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Ehsan Z, Ishman SL, Soghier I, Almeida FR, Boudewyns A, Camacho M, Carno MA, Coppelson K, Ersu RH, Ho ATN, Kaditis AG, Machado AJ, Mitchell RB, Resnick CM, Swaggart K, Verhulst S. Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2024; 209:248-261. [PMID: 37890009 PMCID: PMC10840779 DOI: 10.1164/rccm.202310-1857st] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Indexed: 10/29/2023] Open
Abstract
Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.
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Zhao HY, Kim S, Son MJ. Comparing acupoint catgut embedding and acupuncture therapies for simple obesity: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e31531. [PMID: 36595747 PMCID: PMC9794266 DOI: 10.1097/md.0000000000031531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND This systematic review aimed to assess the effectiveness and safety of acupoint catgut embedding (ACE), which is widely used in simple obese patients. METHODS Nine electronic databases and 2 trial registries were searched from inception to September 2021 without language limitations. All randomized controlled trials involving ACE therapies for simple obesity were included. Assessment of Cochrane's risk of bias and meta-analysis, as well as GRADE evaluation, were also performed. RESULTS A total of 73 randomized clinical trials involving 5872 participants were included. The overall risk of bias was high or unclear. ACE showed higher efficacy in total effective rate, body mass index, and body weight than manual acupuncture. In addition, ACE is more beneficial in total effective rate than electroacupuncture (EA). Moreover, combination therapy of ACE with EA is more effective in total body mass index and body weight than EA alone. CONCLUSIONS Despite some potential improvement, the evidence regarding the effectiveness and efficacy of ACE for simple obesity is inconclusive due to the poor quality of evidence. Further well-designed randomized controlled trials are needed to confirm the effectiveness of ACE for simple obesity.
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Affiliation(s)
- Hui Yan Zhao
- Korean Convergence Medical Science, University of Science and Technology (UST), School of Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
- KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
| | - Sungha Kim
- KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
| | - Mi Ju Son
- KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
- * Correspondence: Mi Ju Son, KM Science Research Division, Korea Institute of Oriental Medicine, 1672 Yuseong-daero, Yuseong-gu, Daejeon 34054, Republic of Korea (e-mail: )
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Kaiser L, Hübscher M, Rissling O, Schulz S, Langer G, Meerpohl J, Schwingshackl L. [GRADE Guidelines: 19. Assessing the certainty of evidence in the importance of outcomes or values and preferences: Risk of bias and indirectness]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2021; 160:78-88. [PMID: 33461905 DOI: 10.1016/j.zefq.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/11/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group defines patient values and preferences as the relative importance patients place on the main health outcomes. We provide GRADE guidance for assessing the risk of bias and indirectness domains for certainty of evidence about the relative importance of outcomes. STUDY DESIGN AND SETTING We applied the GRADE domains to rate the certainty of evidence in the importance of outcomes to several systematic reviews, iteratively reviewed draft guidance and consulted GRADE members and other stakeholders for feedback. RESULTS This is the first of two articles. A body of evidence addressing the importance of outcomes starts at "high certainty"; concerns with risk of bias, indirectness, inconsistency, imprecision, and publication bias lead to downgrading to moderate, low, or very low certainty. We propose the following subdomains of risk of bias: selection of the study population, missing data, the type of measurement instrument, and confounding; we have developed items for each subdomain. The population, intervention, comparison, and outcome elements associated with the evidence determine the degree of indirectness. CONCLUSION This article provides guidance and examples for rating the risk of bias and indirectness for a body of evidence summarizing the importance of outcomes.
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Affiliation(s)
- Laura Kaiser
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland; Universität Witten/Herdecke, Deutschland.
| | - Markus Hübscher
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Olesja Rissling
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Sandra Schulz
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Gero Langer
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Jörg Meerpohl
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland; Cochrane Deutschland, Cochrane Deutschland Stiftung, Freiburg, Deutschland
| | - Lukas Schwingshackl
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland
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GRADE-Leitlinien zu Gerechtigkeit 4. Berücksichtigung der Gerechtigkeit im Gesundheitswesen bei der Entwicklung von GRADE-Leitlinien: von der Evidenz zur Empfehlung. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2020; 156-157:105-112. [PMID: 32863163 DOI: 10.1016/j.zefq.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this paper is to provide detailed guidance on how to incorporate health equity within the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evidence to decision process. STUDY DESIGN AND SETTING We developed this guidance based on the GRADE evidence to decision frame-work, iteratively reviewing and modifying draft documents, in person discussion of project group members and input from other GRADE members. This is a German translation of the original paper published in English. RESULTS Considering the impact on health equity may be required, both in general guidelines and guide-lines that focus on disadvantaged populations. We suggest two approaches to incorporate equity considerations: (1) assessing the potential impact of interventions on equity and (2) incorporating equity considerations when judging or weighing each of the evidence to decision criteria. We provide guidance and include illustrative examples. CONCLUSION Guideline panels should consider the impact of recommendations on health equity with attention to remote and underserviced settings and disadvantaged populations. Guideline panels may wish to incorporate equity judgments across the evidence to decision framework. This is the fourth and final paper in a series about considering equity in the GRADE guideline development process. This series is coming from the GRADE equity subgroup.
