Voznyuk Sasha, Carter Rachel Z, Ridley Julia
Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
BC Centre for Palliative Care, Vancouver, BC, Canada.
Palliat Med. 2025 Jan;39(1):176-185. doi: 10.1177/02692163241286658. Epub 2024 Oct 6.
The limited palliative care evidence base is poorly amenable to existing grading schemes utilized in guidelines. Many recommendations are based on expert consensus or clinical practice standards, which are often considered 'low-quality' evidence. Reinforcing provider hesitancy in translating recommendations to practice has implications for patient care.
To rationalize the selection of an appropriate grading system for rating evidence to support recommendations made in palliative care clinical practice guidelines.
Review of the methodology sections of international palliative care guidelines published in English identified five grading systems comparison: Grading of Recommendations, Assessment, Development and Evaluations (GRADE); the Scottish Intercollegiate Guidelines Network (SIGN); Infectious Diseases Society of America-European Society for Medical Oncology (IDSA-ESMO); Confidence in the Evidence from Reviews of Qualitative research (CERQual) and the National Service Framework for Long Term Conditions (NSF-LTC).
There is heterogeneity among grading systems used in published palliative care or terminal symptom management guidelines. GRADE has been increasingly adopted for its methodological rigour and inter-guideline consistency with other medical associations. CERQual has the potential to support recommendations informed by qualitative evidence, but its role in clinical guidelines is less defined. The IDSA-ESMO system has an intuitive typology with the ability to categorize tiers of lower-quality evidence.
It is challenging to apply commonly used grading systems to the palliative care evidence base, which often lacks robust randomized controlled trials (RCTs). Adoption of IDSA-ESMO offers a feasible and practical alternative for lower-resourced guideline developers and palliative clinicians without a prerequisite for methodological expertise.
有限的姑息治疗证据基础很难适用于指南中现有的分级方案。许多建议基于专家共识或临床实践标准，这些通常被视为“低质量”证据。这加剧了医疗服务提供者在将建议转化为实践时的犹豫，对患者护理产生影响。
为支持姑息治疗临床实践指南中的建议，合理选择合适的证据分级系统。
对以英文发表的国际姑息治疗指南的方法部分进行综述，比较了五个分级系统：推荐分级、评估、制定与评价（GRADE）；苏格兰跨学院指南网络（SIGN）；美国传染病学会 - 欧洲医学肿瘤学会（IDSA - ESMO）；定性研究综述证据的可信度（CERQual）以及长期病症国家服务框架（NSF - LTC）。
已发表的姑息治疗或终末期症状管理指南中使用的分级系统存在异质性。GRADE因其方法严谨性以及与其他医学协会指南间的一致性而越来越多地被采用。CERQual有潜力支持基于定性证据的建议，但其在临床指南中的作用尚不太明确。IDSA - ESMO系统有直观的分类方式，能够对较低质量证据进行分级。
将常用分级系统应用于姑息治疗证据基础具有挑战性，因为该领域通常缺乏有力的随机对照试验（RCT）。对于资源较少的指南制定者和姑息治疗临床医生而言，采用IDSA - ESMO提供了一种可行且实用的替代方案，且无需方法学专业知识。
