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  • The main products of EBM are evidence based guidelines EBGs

    2019-06-10

    The main products of EBM are evidence-based guidelines (EBGs), “systematically developed statements to assist practitioner and patient decision about appropriate health care for specific clinical circumstances” [21]. EBGs indeed substantially improve clinical care [29]. Preliminary steps for guideline development are evaluation of priority settings [14], composition of an expert panel [9], management of conflicts of interests [3], determination of appropriate group processes [10], of important outcomes [22] and of which evidences have to be included [15]. Then developers have to produce synthesis and presentation of evidences [16], exposing criteria for grading evidence and recommendations [23], integrating when possible values (e.g. ethical considerations) and consumer involvement [24]. Next, considerations of cost-effectiveness, affordability and resource implications [7], of equity [17], applicability, transferability and order pyrilamine maleate [25] should be included. The final steps are the report of guidelines recommendations [18], the dissemination and implementation of guidelines [11] and their evaluation [19]. Since EBGs frequently vary widely in quality [26,27], their evaluation is very important. Updating a first systematic review [12,28] found 24 different EBGs appraisal tools. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was a validated, easy-to-use, and transparent tool, which was internationally developed and widely accepted. It was developed through a process of item generation, selection and scaling, field-testing and refinement. The final version of the instrument contained 23 items grouped into six domains: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence [2]. Despite the good review of the AGREE instruments, two important limitations order pyrilamine maleate are present: although it can be used to compare clinical practice guidelines, AGREE instrument does not set a threshold to classify them as good or bad, and it does not assess the quality of the evidence supporting the recommendations [29]. Recently, an improved version of the AGREE, i.e. the AGREE II instrument, has been released [4,5], partly overcoming the previous limitations. Indeed, the introduction of the new item assessing the description of strengths and limitation of the body of evidences can be considered as a precursor for clinical validity or appropriateness of the recommendations. The authors recognize the value of this point, in fact adrenocorticotropic hormone (ACTH) state that the AGREE consortium is targeting this area as its next priority for further study in the AGREE A3 initiative [6].
    Material and methods The guidelines for the treatment of bone metastases by the Italian Society for Medical Oncology (AIOM) are based on: European Society for Medical Oncology (ESMO) guidance on the use of bisphosphonates in solid tumors [1] and on the management of aromatase inhibitor-associated bone loss [13]; Cochrane network reviews; critical review of the literature updated to June 2009. Level of evidences (I–VI) and grade of recommendations (A–E) were provided according to the recommendations of the Italian Centre for the Evaluation of the Efficacy of Health Assistance coordinated by the Italian National Health Institute (Istituto Superiore di Sanità) and are presented in Table 1. Spearman\'s rank correlation coefficient was calculated per each topic of the guidelines, a p value <0.05 was considered statistically significant. The final correlation was performed using a linear regression model (GraphPad Prims version 5.04, La Jolla California USA); linear r2 value was reported to weight the results and a p value <0.05 was considered statistically significant.
    Results The results of our analysis showed a statistically significant correlation between the levels of evidence and the grades of recommendation in the following topics: use of bisphosphonates in metastatic cancers (p<0.01); use of bisphosphonates in the prevention and treatment of cancer treatment induced bone loss (p<0.01); safety of bisphosphonates use (p<0.05); role of bisphosphonates in specific settings (p<0.01); role of orthopedic surgery in bone metastases (p<0.0001); role of radiotherapy in bone metastases (p<0.01).