Bladder Managment for Adults with Spinal Cord Injury - 12

BLADDER MANAGEMENT FOR ADULTS WITH SPINAL CORD INJURY

dence is classified as “opinion” (levels IV and V). A distinction is made between the published opinion of authorities (level IV) and the opinion of those who contributed to these guidelines (level V). However, it should be noted that by the time level V evidence has gone through the exhaustive consensus-building process used in the preparation of these guidelines, it has achieved a level of credibility that is at least equivalent to level IV evidence.

“Scientific evidence” is indicated as “III/V”). In situations in which no published literature exists, consensus of the panel members and outside expert reviewers was used to develop the recommendation and is indicated as “Expert consensus.”

Grad ing o f Panel Consensus
The level of agreement with the recommendation among panel members was assessed as either low, moderate, or strong. Each panel member was asked to indicate his or her level of agreement on a 5-point scale, with 1 corresponding to neutrality and 5 representing maximum agreement. Scores were aggregated across the panel members and an arithmetic mean was calculated. This mean score was then translated into low, moderate, or strong, as shown in Table 2. A panel member could abstain from the voting process for a variety of reasons, including, but not limited to, lack of expertise associated with the particular recommendation.
TA B L E 2

Grading the Guideline Recommendations
After panel members had drafted their sections of the guideline, each recommendation was graded according to the level of scientific evidence supporting it. The framework used by the methodology team is outlined in Table 1. It should be emphasized that these ratings, like the evidence table ratings, represent the strength of the supporting evidence, not the strength of the recommendation itself. The strength of the recommendation is indicated by the language describing the rationale.
TA B L E 1

L ev el s of P an el A gre e m e n t w i t h R e c o m m e n d a t i o n s
Level M e a n A g re e m e n t S c o re

C a t e g o r i e s o f t h e S t re n g t h o f E v i d e n c e Assoc ia ted wi th th e R eco mm en da tio n s
C atego ry De scription

Low Moderate Strong

1.0 to less than 2.33. 2.33 to less than 3.67. 3.67 to 5.0.

A B C

The guideline recommendation is supported by one or more level I studies. The guideline recommendation is supported by one or more level II studies. The guideline recommendation is supported only by one or more level III, IV, or V studies.

REFERENCES

Sources: Sackett, D.L., Rules of evidence and clinical recommendation on the use of antithrombotic agents, Chest 95 (2 Suppl) (1989), 2S-4S; and the U.S. Preventive Health Services Task Force, Guide to Clinical Preventive Services, 2nd ed. (Baltimore: Williams and Wilkins, 1996).

Cook, D.J., C.D. Mulrow, and R.B. Haynes. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med 126 (1997): 376–80.Harris, R.P M. Helfand, S.H. Woolf ., et al. Current methods of the U.S. Preventive Services Task Force. A Review of the Provess. Am J Prev Med 20 (3 Suppl) (2001): 21–35. Jadad, A.R., R.A. Moore, D. Carroll et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Controll Clin Trials 17 (1996): 1–12. Sacks, H.S., J. Berrier, D. Reitman et al. Meta-analyses of randomized controlled trials. N Engl J Med 316 (1987): 450–5. Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Introduction. CMAJ 158 (3 Suppl) (1998): S1–S2. . West, S., V King, T.S. Carey et al. Systems to rate the strength of scientific evidence. Evidence Report/Technology Assessment No. 47 (prepared by Research Triangle Institute, University of North Carolina Evidence-Based Practice Center, under contract no. 290–97–0011). AHRQ pub. no. 02–E016. Rockville, MD: Agency for Healthcare Research and Quality, April 2002. Other useful sources include the following: Canadian Task Force on Preventive Health Care, www.cdphc.org Centre for Evidence Based Medicine, www.minervation.com/cebm/docs/levels.html The Scottish Intercollegiate Guidelines Network, www.sign.ac.uk/ The New Zealand Guidelines Group, www.nzgg.org.nz/

Category A requires that the recommendation be supported by scientific evidence from at least one properly designed and implemented randomized, controlled trial, providing statistical results that consistently support the guideline statement. Category B requires that the recommendation be supported by scientific evidence from at least one small randomized trial with uncertain results; this category also may include small randomized trials with certain results where statistical power is low. Category C recommendations are supported by either nonrandomized, controlled trials or by trials for which no controls are used. If the literature supporting a recommendation comes from two or more levels, the number and level of the studies are reported (e.g., in the case of a recommendation that is supported by two studies—one a level III, the other a level V—the

http://www.cdphc.org http://www.minervation.com/cebm/docs/levels.html http://www.sign.ac.uk/ http://www.nzgg.org.nz/

Bladder Managment for Adults with Spinal Cord Injury

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