NDT Advance Access originally published online on March 6, 2006
Nephrology Dialysis Transplantation 2006 21(5):1145-1153; doi:10.1093/ndt/gfl084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Clinical Practice Guidelines in nephrology—for worse or for better
National Kidney Foundation Center for Clinical Practice Guideline Development and Implementation, Tufts-New England Medical Center, Boston, USA
Correspondence and offprint request to: Katrin Uhlig, Email: kuhlig{at}tufts-nemc.org
Keywords: clinical practice guidelines; systematic review; evidence grading; chronic kidney disease
 |
Introduction |
|---|
 Top Introduction What guidelines are and...Methodological challenges for...Guideline development in...ConclusionsReferences |
|---|
Clinical practice guidelines (CPGs)* (throughout the text, terms marked with an asterisk are defined in Table 1 in alphabetical order) [1] have become important tools in shaping the care of individuals with chronic kidney disease (CKD). CPGs inform patient care, scientific debate, research agendas and policies. At the same time, CPGs have been criticized for restricting the care provided by physicians to patients. This article is intended as a review of selected topics related to guideline development and its application in nephrology, which ultimately aim at informing decision making and improving the quality of care.
|
|
What guidelines are and are not |
|---|
|
TopIntroductionWhat guidelines are and...Methodological challenges for...Guideline development in...ConclusionsReferences |
|---|
The primary purpose of CPGs is to improve patient care. As defined in the Institute of Medicine's 1990 report, guidelines are ‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’[1,2]. CPGs are evidence-based when they are derived from systematic reviews* of the pertinent literature. The evidence is interpreted by experts and forms the basis underlying concrete recommendations for care. A systematic review uses a protocol for identifying, synthesizing and appraising primary research articles. Meta-analyses* are systematic reviews where results of individual studies are quantitatively combined into a single effect estimate. Systematic tabulation of relevant literature facilitates comparison across studies and exploration of reasons for heterogeneity. A systematic approach to literature review lends scientific rigour to guideline development and aims to reduce bias that can occur in narrative reviews*, where the selection of supporting references and their interpretation is at the discretion of the authors.
Geographic variations in health care delivery are widely documented and demonstrate that there is no conformity of practice styles [3]. In nephrology, differences in dialysis care have been shown in different regional dialysis networks and in different countries [4,5]. In general, patient characteristics do not appear to account for all practice variability, which suggests that physician behaviour and system structures play contributing roles [6]. This highlights the need for CPGs to provide guidance on appropriate and effective care.
CPGs can educate providers at a time when practitioners find it challenging to keep up with an increasing rate of scientific publications and look to guidelines as practically oriented, systematically developed literature updates. Yet, CPGs cannot be followed like cookbook recipes. They cannot be detailed enough to spell out an individualized approach, that takes into account all potentially important factors, such as patient needs, preferences, available resources, and limitations unique to an institution or type of practice [7]. They can, however, propel practitioners to the level of knowledge generated by an expert panel that has synthesized the relevant literature and arrived at a consensus* in its interpretation. ‘Expert panels’ in guideline development should consist of individuals who have advanced knowledge in the topic of interest, in methods of systematic review and in critical literature appraisal.
CPGs often focus on improving the management of one particular disease. They have been criticized for not ranking the importance of different recommendations that may apply to a patient with multiple health care problems and for not providing guidance on how to integrate complex regimens for several diseases efficiently [8]. One explanation for this is that expert groups and professional societies naturally focus on issues of care primarily relevant for the patients they care for or represent. Another explanation is that guidelines merely mirror the focus of the supporting evidence. Randomized controlled trials (RCTs), which generate the most rigorous evidence on treatment efficacy, generally examine only one type of intervention in a selected population with one dominant health problem. Evidence on how to integrate the management of several diseases in order to optimize competing health outcomes is sparse. To fill this gap, better methods are needed to stratify individual patients’ risks, to tailor interventions according to risk profile and to effectively deliver multi-factorial interventions. Currently, it is left to providers and their patients to integrate multiple guideline recommendations into a feasible and appropriate health care plan. While CPGs cannot provide an outline for complex disease management, they can provide best care recommendations for those aspects which they do address.
