Pearson S D, Margolis C Z, Davis S, Schreier L K, Sokol H N, Gottlieb L K
Department of Ambulatory Care and Prevention, Harvard Community Health Plan, Boston, MA, USA.
Med Care. 1995 Jun;33(6):643-60.
The authors evaluated the reproducibility of a clinical algorithm consensus development process across three different physician panels at a health maintenance organization. Physician groups were composed of primary care internists, who were provided with identical selections from the medical literature and first-draft "seed" algorithms on the management of two common clinical problems: acute sinusitis and dyspepsia. Each panel used nominal group process and a modified Delphi method to create final algorithm drafts. To compare the clinical logic in the final algorithms, the authors applied a new qualitative and quantitative comparison method, the Clinical Algorithm Patient Abstraction (CAPA). Dyspepsia algorithms from all physician groups recommended empiric anti-acid therapy for most patients, favored endoscopy over barium swallow, and had very similar indications for endoscopy. The average CAPA comparison score among final physician algorithms was 6.1 on a scale of 0 (different) to 10 (identical). Sinusitis algorithms from all groups proposed empiric antibiotic therapy for most patients. Indications for sinus radiographs were similar between two algorithms (CAPA = 4.9), but differed significantly in the third, resulting in lower CAPA scores (average CAPA = 1.9, P < 0.03). The clinical similarity of the algorithms produced by these physician panels suggests a high level of reproducibility in this consensus-driven algorithm development process. However, the difference among the sinusitis algorithms suggests that physician consensus groups using a consensus process that a health maintenance organization can do with limited resources will produce some guidelines that vary due to differences in interpretation of evidence and physician experience.
作者评估了健康维护组织中三个不同医生小组间临床算法共识制定过程的可重复性。医生小组由初级保健内科医生组成，他们收到了医学文献中的相同选段以及关于两种常见临床问题（急性鼻窦炎和消化不良）管理的初稿“种子”算法。每个小组采用名义小组法和改良的德尔菲法来创建最终算法草案。为了比较最终算法中的临床逻辑，作者应用了一种新的定性和定量比较方法——临床算法患者抽象法（CAPA）。所有医生小组的消化不良算法都建议对大多数患者进行经验性抗酸治疗，更倾向于内镜检查而非钡餐检查，并且内镜检查的指征非常相似。最终医生算法之间的平均CAPA比较得分在0（不同）至10（相同）的量表上为6.1。所有小组的鼻窦炎算法都建议对大多数患者进行经验性抗生素治疗。两种算法之间鼻窦X光检查的指征相似（CAPA = 4.9），但在第三种算法中差异显著，导致CAPA得分较低（平均CAPA = 1.9，P < 0.03）。这些医生小组生成的算法在临床上的相似性表明，在这种由共识驱动的算法开发过程中具有高度的可重复性。然而，鼻窦炎算法之间的差异表明，使用健康维护组织在有限资源下能够采用的共识过程的医生共识小组，将产生一些因证据解释和医生经验差异而有所不同的指南。
