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Appendix D: Systems for Rating the Strength of Evidence and Clinical Recommendations
Pages 231-254

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From page 231...
... Appendix D Systems for Rating the Strength of Evidence and Clinical Recommendations 231
From page 232...
... developers in study quality, important inconsistency of results, A voluntary, uncertainty about the directness international, of the evidence, imprecise or collaboration sparse data, and high risk of reporting bias. Increase grade if a very strong association, evidence of a dose– response gradient, presence of all plausible residual confounding would have reduced the observed effect.
From page 233...
... Weak: Trade-offs are less certain -- either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced. The quality of evidence is high and other considerations support a weak recommendation.
From page 234...
... prognosis, rationale for them, tentatively due therapy, to become available in January 2010. One of several UK differential centers with the aim of diagnosis/ This approach has different evidence promoting evidence- symptom rating system depending on the based health care prevalence, and type of healthcare intervention.
From page 235...
... 235 APPENDIX D System for Rating Clinical Recommendations' Strength A: Consistent level 1 studies. B: Consistent level 2 or 3 studies or extrapolationse from level 1 studies.
From page 236...
... Independent, therapy Good evidence: From studies of not-for-profit Audience: strong design for answering the Clinical question addressed. practitioners, Fair evidence: Reasonable policy makers, and consumers evidence, but there may be minimal inconsistency, or uncertainty.
From page 237...
... This typically will be where some aspect of treatment is regarded as such sound clinical practice that nobody is likely to question it. These are shown in the guideline as Good Practice Points, and are marked with a green check.
From page 238...
... Society of B: Adequate subgroup analysis: Nephrology, Canadian Analysis was a priori, performed Coalition for within an adequate RCT and one High Blood of only a few tested, and there Pressure was sufficient sample size within Prevention the examined subgroup to detect a and Control, clinically important difference. The College C: Systematic review or meta of Family Physicians of analysis: Comparison arms are Canada, Heart derived from head-to-head and Stroke comparisons within the same RCT.
From page 239...
... For level d evidence, there must be a clinically important outcome and study population representative of the recommendation population, or an outcome-validated surrogate, or results that are extrapolated from study population to real population. D: Outcome is an unvalidated surrogate for clinically important population, or the applicability of the study is irrelevant.
From page 240...
... Minnesota healthcare providers and payers
From page 241...
... Grade II: Fair evidence The evidence consists of results from studies of strong design for answering the question addressed, but there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or because of minor doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the question addressed, but the results have been confirmed in separate studies and are consistent with minor exceptions at most.
From page 242...
... Family Practice, and primary care • rognosis: SR/meta-analysis P BMJ-USA providers of good-quality cohort studies, prospective cohort study with good follow-up. Level 2: Limited-quality, patient oriented evidence:g • iagnosis: Unvalidated clinical D decision rule, SR/meta-analysis of lower quality studies or studies with inconsistent findings, lower quality diagnostic cohort study or diagnostic case control study.
From page 243...
... C: Consensus, usual practice, opinion, disease-oriented evidence,* or case series for studies of diagnosis, treatment, prevention, or screening.
From page 244...
... G • indings not generalizable to F routine primary care practice. • ack of information on important L health outcomes.
From page 245...
... There is at least moderate certainty that the net benefit is small. Offer or provide this service only if other considerations support the offering or providing the service in an individual patient.
From page 246...
... Audience: C: Consensus opinion of experts, Healthcare providers case studies, or standard of care. American Focus: Pediatric A: Well-designed, randomized Academy of guidelines for controlled trials or diagnostic Pediatrics (AAP)
From page 247...
... , or Class IIB, with level A evidence if based on multiple RCTs with divergent conclusions. Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.
From page 248...
... Class II: Prospective matched group cohort study in a representative population with masked outcome assessment that meets a through d above or an RCT in a representative population that lacks one criteria in a through d. Class III: All other controlled trials (including well-defined natural history controls or patients serving as own controls)
From page 249...
... Recommendation: May be considered or may not be considered. Translation of evidence to recommendation: Level C rating requires at least one Class II study or two consistent Class III studies.
From page 250...
... National Focus: High: High-powered randomized Comprehensive Prevention, clinical trials or meta-analysis. Cancer Network diagnosis, and (NCCN)
From page 251...
... Category 1: The recommendation is based on high-level evidence (e.g., randomized controlled trials) , and there is uniform NCCN consensus.
From page 252...
... d Poor-quality prognostic cohort study refers to one in which sampling is biased in fa vor of patients who already had the target outcome, or the measurement of outcomes is accomplished in < 80 percent of study patients, or outcomes were determined in an unblinded, non-objective way, or there is no correction for confounding errors. e Extrapolations are where data are used in a situation that has potentially clinically important differences than the original study situation.
From page 253...
... g Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life. Disease-oriented evidence measures intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes (e.g., blood pressure, blood chem istry, physiologic function, pathologic findings)
From page 254...
... USPSTF (U.S. Preventive Services Task Force)


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