CPGs contribute to continuous quality improvement when they are implemented and evaluated in clinical practice. It is important to distinguish guidelines from the policies that are derived from them. Guidelines are used to develop clinical performance measures (CPMs)*, which are tools to measure and evaluate health care practices. Linkage of CPGs with CPMs has led to criticism that guidelines form the foundation for auditing and regulation [9]. There is distrust in the reliability and validity of CPMs, because they do not adequately adjust for patient factors or do not focus on central aspects of care. Coupling performance with financial incentives has worried physicians who feel that being measured against collective benchmarks overrides their professional autonomy and acumen. Still, guideline development provides an avenue for health care professionals to participate in the assessment of what is appropriate care, based on medical reasoning.
Although guidelines can provide a foundation for policies, additional considerations need to be incorporated when creating policy decisions. One of these considerations is cost. How costs should be considered in guideline development is a controversial issue. When decision analyses* include estimates of costs as in cost–benefit*, cost–effectiveness* and cost–utility analyses*, different health practices can be compared regarding their returns. For this, the costs of the health practice are considered against the returns resulting from outcomes, which are expressed as monetary benefit, clinical effectiveness or utility. However, the conduct of decision analyses and incorporation of costs explicitly into guideline development requires special expertise. Further limitations are that costs are often based on assumptions and true costs can vary greatly in different contexts and over time. As a practical approach, it has been recommended that guideline panels primarily aim to determine the net medical benefit of a health practice from the patient perspective and that costs be considered separately [10]. Users can then distinguish the medical information and its interpretation from other considerations including costs.
The goal for guideline development panels is not to decide what health services should be offered and how they should be paid for. This task falls on policy makers and local implementers. Guideline developers cannot resolve the tension that exists between the goal of optimizing health care for an individual and the goal of improving public health. At the same time, CPGs can be used as a tool to defend the provision of appropriate services against the pressure of other interests.
|
Methodological challenges for guideline development |
|---|
|
TopIntroductionWhat guidelines are and...Methodological challenges for...Guideline development in...ConclusionsReferences |
|---|
Evidence grading
Methods for guideline development have evolved over the past several years. Checklists for quality criteria of CPGs have been proposed to provide instruction for guideline developers and help users evaluate the quality of a guideline [11–13] The following key attributes for well-developed guidelines are proposed: (i) An evidence-based approach is followed that involves systematic literature searches and comprehensive review of pertinent existing scientific evidence published in peer reviewed journals; (ii) Workgroup composition is interdisciplinary with representation of expertise in relevant clinical domains and in the methods of systematic literature review and appraisal; (iii) Workgroups are independent without the influence of organizations or industry and (iv) Guidelines undergo a review prior to publication which includes feed-back by representatives of patient organizations [7]. So far, guidelines do not consistently adhere to all quality criteria although they are improving [14,15].
One of the proposed quality criteria is that guidelines should be evidence-based and the strength of the recommendations should be graded. In guideline development, grading may occur at several levels: first, when grading the quality of an individual study; second, when grading an aggregate of studies that look at one health care practice and one type of outcome; third, when grading the composite of all studies that evaluate one health practice across all important outcomes; and fourth, when grading the strength of a recommendation. Ideally, the grading at each level would be consistent and transparent and there would be an explicit linkage of the quality of the evidence and the strength of the recommendation.
There are many different scales in use for grading the strength of recommendations and the quality of evidence [16]. However, none has been shown to be superior in direct comparisons. Nor has any been shown to reduce subjectivity in appraisal or predict how guidelines are accepted, implemented or improve clinical outcomes. It remains a sobering fact that translating evidence into a clinical context requires synthesis of facts as well as judgments, which are affected by values and opinions [17]. Nevertheless, grading schemes provide a structured approach to systematic evidence review and appraisal. They help make transparent how evidence and judgments are combined and clarify expectations for implementation. Although no single system may be ideal, harmonizing approaches to grading facilitates communication about the meaning of a guideline. Earlier systems, such as the evidence hierarchy of the Canadian Task Force on the Preventive Health Examination, have focused on the study design to assign a quality grade [18]. These systems are simple and make grading reproducible, but they do not consider the methodological quality of studies (i.e. the extent to which bias was minimized in each study), the quantity and consistency of studies or the magnitude of the effect. More recent systems, for example the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach, incorporate additional dimensions in grading [10,19]. According to the GRADE approach, a collection of randomized clinical trials with serious limitations to the methodological quality of the studies or with inconsistent findings would not be assigned a composite quality grade of ‘high’, while an aggregate of high-quality observational studies that consistently show a large effect size might be. For recent Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines, grading of evidence has followed the GRADE approach with some modifications [10,19]. Overall, grading is a work in progress and methods for grading are expected to further evolve, in particular in the grading of evidence that looks at questions related to diagnosis, prognosis or harms.
