Sanders G D, Nease R F, Owens D K
Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, CA 94305-6019, USA.
J Eval Clin Pract. 2001 May;7(2):175-89. doi: 10.1046/j.1365-2753.2001.00271.x.
Commonly used methods for guideline development and dissemination do not enable developers to tailor guidelines systematically to specific patient populations and update guidelines easily. We developed a web-based system, ALCHEMIST, that uses decision models and automatically creates evidence-based guidelines that can be disseminated, tailored and updated over the web. Our objective was to demonstrate the use of this system with clinical scenarios that provide challenges for guideline development. We used the ALCHEMIST system to develop guidelines for three clinical scenarios: (1) Chlamydia screening for adolescent women, (2) antiarrhythmic therapy for the prevention of sudden cardiac death; and (3) genetic testing for the BRCA breast-cancer mutation. ALCHEMIST uses information extracted directly from the decision model, combined with the additional information from the author of the decision model, to generate global guidelines. ALCHEMIST generated electronic web-based guidelines for each of the three scenarios. Using ALCHEMIST, we demonstrate that tailoring a guideline for a population at high-risk for Chlamydia changes the recommended policy for control of Chlamydia from contact tracing of reported cases to a population-based screening programme. We used ALCHEMIST to incorporate new evidence about the effectiveness of implantable cardioverter defibrillators (ICD) and demonstrate that the cost-effectiveness of use of ICDs improves from $74 400 per quality-adjusted life year (QALY) gained to $34 500 per QALY gained. Finally, we demonstrate how a clinician could use ALCHEMIST to incorporate a woman's utilities for relevant health states and thereby develop patient-specific recommendations for BRCA testing; the patient-specific recommendation improved quality-adjusted life expectancy by 37 days. The ALCHEMIST system enables guideline developers to publish both a guideline and an interactive decision model on the web. This web-based tool enables guideline developers to tailor guidelines systematically, to update guidelines easily, and to make the underlying evidence and analysis transparent for users.
常用的指南制定和传播方法无法让开发者系统地针对特定患者群体调整指南，也难以轻松更新指南。我们开发了一个基于网络的系统——ALCHEMIST，它使用决策模型并自动创建基于证据的指南，这些指南可通过网络进行传播、定制和更新。我们的目标是通过一些为指南制定带来挑战的临床场景来展示该系统的用途。我们使用ALCHEMIST系统为三个临床场景制定指南：（1）青少年女性衣原体筛查；（2）预防心源性猝死的抗心律失常治疗；以及（3）BRCA乳腺癌突变基因检测。ALCHEMIST利用直接从决策模型中提取的信息，并结合决策模型作者提供的额外信息，来生成通用指南。ALCHEMIST为这三个场景中的每一个都生成了基于网络的电子指南。通过使用ALCHEMIST，我们证明，针对衣原体高风险人群定制指南会将衣原体控制的推荐策略从对报告病例的接触者追踪转变为基于人群的筛查计划。我们使用ALCHEMIST纳入了关于植入式心脏复律除颤器（ICD）有效性的新证据，并证明使用ICD的成本效益从每获得一个质量调整生命年（QALY）74400美元提高到了每QALY 34500美元。最后，我们展示了临床医生如何使用ALCHEMIST纳入女性对相关健康状态的效用，从而为BRCA检测制定针对患者的建议；针对患者的建议使质量调整预期寿命提高了37天。ALCHEMIST系统使指南开发者能够在网络上发布指南和交互式决策模型。这个基于网络的工具使指南开发者能够系统地定制指南、轻松更新指南，并让用户清楚了解基础证据和分析。
