Evidence Based Medicine – Guidelines and GRADE methodology

Guidelines and GRADE Methodology

Guidelines are recommendations intended to assist providers and recipients of health care and other stakeholders to make informed decisions. Recommendations may relate to clinical interventions, public health activities, or government policies. ( WHO 2003,2007)

Before forming guidelines, consider –

• Who is the target user of the guideline
•  Who it applies to
•  What is covered? – Eg diagnosis and treatment of diabetic retinopathy
•  Develop key questions

Key Steps –

1. Group Composition & consultation process
2. Managing conflicts of interests
3. Formulate Question
4. Select Outcomes
5. Rate Importance
6. Create Evidence Profile using GRADE-PRO
7. Rate quality of evidence for each Outcome
8. Downgrade or Upgrade evidence based on certainty
9. Grade overall quality of evidence.
10. Formulate recommendations
11. Integrating values and consumer involvement
12. Incorporate considerations – Cost-effectiveness, affordability, applicability and transferability
13. Reporting
14. Dissemination and implementation
15. Evaluation

GRADE (Grading of Recommendations, Assessment, Development and Evaluations) is the most widely adopted tool for grading the quality of evidence and for making recommendations.

The method of applying GRADE ( Ref – https://www.gradeworkinggroup.org/)

1. The certainty in the evidence (also known as quality of evidence or confidence in the estimates) should be defined consistently with the definitions used by the GRADE Working Group.
2. Explicit consideration should be given to each of the GRADE domains for assessing the certainty in the evidence.
3. The overall certainty in the evidence should be assessed for each important outcome using four or three categories (such as high, moderate, low and/or very low) and definitions for each category that are consistent with the definitions used by the GRADE Working Group.
4. Evidence summaries and evidence to decision criteria should be used as the basis for judgments about the certainty in the evidence and the strength of recommendations. Ideally, evidence profiles should be used to assess the certainty in the evidence and these should be based on systematic reviews. At a minimum, the evidence that was assessed and the methods that were used to identify and appraise that evidence should be clearly described.
5. Explicit consideration should be given to each of the GRADE criteria for determining the direction and strength of a recommendation or decision. Ideally, GRADE evidence to decision frameworks should be used to document the considered research evidence, additional considerations and judgments transparently.
6. The strength of recommendations should be assessed using two categories (for or against an option) and definitions for each category such as strong and weak/conditional that are consistent with the definitions used by the GRADE Working Group (although different terminology may be used), such as strong.