Quality of evidence in nephrology
Evidence review in nephrology faces a number of challenges. The long and silent course of CKD makes it difficult and expensive to conduct studies that examine hard clinical outcomes. Therefore, surrogate outcomes are often used to shorten the necessary follow-up time. To study the progression of CKD, laboratory parameters, such as the level of glomerular filtration rate (GFR) or proteinuria, are commonly used. It remains an area of active investigation how changes in surrogate outcomes early in the disease predict subsequent changes in the risk for kidney failure. In addition, patients with CKD face an increased risk of cardiovascular disease (CVD) [20,21]. Therefore, outcomes for CVD and interventions to reduce CVD risk need to be included in the study of patients with CKD.
Despite the recognition of CKD as a public health problem, the recruitment of individuals with CKD in the stages of disease prior to kidney failure is difficult. These patients predominantly receive care by non-nephrologists (such as providers in family medicine, internal medicine, endocrinology and diabetes care, cardiology, vascular medicine and surgery). Until recently, the definition and staging of CKD in research studies was heterogeneous. Early stages of CKD were not recognized and large subpopulations with unrecognized CKD were included in studies of diabetes, hypertension or CVD. The use of the K/DOQI classification for CKD should result in a more consistent characterization of patients [22]. What remains unresolved is the problem of misclassification of the type of kidney disease since the aetiological diagnosis is often presumptive and a definitive histo-pathological diagnosis is usually not available. Still the type of kidney disease has important implications for the risk of progression and concomitant diseases.
These methodological problems in the study of CKD may partly explain why the number of large, high-quality clinical studies that examine hard clinical outcomes is relatively limited in nephrology [23]. This is relevant for guideline development since the quality of systematic reviews and the strength of the conclusions that can be drawn depend on the quality of the source literature. At present, many aspects of care for patients with earlier stages of CKD are largely based on extrapolating evidence from studies of individuals without kidney disease. Thus, guideline developers in nephrology face complex issues when integrating and appraising bodies of literature.
Guidelines in nephrology have so far focused primarily on topics related to CKD, namely testing, evaluation and treatment for CKD, its complications and concomitant diseases (Table 2). There is a growing movement among experts to expand guideline development to the area of acute kidney injury (formerly acute renal failure). Expansion of CPGs to this area faces the challenge of lack of standardized definitions and limited understanding of the epidemiology and natural history of this entity.
|
|
Guideline development in nephrology |
|---|
|
TopIntroductionWhat guidelines are and...Methodological challenges for...Guideline development in...ConclusionsReferences |
|---|
Several professional societies in nephrology develop English language CPGs (Table 2). In addition, other agencies, committees and organizations issue guidelines that are relevant to the care of individuals with kidney diseases, for example on hypertension or diabetes. The authors participate in the development of guidelines for the National Kidney Foundation's K/DOQI [24,25]. In the following section, the current process of K/DOQI guideline development is described as an example of what workgroup experts do when developing a guideline. However, discussion of all aspects of guideline methodology is beyond the scope of this review.
Table 3 provides an overview of the process followed in the development of recent K/DOQI guidelines. A guideline is initiated after a topic relevant to clinical practice has been selected by the K/DOQI Chairs and Advisory Board. Workgroup chairs are appointed, who recruit workgroup members with expertise in the relevant areas and clinical disciplines. An evidence review team (ERT) consisting of a staff of methodology and nephrology experts is contracted to guide the workgroup through the systematic review and the critical literature appraisal. The timeline for development of a new guideline is approximately 2 years, with four in-person meetings of the workgroup and the ERT.
|
An important step of guideline development is the generation of a comprehensive list of well-formulated questions that relate to important clinical problems. For each question the ‘PICO’ criteria are specified for population of interest, intervention or predictor of interest, comparison group and outcome(s) of interest [26]. In addition, desired study design, required duration of follow-up, and minimal number of subjects per study are specified for each question. These criteria are used for including studies when screening abstracts and articles.