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Lietz M, Angelescu K, Markes M, Molnar S, Runkel B, Schell L, Meerpohl JJ. [GRADE: Evidence to Decision (EtD) framework for coverage decisions]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2020; 150-152:134-141. [PMID: 32451188 DOI: 10.1016/j.zefq.2020.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Coverage decisions are decisions by third party payers about whether and how much to pay for technologies or services, and under what conditions. Given their complexity, a systematic and transparent approach is needed. The DECIDE project, a GRADE working group initiative funded by the European Union, has developed GRADE Evidence to Decision (EtD) frameworks for different types of decisions, including coverage ones. METHODS We used an iterative approach, including brainstorming to generate ideas, consultation with stakeholders, user testing, and pilot testing of the framework. RESULTS The general structure of the EtD includes formulation of the question, an assessment using 12 criteria, and conclusions. Criteria that are relevant for coverage decisions are similar to those for clinical recommendations from a population perspective. Important differences between the two include the decision-making processes, accountability, and the nature of the judgments that need to be made for some criteria. Although cost-effectiveness is a key consideration when making coverage decisions, it may not be the determining factor. Strength of recommendation is not directly linked to the type of coverage decisions, but when there are important uncertainties, it may be possible to cover an intervention for a subgroup, in the context of research, with price negotiation, or with restrictions. CONCLUSION The EtD provides a systematic and transparent approach for making coverage decisions. It helps ensure consideration of key criteria that determine whether a technology or service should be covered and that judgments are informed by the best available evidence.
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Affiliation(s)
- Martina Lietz
- Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), Köln, Deutschland.
| | - Konstanze Angelescu
- Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), Köln, Deutschland
| | - Martina Markes
- Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), Köln, Deutschland
| | - Sandra Molnar
- Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), Köln, Deutschland
| | - Britta Runkel
- Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), Köln, Deutschland
| | - Lisa Schell
- Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), Köln, Deutschland
| | - Jörg J Meerpohl
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland; Cochrane Deutschland, Cochrane Deutschland Stiftung, Freiburg, Deutschland
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Morche J, Freitag S, Hoffmann F, Rissling O, Langer G, Nußbaumer-Streit B, Toews I, Gartlehner G, Meerpohl JJ. GRADE-Leitlinien: 18. Wie ROBINS-I und andere Instrumente zur Einschätzung des Risikos für Bias von nicht-randomisierten Studien verwendet werden sollten, um die Vertrauenswürdigkeit eines Evidenzkörpers zu bewerten. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2020; 150-152:124-133. [DOI: 10.1016/j.zefq.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kallenbach M, Conrad S, Hoffmann F, Matthias K, Gartlehner G, Langer G, Meerpohl J. [GRADE: Using evidence to decision frameworks for adoption, adaptation and de novo generation of trustworthy guideline recommendations - GRADE-ADOLOPMENT]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2019; 144-145:90-99. [PMID: 31399391 DOI: 10.1016/j.zefq.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Guideline developers can: (1) adopt existing recommendations from others; (2) adapt existing recommendations to their own context; or (3) create recommendations de novo. Monetary and nonmonetary resources, credibility, maximization of uptake, as well as logical arguments should guide the choice of the approach and processes. OBJECTIVES To describe a potentially efficient model for guideline production based on adoption, adaptation, and/or de novo development of recommendations utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks. STUDY DESIGN AND SETTING We applied the model in a new national guideline program producing 22 practice guidelines. We searched for relevant evidence that informs the direction and strength of a recommendation. We then produced GRADE EtDs for guideline panels to develop recommendations. RESULTS In two waves, a total of 80 EtD frameworks was produced approximately 4 months and 146 EtDs in about 6 months. Use of the EtD frameworks allowed panel members to understand judgments of other guideline groups about the criteria that bear on guideline recommendations and then make their own judgments about those criteria in a systematic approach. CONCLUSION The "GRADE-ADOLOPMENT" approach to guideline production combines adoption, adaptation, and, as needed, de novo development of recommendations. If guideline developers apply EtD criteria more widely and make their work publically available, this approach should prove even more useful.
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Affiliation(s)
- Maria Kallenbach
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland.
| | - Susann Conrad
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Frauke Hoffmann
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Katja Matthias
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Gerald Gartlehner
- Department für Evidenzbasierte Medizin und Klinische Epidemiologie, Donau-Universität Krems, Krems, Österreich; RTI International, 3040 Cornwallis Drive, Research Triangle Park, NC, USA
| | - Gero Langer
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Jörg Meerpohl
- Institut für Evidenz in der Medizin (für Cochrane Deutschland Stiftung), Universitätsklinikum Freiburg - Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland; Cochrane Deutschland, Cochrane Deutschland Stiftung, Freiburg, Deutschland
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