Clinicians and policymakers are recognizing the importance of measuring health-related quality of life (HRQL) to inform patient management and policy decisions. Self- or interviewer-administered questionnaires can be used to measure cross-sectional differences in quality of life between patients at a point in time (discriminative instruments) or longitudinal changes in HRQL within patients during a period of time (evaluative instruments). Both discriminative and evaluative instruments must be valid (really measuring what they are supposed to measure) and have a high ratio of signal to noise (reliability and responsiveness, respectively). Reliable discriminative instruments are able to reproducibly differentiate between persons. Responsive evaluative measures are able to detect important changes in HRQL during a period of time, even if those changes are small. Health-related quality of life measures should also be interpretable--that is, clinicians and policymakers must be able to identify differences in scores that correspond to trivial, small, moderate, and large differences. Two basic approaches to quality-of-life measurement are available: generic instruments that provide a summary of HRQL; and specific instruments that focus on problems associated with single disease states, patient groups, or areas of function. Generic instruments include health profiles and instruments that generate health utilities. The approaches are not mutually exclusive. Each approach has its strengths and weaknesses and may be suitable for different circumstances. Investigations in HRQL have led to instruments suitable for detecting minimally important effects in clinical trials, for measuring the health of populations, and for providing information for policy decisions.
Users of clinical practice guidelines and other recommendations need to know how much confidence they can place in the recommendations. Systematic and explicit methods of making judgments can reduce errors and improve communication. We have developed a system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts. In this article we present a summary of our approach from the perspective of a guideline user. Judgments about the strength of a recommendation require consideration of the balance between benefits and harms, the quality of the evidence, translation of the evidence into specific circumstances, and the certainty of the baseline risk. It is also important to consider costs (resource utilisation) before making a recommendation. Inconsistencies among systems for grading the quality of evidence and the strength of recommendations reduce their potential to facilitate critical appraisal and improve communication of these judgments. Our system for guiding these complex judgments balances the need for simplicity with the need for full and transparent consideration of all important issues.
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) Results. Both "strong" and "conditional" recommendations were made for OA management. Modalities conditionally recommended for the management of hand OA include instruction in joint protection techniques, provision of assistive devices, use of thermal modalities and trapeziometacarpal joint splints, and use of oral and topical nonsteroidal antiinflammatory drugs (NSAIDs), tramadol, and topical capsaicin. Nonpharmacologic modalities strongly recommended for the management of knee OA were aerobic, aquatic, and/or resistance exercises as well as weight loss for overweight patients. Nonpharmacologic modalities conditionally recommended for knee OA included medial wedge insoles for valgus knee OA, subtalar strapped lateral insoles for varus knee OA, medially directed patellar taping, manual therapy, walking aids, thermal agents, tai chi, selfmanagement programs, and psychosocial interventions. Pharmacologic modalities conditionally recommended for the initial management of patients with knee OA included acetaminophen, oral and topical NSAIDs, tramadol, and intraarticular corticosteroid injections; intraarticular hyaluronate injections, duloxetine, and opioids were conditionally recommended in patients who had an inadequate response to initial therapy. Opioid analgesics were strongly recommended in patients who were either not willing to undergo or had contraindications for total joint arthroplasty after having failed medical therapy. Recommendations for hip OA were similar to those for the management of knee OA. Conclusion. These recommendations are based on the consensus judgment of clinical experts from a wide range of disciplines, informed by available evidence, balancing the benefits and harms of both nonpharmacologic and pharmacologic modalities, and incorporating their preferences and values. It is hoped that these recommendations will be utilized by health care providers involved in the management of patients with OA.