Data from eligible studies are extracted onto standardized forms and the methodological quality and applicability of each study is assessed. Summary tables are drafted that tabulate the information from each study in a condensed form. For each question the balance of benefits and harms of the health practice is summarized and the quality of the supporting evidence is judged. Thereafter, the workgroup implicitly considers additional issues such as availability of a service, special features of health systems and costs to determine whether a guideline recommendation can be issued and of what strength. Care is taken to make recommendations that are actionable and specific. They are written in the form of ‘what should be done in whom, when, where and how often’. Algorithms* are developed to organize recommendations into a logical sequence. Workgroup members are prompted to describe limitations of the evidence and to provide detailed recommendations for future research that will fill important gaps of knowledge. The CPG draft undergoes internal and public review. The workgroup then revises the guidelines in response to comments from reviewers and submits the guideline document for publication.
When evidence is not sufficient to support an evidence-based guideline, K/DOQI workgroups have issued recommendations based on a consensus. In these cases, the literature has been reviewed and the evidence is not deemed to definitively answer the clinical question but the workgroup wishes to provide guidance to the practitioner. Distinguishing these workgroup consensus statements from evidence-based guidelines clarifies that they are not meant to be used as a foundation for CPMs and should not obstruct future research on the topic.
Guideline implementation
After CPGs have been developed, they need to be implemented. Implementation aims at bridging the gap between best evidence and actual practice and to shorten the delay encountered in the translation of new research findings [27]. Successful implementation is tailored to target practice settings. A first step is to analyse regional practice patterns and compare them against the recommendations in CPGs. Knowledge of local health priorities and structures forms the basis for decisions on how to adopt the guidelines. A growing body of empirical experience on which system changes produce better care and which strategies facilitate such changes can inform the design of implementation strategies [28]. The quality improvement cycle is closed by periodic updating of guidelines to incorporate new research findings and experience gained from evaluation of CPGs implementation. Figure 1 shows the feed-back loop between research, guideline development, implementation and evaluation.
|
Guideline implementation is often not rigorously evaluated and it is difficult to attribute changes in practice solely to the issuance of a guideline. Table 4 shows a chronology of selected events in guideline development and implementation in nephrology. A temporal relationship does not establish what is cause or effect. It also remains to be demonstrated that these activities improve clinical patient outcomes.
|
As can be seen in Table 4, the reaction to guidelines can vary. While some recommendations from CPGs have been widely adopted, others have been the topic of debate or have been contradicted by subsequent research. Evidence-based CPGs can only be definitive if they are supported by high-quality evidence. Yet the lifespan of medical knowledge is limited and even high-quality clinical research can be contradicted by subsequent studies [29]. This highlights the importance of updating CPGs to keep them current, especially when new scientific evidence becomes available.
Challenges in international guideline development
The coexistence of several independent guideline development programs in nephrology allows for diversity in development and tailoring of CPGs specific to particular settings. It also protects against monopolies in topic selection or bias from strong special interests. Yet as the list of CPGs published in Table 1 reveals, a number of topics have been dealt with in guidelines issued by several societies within a few years of each other. Fragmentation of efforts has thus resulted in redundancy and variations in specific guideline recommendations. There has also until recently been little coordination to standardize or advance the methods of guideline development in the specialty.
In response to this situation, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative aims to integrate guideline development in the domain of kidney diseases [30,31]. Advantages of international coordination are consolidation of evidence review tasks and avoidance of duplication of efforts. On the other hand, some of the methodological challenges in guideline development are compounded in the context of international guideline development. Ideally, evidence would be global and implementation would be local. If evidence were a universal truth, evidence review could proceed independently of local considerations, and local implementation groups could then develop recommendations based on systematic reviews and apply them to specific contexts. However, evidence itself may not be independent of factors that relate to the context in which it is generated. The origin of clinical research studies lies disproportionately in developed countries, which affects the conclusions that can be drawn from the findings. The research agenda and interests and perceived health needs of funding bodies influence the questions being studied. The applicability of the findings relates to the populations studied. In the absence of exclusively objective review criteria, selection for publication, appraisal of the quality of evidence and the interpretation of benefits and harms are subject to the judgments and interpretations of reviewers, who are disproportionately based in European and North American countries. On the other hand, while implementation has to be conducted in a local context, some general principles and methods of implementation may apply. Development of implementation strategies and protocols can be informed by comparing implementation experiences and protocols from different settings. This helps distinguish barriers to quality improvement that are intrinsic to systems from those that are related to processes and identify strategies for overcoming them.
