The GRADE framework for moving from evidence to recommendations. - - PowerPoint PPT Presentation

The GRADE framework for moving from evidence to recommendations.

Eddy Lang Senior Researcher Alberta Health Services Associate Professor University of Calgary Peter Morley Associate Professor Director of Medical Education Senior Specialist, Intensive Care Royal Melbourne Hospital University of Melbourne

Overview

• The GRADE conceptual framework for

developing recommendations

• Four dimensions
• Language consideration

Evidence-based clinical decisions

Research evidence Patient values and preferences Clinical circumstances Expertise

Haynes et al. 2002

3

GRADE: Making recommendations

Factors to consider Quality of the evidence Balance between benefits and harms Patient values and preferences Resource use (cost, human resources, etc.) Strength of recommendation Wording Strong recommendation for We recommend... Strong recommendation against We recommend not... Weak/conditional recommendation for We suggest... Weak/conditional recommendation against We suggest not....

Quality of evidence

Balance of benefits versus harms and burdens

Weak or conditional recommendation

Conditional Strong

For

Against

Strong recommendation

Conditional Strong

For

Against

Weak or conditional recommendation

Conditional Strong

For

Against

Strong recommendation

Conditional Strong For Against

Values and preferences

• What is the evidence?

Resource Implications

• What is the evidence?

Other factors in decision making

Four Factors Quality of the evidence Balance between desirable and undesirable effects Values and preferences Resource Use

Strength of recommendati

• n

STRONG WEAK/ CONDITIONAL

• Inconsistency across/within
• 31.6% did not make recommendations

clearly

– Most of them not written as executable actions

• 52.7% did not indicate strength

15

Action oriented recommendations

[weak/strong] recommendation, [MODERATE] evidence

Wording 1 Wording 2 Wording 3 Strong recommendation FOR We recommend… Clinicians should… We recommend… Weak recommendation FOR We suggest Clinicians might… We conditionally recommend… Weak recommendation AGAINST We suggest...not Clinicians might not… We conditionally recommend...not Strong recommendation AGAINST We recommend …not Clinicians should not… We recommend …not

Implications of a strong recommendation

• Policy makers: The recommendation can be

adapted as a policy in most situations

• Patients: Most people in this situation would

want the recommended course of action and only a small proportion would not

• Clinicians: Most patients should receive the

recommended course of action

Implications of a conditional/weak recommendation

• Policy makers: There is a need for substantial

debate and involvement of stakeholders

• Patients: The majority of people in this

situation would want the recommended course

• f action, but many would not
• Clinicians: Be more prepared to help patients to

make a decision that is consistent with their own values/decision aids and shared decision making

Conclusions

• Recommendations guided by but not

locked to Q of E

• Other consideration can be enlisted
• Promotes transparency
• Addresses resource s / costs without

formal economic analysis

• Recommendations none the less but few

strong

Thank You