International guidelines on asthma management indicate that the primary goal of treatment should be optimum asthma control. The aim of this study was to develop and validate the Asthma Control Questionnaire (ACQ).The authors generated a list of all symptoms used to assess control and sent it to 100 asthma clinicians who were members of guidelines committees (18 countries). They scored each symptom for its importance in evaluating asthma control. From the 91 responses, the five highest scoring symptoms were selected for the ACQ. In addition, there is one question on b 2 -agonist use and another on airway calibre (total questions=7). The ACQ was tested in a 9-week observational study of 50 adults with symptomatic asthma. The ACQ and other measures of asthma health status were assessed at baseline, 1, 5 and 9 weeks.In patients whose asthma was stable between clinic visits, reliability of the ACQ was high (intraclass correlation coefficient (ICC)=0.90). The questionnaire was very responsive to change in asthma control (p<0.0001). Cross-sectional and longitudinal validity were supported by correlations between the ACQ and other measures of asthma health status being close to a priori predictions.In conclusion, the Asthma Control Questionnaire has strong evaluative and discriminative properties and can be used with confidence to measure asthma control. Eur Respir J 1999; 14: 902±907. International guidelines indicate that the primary goal of asthma treatment is to achieve optimum control (minimization of day and night time symptoms, bronchoconstriction and short-acting b-agonist use) and thus reduce the risk of life-threatening exacerbations and long-term morbidity [1±4]. COCKCROFT and SWYSTUN [5] have pointed out that asthma "control" concerns the adequacy of treatment, whilst "severity" concerns the underlying disease process: "the common perception that well-controlled asthma is synonymous with mild asthma and that poorly controlled asthma is synonymous with severe asthma is erroneous".A number of questionnaires are described as measuring "asthma severity". In some, the term "severity" has been used appropriately [6,7] and the instruments validated against other measures of airway pathology. No questionnaires have been specifically developed and validated to measure asthma control. Without such an instrument, a simple, quantified method for identifying patients at risk and for evaluating the effects of treatment has been lacking.The authors developed the Asthma Control Questionnaire (ACQ) using recognized procedures for questionnaire specification, item selection and scaling [8] and the authors have examined the measurement properties necessary for its use in clinical practice, clinical trials and cross-sectional surveys [9]. The aim was to develop a simple questionnaire that could be completed in the clinic without daily recordings of symptoms, medication use and airway calibre.
Guideline developers use a bewildering variety of systems to rate the quality of the evidence underlying their recommendations. Some are facile, some confused, and others sophisticated but complexIn 2004 the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group presented its initial proposal for patient management. In this second of a series of five articles focusing on the GRADE approach to developing and presenting recommendations we show how GRADE has built on previous systems to create a highly structured, transparent, and informative system for rating quality of evidence.A guideline's formulation should include a clear question Any question addressing clinical management has four components: patients, an intervention, a comparison, and the outcomes of interest.2 For example, consider the following: in patients with pancreatic carcinoma undergoing surgery, what is the impact of a modified resection that preserves the pylorus compared with a standard wide tumour resection-variations of the Whipple procedure-on short term and long term mortality, blood transfusions, bile leaks, hospital stay, and problems with gastric emptying?Guideline developers should address the importance of their outcomes GRADE challenges guideline developers to specify all outcomes that are of importance to patients as they begin the guideline development process, and to differentiate the critical outcomes from the important but not critical ones.3 Figure 1 presents a hierarchy of patient important outcomes regarding the impact of phosphate lowering drugs in patients with renal failure. GRADE suggests a nine point scale to judge importance. The upper end of the scale, 7 to 9, identifies outcomes of critical importance for decision making. Ratings of 4 to 6 represent outcomes that are important but not critical. Ratings of 1 to 3 are items of limited importance. Guideline panels should strive for the sort of explicit approach that this example represents.Judging the quality of evidence requires consideration of the context GRADE provides a definition for the quality of evidence in the context of making recommendations. The quality of evidence reflects the extent to which confidence in an estimate of the effect is adequate to support recommendations. This definition has two important implications. Firstly, guideline panels must make judgments about the quality of evidence relative to the specific context in which they are using the evidence. Secondly, because systematic reviews do not-or at least should not-make recommendations, they require a different definition. For systematic reviews, the quality of evidence reflects the extent of confidence that an estimate of effect is correct.Study design is important in determining the quality of evidence As with early systems of grading the quality of evidence, 4 GRADE's approach begins with the study design. For recommendations addressing alternative management strategies-as opposed to issues of establishing prognosis or the accuracy of diagnostic testsrandomise...
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
334 Leonard St
Brooklyn, NY 11211
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.