The dilemma of how an international guideline can adequately be mindful of all possible permutations of patients, contexts, or health care systems is highlighted by the following example. A guideline to periodically test individuals on dialysis for hepatitis C may help reduce transmission in the dialysis unit in certain countries. In other countries, a recommendation to periodically test blood donors may improve the safety of the blood supply. Both guidelines aim at reducing hepatitis C infections in the dialysis population. How the question is framed will depend on the perspective of the individuals in the workgroup and which strategy is followed will depend on the perspective of the implementers.
In the face of these problems, a practical approach is to harmonize methods for guideline development and grading to facilitate sharing of evidence reports. Local guideline adoption groups can then appraise how the evidence and judgments translate into their settings and how system-specific considerations affect the content or strength of locally issued recommendations.
As has been outlined above, additional considerations affect the prioritization and planning of services to be implemented. Decisions regarding the allocation of resources in a national or regional context will be guided by the aim to optimize individual patients’ health, but will also need to consider other key social goals and preferences as well as the relative cost effectiveness of practices in a particular setting [32,33].
|
Conclusions |
|---|
|
TopIntroductionWhat guidelines are and...Methodological challenges for...Guideline development in...ConclusionsReferences |
|---|
Evidence-based CPGs provide systematic reviews of bodies of evidence with the goal of making this information available to users in a practical format. The ultimate goal is to inform decision making and improve the quality of care. Presently, health care systems face a greater demand for accountability and cost containment and guidelines are used as tools to reduce practice variability. Still, guidelines need to be applied to unique patient settings and health care providers have the final responsibility—and therefore must also have the final authority—to follow the recommendations or not. This decision-making process requires incorporation of patient preferences and weighing whether exemptions or deviations from recommendations are justified.
Over the past several years, the process of guideline development has become more rigorous and evidence-based. Consistency and transparency in grading the quality of evidence remains a challenge. Furthermore, the literature in nephrology is characterized by a limited number of high-quality clinical trials. Yet, the record of guidelines in nephrology suggests that CPGs—as imperfect as they may be—have had an impact. When guideline recommendations pertain to complex clinical processes, implementation has to take an approach that is mindful of specific health care settings and systems. This challenge is augmented in the context of international guideline development, where local recommendations may differ in content or strength for different populations or settings. Future efforts need to improve the methods and efficiency of developing new guidelines and of updating existing guidelines. Finally, since evidence-based guideline can only be as solid as the evidence they are based on, the body of literature in nephrology, that rigorously addresses clinically relevant questions, needs to be expanded.
|
Acknowledgments |
|---|
The authors acknowledge the contributions of the following individuals in the development and refinement of the K/DOQI guideline development process: current and past K/DOQI and KDIGO Chairs Adeera Levin, Michael Rocco, Garabed Eknoyan, Nathan Levin and Norbert Lameire; staff at the National Kidney Foundation (NKF) Kerry Willis, Donna Fingerhut and Anthony Gucciardo. The authors wish to thank Chairs and Members in K/DOQI workgroups, fellows, research assistants and faculty in the Division of Nephrology and the Center for Clinical Evidence Synthesis at Tufts-New England Medical Center, who have taught us to improve the process through their participation in guideline development. The authors are grateful to Amy Earley for editorial assistance in the preparation of this manuscript. The authors acknowledge funding by the NKF to support the work of the NKF Center for Clinical Practice Guideline Development and Implementation at Tufts-New England Medical Center.
