Page 343 Guide to Pain Management in Low-Resource Settings

Setting up Guidelines for Local Requirements 331

Table 2
Strategies used for developing practice guidelines
Strategy Description
Identifi cation of a A regional health problem is identifi ed. Th e impact of this problem on the population and the usefulness of
regional medical practice guidelines is analyzed. If needed, a consensus group for the development of guidelines (for manage-
problem ment, care, diagnosis, etc.) is formed.
Selection of a group Formed by specialists from areas related to the guideline topic. Selection criteria include experience (more
of experts than 5 years) in this particular fi eld, in clinical research, in grading the evidence for recommendations, and/
or an academic profi le. Clinical practitioners recommended from the national medical associations related to
this specifi c area are also included. Experts must not have any confl ict of interest.
Identifying medical A questionnaire to evaluate the medical tendencies (for diagnosis, management, care, etc.) is developed by the
tendencies group of experts. Items on the questionnaire are based on the statements made by other consensus groups,
clinical guidelines, clinical pathways, or clinical algorithms. Results from questionnaires are sent to the se-
lected experts.
Review of the From the selected guideline topic, a focused review of the literature is made. Th is process is achieved using
literature diverse electronic medical databases (PubMed, EMBASE, LILACS, and others). Cross-reference of selected
documents is made. Resources to obtain references are provided by the national institutes of health, national
medical associations, and nonprofi t organizations.
Sending evidence to Results from the review of the literature are send to the group of selected experts. Th e objective is that every
the selected experts participant have the opportunity to analyze the literature before the consensus meeting.
Elaborating recom- A consensus meeting is held to analyze the results obtained from the questionnaire and to develop specifi c
mendations recommendations (for management, diagnosis, education, care, etc.). Every recommendation is considered for
further review based on the group’s expertise and the results from the review of the literature.
Preliminary results From the consensus meeting a preliminary report is obtained. Each of the recommendations is submitted to
a focused review of the scientifi c evidence. Meta-analysis, systematic reviews, randomized controlled trials,
randomized uncontrolled trials, and case reports for each specifi c recommendation are analyzed. If there are
no studies, the recommendation is “based on consensus group expertise.” Results from this search are sent to
the group of experts.
Grading recom- Feedback from the group of experts about the evidence to endorse a recommendation is analyzed. Th e
mendations method for grading for every recommendation is described in Table 3.
Preliminary practice A preliminary document is sent to the consensus group. Final notes from the participants are considered, and
guidelines a fi nal document is elaborated.
Review of the fi nal Th e fi nal document is sent to the participants for approval (as many times as needed). After this process is
document completed, the document is sent for publication in a peer-reviewed journal.
Implementation of Extensive education among clinicians, health care administrators, policy makers, benefi t managers, and
guidelines patients and their families is performed in every fi liation center from each consensus participant. Conferences
at regional congresses or medical meetings are provided. Local eff orts to implement guidelines require the
commitment of the participants.
Follow-up and A questionnaire designed to evaluate clinicians’ knowledge of the guidelines or their outcome is performed.
evaluation of the Evaluation is obtained by the method developed by the AGREE Collaboration Group.
guidelines
Information extracted from: Frances [ref. 2], Guevara-López et al. [ref. 3]. AGREE Collaboration Group: www.agreecollaboration.org;
National Institute for Health and Clinical Excellence (UK): www.nice.org.uk.

How does the scientifi c evidence Grading methods take into account the study
grade the recommendations design, benefi ts and harms, and outcome (Canadi-
an Task Force, U.S. Preventive Services Task Force,
of practice guidelines?
GRADE working group, SIGN method, SORT taxon-
In 1979, the Canadian Task Force on Periodic Health omy, etc.). A description of a strategy for grading the
Examination made the fi rst eff orts to characterize the evidence according to the methodology of the study is
level of evidence underlying health care recommenda- described here:
tions and their strength. Since then, a wide variety of • Level 1: Evidence is extracted from systematic re-
methods have been developed for “grading” the strength views of relevant controlled clinical trials (with
of the evidence on which recommendations are made. meta-analysis when possible)