Anesthesiology. 2021 Jul 1;135(1):31-56. doi: 10.1097/ALN.0000000000003808.
Although there are thousands of published recommendations in anesthesiology clinical practice guidelines, the extent to which these are supported by high levels of evidence is not known. This study hypothesized that most recommendations in clinical practice guidelines are supported by a low level of evidence.
A registered (Prospero CRD42020202932) systematic review was conducted of anesthesia evidence-based recommendations from the major North American and European anesthesiology societies between January 2010 and September 2020 in PubMed and EMBASE. The level of evidence A, B, or C and the strength of recommendation (strong or weak) for each recommendation was mapped using the American College of Cardiology/American Heart Association classification system or the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The outcome of interest was the proportion of recommendations supported by levels of evidence A, B, and C. Changes in the level of evidence over time were examined. Risk of bias was assessed using Appraisal of Guidelines for Research and Evaluation (AGREE) II.
In total, 60 guidelines comprising 2,280 recommendations were reviewed. Level of evidence A supported 16% (363 of 2,280) of total recommendations and 19% (288 of 1,506) of strong recommendations. Level of evidence C supported 51% (1,160 of 2,280) of all recommendations and 50% (756 of 1,506) of strong recommendations. Of all the guidelines, 73% (44 of 60) had a low risk of bias. The proportion of recommendations supported by level of evidence A versus level of evidence C (relative risk ratio, 0.93; 95% CI, 0.18 to 4.74; P = 0.933) or level of evidence B versus level of evidence C (relative risk ratio, 1.63; 95% CI, 0.72 to 3.72; P = 0.243) did not increase in guidelines that were revised. Year of publication was also not associated with increases in the proportion of recommendations supported by level of evidence A (relative risk ratio, 1.07; 95% CI, 0.93 to 1.23; P = 0.340) or level of evidence B (relative risk ratio, 1.05; 95% CI, 0.96 to 1.15; P = 0.283) compared to level of evidence C.
Half of the recommendations in anesthesiology clinical practice guidelines are based on a low level of evidence, and this did not change over time. These findings highlight the need for additional efforts to increase the quality of evidence used to guide decision-making in anesthesiology.
尽管在麻醉学临床实践指南中有数千条已发表的建议，但这些建议得到高水平证据支持的程度尚不清楚。本研究假设大多数临床实践指南中的建议都得到了低水平证据的支持。
对 2010 年 1 月至 2020 年 9 月期间北美和欧洲主要麻醉学会的麻醉循证建议进行了注册（Prosp er o CRD42020202932）系统评价，检索了 PubMed 和 EMBASE。使用美国心脏病学会/美国心脏协会分类系统或推荐评估、制定和评估（GRADE）系统对每个建议的证据水平 A、B 或 C 以及建议的强度（强或弱）进行映射。感兴趣的结果是得到证据水平 A、B 和 C 支持的建议比例。研究考察了随时间推移证据水平的变化。使用评估研究和评估指南的适用性（AGREE）II 评估偏倚风险。
共审查了 60 份指南，其中包含 2280 条建议。证据水平 A 支持 16%（2280 条建议中的 363 条）和 19%（1506 条强建议中的 288 条）的总建议。证据水平 C 支持 51%（2280 条建议中的 1160 条）和 50%（1506 条强建议中的 756 条）的所有建议。在所有指南中，73%（60 份中的 44 份）的偏倚风险较低。证据水平 A 与证据水平 C（相对风险比，0.93；95%CI，0.18 至 4.74；P=0.933）或证据水平 B 与证据水平 C（相对风险比，1.63；95%CI，0.72 至 3.72；P=0.243）的建议得到支持的比例并没有随着指南的修订而增加。发表年份也与证据水平 A（相对风险比，1.07；95%CI，0.93 至 1.23；P=0.340）或证据水平 B（相对风险比，1.05；95%CI，0.96 至 1.15；P=0.283）的建议得到证据水平 A 或证据水平 B 的支持比例的增加无关。
麻醉学临床实践指南中一半的建议是基于低水平的证据，而且这并没有随着时间的推移而改变。这些发现突出表明需要做出更多努力来提高用于指导麻醉学决策的证据质量。