Conflict of interest statement. All authors are involved with the development of K/DOQI Clinical Practice Guidelines and receive salary support by the National Kidney Foundation (NKF) for work conducted at the NKF Center for Clinical Practice Guideline Development and Implementation.
|
References |
|---|
|
TopIntroductionWhat guidelines are and...Methodological challenges for...Guideline development in...ConclusionsReferences |
|---|
- Field MJ, Lohr KN, eds. Clinical Practice Guidelines – Directions for a New Program. National Academy Press, Washington, DC: 1990
- Woolf SH. Practice guidelines: a new reality in medicine. I. Recent developments. Arch Int Med 1990; 150: 1811–1818
[Abstract/Free Full Text] - Wennberg JE. Understanding geographic variations in health care delivery. N Engl J Med 1999; 340: 52
[Free Full Text] - Goodkin DA, Mapes DL, Held PJ. The dialysis outcomes and practice patterns study (DOPPS): how can we improve the care of hemodialysis patients? Semin Dial 2001; 14: 157–159[CrossRef][Web of Science][Medline]
- Collins AJ, Roberts TL, St Peter WL, Chen SC, Ebben J, Constantini E. United States Renal Data System assessment of the impact of the National Kidney Foundation – Dialysis Outcomes Quality Initiative guidelines. Am J Kidney Dis 2002; 39: 784–795[Web of Science][Medline]
- Ashton CM, Petersen NJ, Souchek J et al. Geographic variations in utilization rates in veterans affairs hospitals and clinics. N Engl J Med 1999; 340: 32–39
[Abstract/Free Full Text] - KDOQI Disclaimer Website. Accessed 11/16/2005. http://www.kidney.org/professoinals/kdoqi/guidelines_updates/doqiup_disclaimer.html 2005
- O'Connor PJ. Adding value to evidence-based clinical guidelines. JAMA 2005; 294: 741–743
[Free Full Text] - Epstein AM, Lee TH, Hamel MB. Paying physicians for high-quality care. New Engl J Med 2004; 350: 406–410
[Free Full Text] - Atkins D, Best D, Briss PA, GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 1490
[Abstract/Free Full Text] - The AGREE Collaboration. Appraisal of Guidelines Research & Evaluation (AGREE). Instrument, Training Manual. Accessed 11/16/2005. http://www/agreecollaboration.org/pdf/agreeinstrumentfinal.pdf 2003
- Shiffman RN, Shekelle P, Overhage JM, Slutsky J, Grimshaw J, Deshpande AM. Standardized reporting of clinical practice guidelines: a proposal from the Conference on Guideline Standardization. Ann Inter Med 2003; 139: 493–498
[Abstract/Free Full Text] - Cluzeau FA, Littlejohns P, Grimshaw JM, Feder G, Moran SE. Development and application of a generic methodology to assess the quality of clinical guidelines. Int J Qual Health Care 1999; 11: 21–28
[Abstract/Free Full Text] - Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA 1999; 281: 1900–1905
[Abstract/Free Full Text] - Grilli R, Magrini N, Penna A, Mura G, Liberati A. Practice guidelines developed by specialty societies: the need for a critical appraisal. Lancet 2000; 355: 103–106[CrossRef][Web of Science][Medline]
- Schunemann HJ, Best D, Vist G, Oxman AD, GRADE Working Group. Letters, numbers, symbols and words: how to communicate grades of evidence and recommendations. CMAJ 2003; 169: 677–680
[Abstract/Free Full Text] - GRADE Working Group. Systems for grading the quality of evidence and the strength of recommendations II: a pilot study of a new system for grading the quality of evidence and the strength of recommendations. BMC Health Serv Res 2005; 5: 25[CrossRef][Medline]
- The periodic health examination. Canadian Task Force on the Periodic Health Examination. CMAJ 1979; 121: 1193–1254[Medline]
- Uhlig K, MacLeod A. Adoption of a modified GRADE approach for grading of KDIGO guidelines. [Abstract]. 3rd Guideline International Network (GIN) Conference 2005; Lyon, France
- Sarnak M, Levey A, Schoolwerth A et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on kidney in cardiovascular disease, high blood pressure research, clinical cardiology, and epidemiology and prevention. Hypertension 2003; 42: 1050–1065
[Free Full Text] - Vanholder R, Massy Z, Argiles A et al. Chronic kidney disease as cause of cardiovascular morbidity and mortality. Nephrol Dial Transplant 2005; 20: 1048–1056
