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Aprendiendo sobre GRADE

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GRADE: sistema para evaluar la calidad de la evidencia y hacer recomendaciones en salud

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  • DOWNLOAD THE BOOK INTO AVAILABLE FORMAT (New Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://urlzs.com/UABbn } ......................................................................................................................... Download Full EPUB Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download Full doc Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download PDF EBOOK here { https://urlzs.com/UABbn } ......................................................................................................................... Download EPUB Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download doc Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THE can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THE is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBOOK .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, CookBOOK, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, EBOOK, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THE Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THE the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THE Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
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  • DOWNLOAD THE BOOK INTO AVAILABLE FORMAT (New Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://urlzs.com/UABbn } ......................................................................................................................... Download Full EPUB Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download Full doc Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download PDF EBOOK here { https://urlzs.com/UABbn } ......................................................................................................................... Download EPUB Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download doc Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THE can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THE is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBOOK .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, CookBOOK, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, EBOOK, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THE Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THE the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THE Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
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  • DOWNLOAD THE BOOK INTO AVAILABLE FORMAT (New Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://urlzs.com/UABbn } ......................................................................................................................... Download Full EPUB Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download Full doc Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download PDF EBOOK here { https://urlzs.com/UABbn } ......................................................................................................................... Download EPUB Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download doc Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THE can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THE is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBOOK .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, CookBOOK, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, EBOOK, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THE Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THE the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THE Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
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  • DOWNLOAD THE BOOK INTO AVAILABLE FORMAT (New Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://urlzs.com/UABbn } ......................................................................................................................... Download Full EPUB Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download Full doc Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download PDF EBOOK here { https://urlzs.com/UABbn } ......................................................................................................................... Download EPUB Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download doc Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THE can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THE is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBOOK .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, CookBOOK, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, EBOOK, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THE Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THE the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THE Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
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Aprendiendo sobre GRADE

  1. 1. Prevención de caídas en el anciano Eli Urrestarazu, Mikel Moreno, Rafa Rotaeche (Grupo MBE Ostazen) 26 Octubre 2018
  2. 2. Contenido • GRADE introducción para lectores de revisiones y recomendaciones (GPC) • La US Preventive Task Force y GRADE
  3. 3. Fundamentos de la sesión http://www.gradeworkinggroup.org/ https://www.fisterra.com/guias-clinicas/la-evaluacion-calidad-evidencia-graduacion-fuerza-recomendaciones-sistema-grade/
  4. 4. Fundamentos de la sesión 4-interactive Evidence to Decision framework 3-interactive Summary of Findings2-Guideline Development Tool1-GRADE Handbook
