Department of Anesthesiology, University of Ottawa and The Ottawa Hospital, General Campus, Suite CCW1401, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
Can J Anaesth. 2013 Feb;60(2):143-51. doi: 10.1007/s12630-012-9855-9. Epub 2012 Dec 5.
The purpose of this narrative review is to discuss the impact of clinical practice guidelines on the outcomes of care and patient safety.
The care provided to patients has a high degree of variability, including some care that is discordant with available evidence. This inconsistency has implications for patient safety as some patients receive care that is unlikely beneficial yet may be harmful, while others are denied care that would clearly be helpful. The medical literature is expanding at an alarming rate; its quality and reliability is often poor; study methodology is frequently suboptimal, and reversal is common, even among frequently cited articles. For decades, specialty societies and other agencies have been providing clinical practice guidelines to assist physicians with the integration of evidence into clinical decision-making. Implementation of guidelines has been variable, and their goals are often not achieved due to failed uptake and application. The reasons for this shortcoming are complex and some explanations are valid. Many guidelines have not been evidence-based and many have been methodologically unsound. Physician autonomy likely also plays an important role in guideline uptake; an updated concept of autonomy that embraces appropriate guidelines is long overdue.
Under certain conditions, guidelines can add value to care and improve outcomes; they need to be evidence-based, methodologically sound, and appropriately applied to patients and clinical scenarios. Simply summarizing evidence in a guideline is an inadequate process. To achieve the benefit of guidelines, implementation strategies need to be robust.
本文旨在讨论临床实践指南对医疗效果和患者安全的影响。
患者所接受的医疗护理存在高度变异性，其中一些护理措施与现有证据不符。这种不一致性对患者安全产生了影响，因为一些患者接受的护理可能无益甚至有害，而另一些患者则被剥夺了明显有益的护理。医学文献的增长速度令人震惊，其质量和可靠性往往较差，研究方法也常常不尽如人意，甚至在经常被引用的文章中也经常出现逆转。几十年来，专业学会和其他机构一直在提供临床实践指南，以帮助医生将证据融入临床决策。指南的实施情况参差不齐，由于未能被采纳和应用，其目标往往无法实现。造成这种缺陷的原因很复杂，有些解释是合理的。许多指南缺乏循证依据，许多指南在方法学上也不够严谨。医生的自主权可能也是指南采纳的一个重要因素，更新的自主权概念应该包含适当的指南，这已经是刻不容缓的事情。
在某些条件下，指南可以为医疗护理增加价值并改善结果；它们需要基于证据，方法学上合理，并适当地应用于患者和临床情况。仅仅在指南中总结证据是不够的。为了从指南中获益，实施策略需要强大。
