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Evidence to Decision Framework for Public Health: Opportunity for Collaboration
Michele Hilton BoonMiloslav Klugar @[email protected]
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Declarations of Interest
Presented by members of the:• GRADE Working Group www.gradeworkinggroup.org• Masaryk University• University of Glasgow • Cochrane Czech Republic• Czech CEBHC JBI centre of excellence • Czech Health Research Council• Cochrane Public Health• Miloslav Klugar has no direct financial conflicts of interest• Michele Hilton Boon has no direct financial conflicts of interest
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Objectives• Background information
• Need for one unified concept
• Overlap of WHO-INTEGRATE with NICE and GRADE EtD
• Thematic analysis
• GRADE EtD for Public Health
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Background information
• Map of evidence-to-decision frameworks: development over time and common themes
• Where we’ve been and how we got here
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Pre-EBM guidelines GOBSAT Method
• ‘Good old boys sat around the table’
• Initial approach to development of recommendations within guidelines
• Based on expert opinion, powerful figures, eminence based medicine
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Pre-EBM guidelines (GOBSAT; black box)
Evidence Interpretation /Contextualisation of
Evidence
Recommendation
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Early evidence-based guidelines (e.g. SIGN)
Evidence Interpretation /Contextualisation of
Evidence
Recommendation
Systematic review (Cochrane-derived methods)
Considered judgment framework 1 Consistency 2 Applicability 3 Acceptability 4 Costs and feasibility
Graded A, B, C, D
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GRADE (standardisation of rigorous and transparent methods)
Evidence Interpretation /Contextualisation of
Evidence
Recommendation
Systematic review Summary of Findings Rating certainty of evidence
EtD
frameworks
Strong or Weak/Conditional
GRADE EtDs
…more? Or common ground?
WHO-INTEGRATE
Other GL developers
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Methods of guidelines development
• development- full-process guideline
method No1
• adoption- adapted guideline, derived guidelinemethod No2
cebhc.upol.cz
• adaptation- adapted guideline, derived guideline
method No3
• adolopmentcombining adoption adaptation and developmentmethod No4
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What methodology to use?
OR
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Priority Setting
Updating
Conf
lict-o
f-Int
eres
t Con
sider
atio
ns
Guideline Group Membership &
Processes
Documenting Guideline Developm
ent Process & Decisions
Guideline Panel
Oversight Committee
Consumers & Stakeholders
Working Groups
Organization, Budget, Planning & Training
Developing Recommendations & Determining their Strength
Wording of Recommendations
Reporting & Peer Review
Dissemination & Implementation
Evaluation & Use
Effects(Interventions, Diagnostic Tests)
Importance of Outcomes and Interventions, Values, Preferences & Utilities
Baseline Risk, Burden of Disease, Resource Use, Effects on Equity & Other Information
Target Audience & Topic Selection
(PICO) Question Generation
Summarizing Evidence & Considering Additional Information
Judging Quality, Strength or Certainty of Body of Evidence
Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise. CMAJ. 2014 Feb 18;186(3):E123-42. http://cebgrade.mcmaster.ca/guidecheck.html
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MAKES
ADOPTION/ADAPTATION/ADOLOPMENT
Easy, Fast, Transparent
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GRADE HS-PH EtD WHO-INTEGRATE NICE PMG20 §9.1
• Priority of the problem• Benefits and harms• Certainty of the
evidence• Outcome importance• Balance between
benefits and harms• Resource use• Equity• Acceptability• Feasibility of
implementation
• Balance of health benefits and harms
• Human rights and sociocultural acceptability
• Health equity, equality and non-discrimination
• Societal implications• Financial and economic
considerations• Feasibility and health
system considerations• Quality of evidence
(“metacriterion”)
• Quality of the evidence• Trade-off between
benefits and harms of an intervention
• Trade-off between economic considerations and resource use
• Extrapolation of evidence
• Availability of evidence to support implementation (including evidence from practice)
• Size of effect and potential impact on population health
• Wider basis for making recommendations: any ethical issues, social value judgements, equity considerations and inequalities in outcomes, policy imperatives, and equality legislation
• Conceptual framework or logic model
• Equality considerations• Insufficient evidence.
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Common elements
• Certainty (quality) of evidence• Equity/equality• Feasibility of implementation• Benefits and harms• Economic considerations
This Photo by Unknown Author is licensed under CC BY
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Differences• GRADE:
• Acceptability• Priority of the problem
• WHO-INTEGRATE: • Societal implications [social
determinants and sustainability]• Human rights and sociocultural
acceptability
• NICE PMG20:• Policy imperatives• Social value judgements
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Implications?
• Have a conversation about ‘missing’ elements in GRADE HS-PH EtDe.g. societal implications
• Identify examples from practice• Systematically investigate usage of HS-PH EtD across PH guideline
developers; further research?• Improve GRADE handbook chapter, collating existing guidance• Priorities for more detailed guidance? (e.g. equity already exists; are
new project groups needed e.g. human rights?)
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Thank you for listening.