  5. 5. Systematic review Guideline development P I C O Outcome Outcome Outcome Outcome Critical Important Critical Not Summary of findings & estimate of effect for each outcome Grade overall quality of evidence across outcomes based on lowest quality of critical outcomes Randomization increases initial quality 1. Risk of bias 2. Inconsistency 3. Indirectness 4. Imprecision 5. Publication bias GradedownGradeup 1. Large effect 2. Dose response 3. Confounders Very low Low Moderate High Formulate recommendations: • For or against (direction) • Strong or conditional/weak (strength) By considering:  Quality of evidence  Balance benefits/harms  Values and preferences Revise if necessary by considering:  Resource use (cost) • “We recommend using…” • “We suggest using…” • “We recommend against using…” • “We suggest against using…”
  6. 6. Formulando recomendaciones con GRADE http://www.gacetasanitaria.org/es-marcos-grade-evidencia-decision-etd--articulo-S0213911117301206 http://www.gacetasanitaria.org/es-marcos-grade-evidencia-decision-etd--articulo-S0213911117301218
  7. 7. Definiciones Certeza (calidad)de la evidencia/: indica hasta qué punto podemos confiar en que el estimador del efecto es correcto. Fuerza de la recomendación: indica hasta qué punto podemos confiar si poner en práctica la recomendación conlleva más beneficios que riesgos
  8. 8. Pregunta clínica Resumen de la evidencia para los desenlaces de interés •Riesgo de sesgo •Inconsistencia •Falta de evidencia directa •Imprecisión •Sesgo de publicación ReducirsiAumentarsi •Gran estimador del efecto •Relación dosis – respuesta •Ausencia de confusores Evaluación de la calidad de la evidencia Confianza en los estimadores del efecto ALTA  MODERADA  BAJA  MUY BAJA  1. SÍNTESIS DE LA EVIDENCIA CIENTÍFICA Y EVALUACIÓN DE LA CERTEZA DE LA EVIDENCIA Certeza/calidad de la evidencia Resultado clave Resultado crítico Resultado importante
  9. 9. Pregunta clínica estructurada Pacientes Adultos con diabetes tipo 2, mal controlado con metformina Intervención MET+SU; MET+Glitazona; MET+Meglitinidas; MET+DPP- 4; MET+ GLP-1; Met-SGLT- Comparación MET+Placebo. Comparaciones MET+SU (vs. resto de combinaciones en biterapia). Resultados Mortalidad; Complicaciones macrovasculares y microvasculares; HbA1c; Peso; Hipoglucemia; Efectos adversos; Coste. Tipo de estudio RS de ECA, ECA con resultados de morbimortalidad Nuevos estudios y pregunta PICO Biterapia
  10. 10. 9 8 7 6 5 4 3 2 1 7-9 Clave para la Toma de decisiones 4-6 Importante pero no clave Nº estudios 1-3 No importante para los pacientes Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol 2011;64(4):395-400. 1. Clasificación numérica en tres categorías Clasificación de las variables de resultado
  11. 11. Variable Puntuación Importancia Mortalidad 9 CRITICA Infarto Miocardio 8,8 CRITICA Mortalidad CV 8,5 CRITICA ACV 8,16 CRITICA I.Renal 7,75 CRITICA ECV mayores 7,6 CRITICA Insuf cardíaca 7,08 CRITICA Arteriop.Perifer 6,66 IMPORTANTE Angina que requiere ingreso 6,6 IMPORTANTE Calidad Vida 6,5 IMPORTANTE Revasc coronaria 6,4 IMPORTANTE Abandono por efectos 2º 6,25 IMPORTANTE Progresión de Retinopatía 6,25 IMPORTANTE Hipoglucemia 6,25 IMPORTANTE Incidencia Diabetes 5,5 IMPORTANTE Cumplimiento 5,16 IMPORTANTE Deterioro P Funcion renal 5,08 IMPORTANTE Microalbuminuria 5 IMPORTANTE Peso 4,8 IMPORTANTE Cifras de HbA1c 4,75 IMPORTANTE Importancia de las variables de resultado
  12. 12. Limitaciones en el diseño (riesgo de sesgo)  En el sistema GRADE - los ECA (comienzan como evidencia de alta calidad) - los estudios observacionales (comienzan como evidencia de baja calidad) Ambos tipos pueden disminuir su calidad si los estudios presentan un alto riesgo de sesgo  El riesgo de sesgo no se evalúa por estudio sino por desenlace y puede variar según desenlace
  13. 13. CALIDAD DISEÑO FACTORES QUE PUEDEN DISMINUIR LA CALIDAD ALTA Es muy improbable que la aparición de nuevos estudios cambien nuestra confianza en la estimación del efecto y puedan cambiarla Ensayos Controlados Aleatorizados  Calidad del estudio  Importantes inconsistencias  Evidencia directa o indirecta  Datos imprecisos o escasos  Alta probabilidad de sesgo de publicación MODERADA: Es probable que la aparición de nuevos estudios tenga un impacto importante en la confianza en la estimación del efecto y pueda cambiarla. BAJA: Es muy probable que la aparición de nuevos estudios tenga un impacto importante en la confianza en la estimación del efecto y es probable que cambie Estudios Observacionales FACTORES QUE PUEDEN AUMENTAR LA CALIDAD Magnitud del efecto importante Gradiente dosis-respuesta relevante Impacto de las variables de confusión plausiblesMUY BAJA: Cualquier estimación del efecto es muy incierto. JUZGANDO LA CALIDAD DE LA EVIDENCIA
  14. 14. Evaluación de la calidad Nº de estudios Diseño Riesgo de sesgo Consistencia Evidencia indirecta Precisión Sesgo de publicación Desenlace Desenlace Desenlace Limitaciones en el diseño de los estudios (riesgo de sesgo)
  15. 15. EVALUACIÓN DE LA CALIDAD DE LA EVIDENCIA EN RS de ECA  El propio diseño (ECA)  El riesgo de sesgo (aleatorización, enmascaramiento, pérdidas, interrupción prematura por beneficio…)  Evidencia directa/indirecta: PICO  Consistencia (¿heterogeneidad? ¿Es apropiado agregar datos?  Precisión  Sesgo de publicación JUZGANDO LA CALIDAD DE LA EVIDENCIA ECA RS
  16. 16. Evidencia indirecta • Diferencias en la población • Diferencias en la intervención • Desenlaces intermedios (desenlaces subrogados) • Comparaciones indirectas JUZGANDO LA CALIDAD DE LA EVIDENCIA
  17. 17. Evidencias indirectas Pregunta Causa de evidencia indirecta Esteroides inhalados en el niño pequeño con Asma ECAs sólo en el niño mayor Paciente “experto” en la gestión de la enfermedad crónica ECA realizados en sistemas privados de asistencia sanitaria Oseltamivir en la gripe aviar Sólo existen ECA en la gripe pandémica Endarterectomía en la población general Mortalidad en Hospitales Medicare vs Hospitales Universitarios AINE no incluido en la revisión ¿efecto de clase?
