2.1. Fundamento teórico
2.1.7. PeopleSoft Compass Methodology de Oracle
III Opinion of respected authorities, descriptive studies, case reports, and expert committees
Table A-2: Overall Quality Good High grade evidence (I or II-1) directly linked to health outcome
Fair
High grade evidence (I or II-1) linked to intermediate outcome;
or
Moderate grade evidence (II-2 or II-3) directly linked to health outcome
Poor Level III evidence or no linkage of evidence to health outcome
Table A-3: Net Effect of the Intervention
Substantial
More than a small relative impact on a frequent condition with a substantial burden of suffering;
or
A large impact on an infrequent condition with a significant impact on the individual patient level.
Moderate
A small relative impact on a frequent condition with a substantial burden of suffering;
or
A moderate impact on an infrequent condition with a significant impact on the individual patient level.
Small
A negligible relative impact on a frequent condition with a substantial burden of suffering;
or
A small impact on an infrequent condition with a significant impact on the individual patient level.
Zero or Negative
Negative impact on patients;
or
No relative impact on either a frequent condition with a substantial burden of suffering; or an infrequent condition with a significant impact on the individual patient level.
Appendix A - Page 96 Table A-4: Final Grade of Recommendation
The net benefit of the intervention
Quality of
Evidence Substantial Moderate Small
Zero or Negative
Good A B C D
Fair B B C D
Poor I I I I
Evidence Rating System
A A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.
B A recommendation that clinicians provide (the service) to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.
C No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D Recommendation is made against routinely providing the intervention to asymptomatic patients.
At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
LACK OF EVIDENCE – CONSENSUS OF EXPERTS
Where existing literature was ambiguous or conflicting, or where scientific data was lacking on an issue, recommendations were based on the clinical experience of the Working Group.
ALGORITHM FORMAT
The goal in developing the guideline for management of SUD was to incorporate the information into a format which would maximally facilitate clinical decision-making. The use of the algorithm format was chosen because of the evidence that such a format improves data collection, diagnostic and therapeutic decision-making and changes patterns of resource use. However, few guidelines are published in such a format.
VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders
Appendix A - Page 97
The algorithmic format allows the provider to follow a linear approach to critical information needed at the major decision points in the clinical process, and includes:
• An ordered sequence of steps of care
• Recommended observations
• Decisions to be considered
• Actions to be taken
A clinical algorithm diagrams a guideline into a step-by-step decision tree. Standardized symbols are used to display each step in the algorithm (Society for Medical Decision-Making Committee, 1992). Arrows connect the numbered boxes indicating the order in which the steps should be followed.
Rounded rectangles represent a clinical state or condition.
Hexagons represent a decision point in the guideline, formulated as a question that can be answered Yes or No. A horizontal arrow points to the next step if the answer is YES. A vertical arrow continues to the next step for a negative answer.
Rectangles represent an action in the process of care.
Ovals represent a link to another section within the guideline.
A letter within a box of an algorithm refers the reader to the corresponding annotation. The annotations elaborate on the recommendations and statements that are found within each box of the algorithm. Included in the annotations are brief discussions that provide the underlying rationale and specific evidence tables. Annotations indicate whether each recommendation is based on scientific data or expert opinion. A complete bibliography is included in the guideline.
REFERENCES
Agency for Health Care Policy and Research (AHCPR). Manual for conduction systematic review. Draft. August 1996. Prepared by Steven H. Woolf.
Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, Atkins D; Methods Work Group, Third US Preventive Services Task Force Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med 2001 Apr;20(3 Suppl):21-35.
Society for Medical Decision-Making Committee (SMDMC). Proposal for clinical algorithm standards, SMDMC on Standardization of Clinical Algorithms. Med Decis Making 1992 Apr- Jun;12(2):149-54.
United States Preventive Service Task Force (USPSTF). Guide to clinical preventive services. 2nd
edition. Washington, DC: US Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 1996.
Woolf SH. Practice guidelines, a new reality in medicine II. Methods of developing guidelines. Arch Intern Med 1992 May;152(5):946-52.
Appendix B - Page 98