, Endostar combined with chemotherapy could increase the total effective rate (RR=1.85, 95%CI 1.56 to 2.11, Plt;0.000 01), and the clinical benefit response (RR=1.21, 95%CI 1.14 to 1.29, Plt;0.000 01), but decrease the incidence risk of leukopenia (RR=0.89, 95%CI 0.82 to 0.97, P=0.006). There were no signficant differences between the two groups in decreasing thrombocytopenia (RR=0.87, 95%CI 0.74 to 1.03, P=0.10), impaired renal function (RR=0.96, 95%CI 0.69 to 1.34, P=0.82), nausea and vomiting (RR=0.92, 95%CI 0.84 to 1.01, P=0.08) and other side effects. Based on GRADE, the level of evidence was Grade C, and the strength of recommendation was 2. Conclusion The present results of clinical trials show that Endostar combined with chemotherapy for NSCLC is a safe and effective therapy without increasing the toxic reaction and side effects; and based on GRADE, the level of evidence was Grade 2C, and the strength of recommendation was 2. However, in view of the limitations of this study, it is suggested that large-scale, high-quality researches on basic and clinical fields should be performed to further verify the above conclusion by critical outcome indicators.
The focus of health equity is to enable the public to have fair access to health services and achieve satisfactory health outcomes. With research developments, guideline developers increasingly pay more attention to the fairness in the practice guidelines and have carried out exploration and practice in the relevant guidelines. The GRADE working group has begun to investigate how to use GRADE to assess health equity in practice guidelines since 2014. In 2017, the series of methodological guidelines of health equity in guideline development was officially published. It proposed 5 approaches to evaluate health equity and pointed out current methodological challenges of applying GRADE to assess health equity. This paper aims to introduce the GRADE equity guidelines, so as to provide a reference for Chinese researchers in their practice.
Adapting the existing guidelines in the context of specific regions can improve the efficiency of guidelines development, and reduce cost and time for developing guidelines. ADOLOPMENT is a methodological tool for guidelines adaptation, which was developed by the GRADE Working Group based on the standardized international guidelines making process. With ADOLOPMENT, developers can effectively use existing guidelines and evidence, avoid duplication of the evidence evaluation, and record the process from evidence to recommendations, which will ensure the transparency of adaptation, help users to understand the process, and improve the acceptability and credibility of guideline adaptation. This paper aims to introduce the ADOLOPMENT and its application.
This article discussed the development and current situation about both national and international diagnostic practice guidelines, as well as the role of evidence based medicine and systematic reviews in the development of such guidelines. Authors also analyzed the opportunities and challenges developers faced, and the methods and processes of development. Finally, authors proposed several strategic suggestions about how to improve the quality of diagnostic practice guideline in China.