  18. 18. Tabla de evidencia estudios TECOS,EXAMINE y SAVOR-TIMI IDDP4 (Sitagliptina, Alogliptina y Saxagliptina vs tto habitual en Dm2 en prevención 2ª 1:Pérdidas elevadas y no se proporciona información sobre la OSA en un ensayo 2:El intervalo de confianza amplio( cruza el umbral de relevancia clínica)
  19. 19. •Calidad de la evidencia •Balance entre beneficios y riesgos (incluida la “carga de tratamiento”) •Uso de recursos y costes •Valores y preferencias de los pacientes •Otros factores: aceptabilidad, equidad implementabilidad De la evidencia a la decisión/recomendación (EtD) Factores a considerar
  20. 20. • Calidad de la evidencia • Balance entre beneficios y riesgos • Uso de recursos • Valores y preferencias de los pacientes • Equidad • Aceptabilidad • Factibilidad Valorar factores específicos del contexto Dirección de la recomendación • A favor del procedimiento • En contra del procedimiento Fuerza de la recomendación: • Fuerte • Débil/Condicional Formulación de la recomanación Marco de la evidencia a las decisiones/recomendaciones  Fuerza de la recomendación: indica hasta qué punto podemos confiar si poner en práctica la recomendación conlleva más beneficio que riesgo Formulación de las recomendaciones
  21. 21. Dirección de la recomendación • A favor del procedimiento • En contra del procedimiento Fuerza de la recomendación •Fuerte • Débil/Condicional De la evidencia a la recomendación (EtD)
  22. 22. Recomendación fuerte Recomendación débil Para pacientes La mayoría de las personas estarían de acuerdo con la acción recomendada y solo una pequeña proporción estaría en desacuerdo. Las herramientas formales para la toma de decisiones probablemente no serán necesarias para ayudar a las personas a tomar decisiones coherentes con sus valores y preferencias. La mayoría de las personas en esta situación estarían de acuerdo con la acción sugerida, pero muchas estarían en desacuerdo. Las herramientas de toma de decisiones pueden ser útiles como ayuda para la toma de decisiones coherentes con los valores y preferencias de cada persona. Para profesionales sanitarios La mayoría de las personas debería recibir la intervención recomendada. Reconoce que habrá diferentes opciones apropiadas para cada paciente individual y que se deberá alentar a que cada paciente alcance una decisión de manejo coherente con sus valores y preferencias. Las herramientas para la toma de decisiones pueden ser útiles como ayuda para la toma de decisiones coherentes con los valores y preferencias de cada persona. Para decisores/gestore s La recomendación puede ser adaptada a la política sanitaria en la mayoría de las situaciones. La aplicación de esta recomendación incluida puede servir de criterio de calidad o indicador de rendimiento La formulación de políticas sanitarias requerirá considerables debates y la participación de los diversos grupos de interés
  23. 23. Jornada Científica 2016 8.- Formulación de las recomendaciones Redacción y justificación
  24. 24. https://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services-task-force-ratings
  25. 25. https://www.uspreventiveservicestaskforce.org/Page/Name/se ction-7-formulation-of-task-force-recommendations
  26. 26. https://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services-task-force-ratings

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