[Abstract/Free Full Text] - National Kidney Foundation. K/DOQI Clinical Practice Guidelines for chronic kidney disease: evaluation, classification, and stratification. American J Kidney Dis 2002; 39 [Suppl 1]: S1–S266
- Strippoli GF, Craig JC, Schena FP. The number, quality, and coverage of randomized controlled trials in nephrology. J Am Soc Nephrol 2004; 15: 411–419
[Abstract/Free Full Text] - Eknoyan G, Levin NW, Eschbach JW et al. Continuous quality improvement: DOQI becomes K/DOQI and is updated. National Kidney Foundation's Dialysis Outcomes Quality Initiative. Am J Kidney Dis 2001; 37: 179–194[Web of Science][Medline]
- Steinberg EP, Eknoyan G, Levin NW et al. Methods used to evaluate the quality of evidence underlying the National Kidney Foundation-Dialysis Outcomes Quality Initiative Clinical Practice Guidelines: description, findings, and implications. Am J Kidney Dis 2000; 36: 1–11[Web of Science][Medline]
- Counsell C. Formulating questions and locating primary studies for inclusion in systematic reviews. Ann of Intern Med 1997; 127: 380–7
[Abstract/Free Full Text] - Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts. Treatments for myocardial infarction. JAMA 1992; 268: 240–248
[Abstract/Free Full Text] - Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Affair 2001; 20: 64–78
[Abstract/Free Full Text] - Ioannidis JP. Contradicted and initially stronger effects in highly cited clinical research. JAMA 2005; 294: 218–228
[Abstract/Free Full Text] - Eknoyan G, Lameire N, Barsoum R et al. The burden of kidney disease: improving global outcomes. Kidney Int 2004; 66: 1310–1314[CrossRef][Web of Science][Medline]
- Kidney Disease: Improving Global Outcomes (KDIGO). Accessed 1/19/2006. http://www.kdigo.org/welcome.htm 2006
- Murray CJ, Frenk J. A framework for assessing the performance of health systems. B World Health Organ 2000; 78: 717–731
- Hutubessy R, Chisholm D, Edejer TT, and WHO Choice. Generalized cost-effectiveness analysis for national-level priority-setting in the health sector. Cost Eff Resour Alloc 2003 Dec 19; 1(1): 8
- National Kidney Foundation. K/DOQI Clinical Practice Guidelines for bone metabolism and disease in children with chronic kidney disease. Am J Kidney Diseases 2005; 46 [Suppl 1]: S1–S103
- Chobanian A, Bakris G, Black H et al. The Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA 2003; 289: 2560–2572
[Abstract/Free Full Text] - Drueke T, Moe S. Disturbances of bone and mineral metabolism in chronic kidney disease: an international initiative to improve diagnosis and treatment. Nephrol Dial Transplant 2004; 19: 534–536
[Free Full Text] - Levey AS, Eckardt KU, Tsukamoto Y et al. Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2005; 67: 2089–2100[CrossRef][Web of Science][Medline]
- Renal Physicians Association. New ICD-9 Codes for Chronic Kidney Disease. Effective 10/1/2005. Accessed 11/18/2005. http://www.renalmd.org/documents/ICD-9RevisedCKDCodenarrative.pdf 2005
- National Kidney Disease Education Program. Accessed 11/16/2005. www.nkdep.nih.gov 2005
- Wanner C, Krane V, Marz W et al. Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. N Engl J Med 2005; 353: 238–248
[Abstract/Free Full Text] - Lohr KN, Eleazer K, Mauskopf J. Health policy issues and applications for evidence-based medicine and clinical practice guidelines. Health Policy 1998; 46: 1–19[CrossRef][Web of Science][Medline]
Accepted in revised form: 7. 2.06
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  E. Will Intention and outcome in guideline-based nephrological practice: a suitable space for 'clinical technology' Nephrol. Dial. Transplant., November 1, 2007; 22(11): 3110 - 3114. [Full Text] [PDF]
|
|
|
|
|
|
I. C. Macdougall, K.-U. Eckardt, and F. Locatelli Latest US KDOQI Anaemia Guidelines update what are the implications for Europe? Nephrol. Dial. Transplant., October 1, 2007; 22(10): 2738 - 2742. [Full Text] [PDF]
|
|
|
|
 |
|
 D. Van Wyck, K.-U. Eckardt, K. Uhlig, M. Rocco, and A. Levin Appraisal of Evidence and Control of Bias in the Kidney Disease Outcomes Quality Initiative Guideline Development Process Clin. J. Am. Soc. Nephrol., January 1, 2007; 2(1): 8 - 10. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||