Transcript HelpDesk Answers Concise Answers to Clinical Questions

HelpDesk Answers
Evaluating the Evidence
(Strength of Recommendations)
COREY LYON, D.O.
UNIVERSITY OF COLORADO
Objectives
 Gain an understanding for use of Strength of
Recommendations (SOR)
 Exposure to the algorithm for assigning a SOR
 Practice assigning a SOR to a clinical
recommendation
Strength of Recommendation (SOR)
 A recommendation for clinical practice based on a
body of evidence

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Takes into account the level of evidence of individual studies
Type of outcomes measured (patient-oriented or diseaseoriented)
 This is a straightforward, comprehensive, user
friendly grading system.

Created by family physicians to be used in the family medicine
literature.
Critical Components of an HDA
 Clinical Question
 Evidence Based Answer (35-75 words, with
SOR grade)
 Evidence Summary (250-350 words)
 References (100-200 words, with LOEs)
Note that the Evidence Based Answer needs to have a SOR
assigned to it, which shows the reader what type of
evidence the answer is drawn upon.
Strength of Recommendations
 All Help Desk Answers need a SOR grade, which is
based on the body of evidence from the Evidence
Based Summary
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Assigning a SOR to your clinical answer guides readers on the
strength of the recommendation based on the available
evidence
In your Evidence Based Answer, every SOR needs an
explanatory phrase explaining why the grade was given

For example; “SOR A, based on 2 RCTs with consistent findings”
Strength of Recommendation –
Definitions
http://www.jfponline.com/Pages.asp?AID=1635
Algorithm for determining the strength of recommendation based on a body evidence
SOR Example 1 – Assign the SOR
Assign a SOR to this Recommendation:
“Mechanical intervention with a back brace is
effective for low back pain.”
This recommendation is based on a Cochrane review of 7
clinical trials that are consistent in their support of a
mechanical intervention for low back pain, but the trials were
poorly designed (ie, unblinded, nonrandomized, or with
allocation to groups unconcealed).
a)SOR A
b)SOR B
c)SOR C
SOR Example 1 – Assign the SOR
Assign a SOR to this Recommendation:
“Mechanical intervention with a back brace is
effective for low back pain.”
This recommendation is based on a Cochrane review of 7
clinical trials that are consistent in their support of a
mechanical intervention for low back pain, but the trials were
poorly designed (ie, unblinded, nonrandomized, or with
allocation to groups unconcealed).
a)SOR A
b)SOR B – consistent, but lower quality trials
c)SOR C
SOR Example 2 – Assign the SOR
Recommendation: “Drug A is an effective
treatment in pulmonary fibrosis.”
This recommendation is based on a meta-analysis of 9 highquality clinical trials of the use of this new Drug A in the
treatment of pulmonary fibrosis. Two of the studies find
harm, 2 find no benefit, and 5 show some benefit. The
strength of recommendation in favor of this drug would be?
a)SOR A
b)SOR B
c)SOR C
SOR Example 2 – Assign the SOR
Recommendation: “Drug A is an effective
treatment in pulmonary fibrosis.”
This recommendation is based on a meta-analysis of 9 highquality clinical trials of the use of this new Drug A in the
treatment of pulmonary fibrosis. Two of the studies find
harm, 2 find no benefit, and 5 show some benefit. The
strength of recommendation in favor of this drug would be?
a)SOR A
b)SOR B – High quality trials with inconsistent
results
c)SOR C
SOR Example 3 – Assign the SOR
Recommendation: “Drug A increases the forced
expiratory volume in 1 second (FEV1) and peak
flow rate in patients with an acute asthma
exacerbation.”
This recommendation is based on a RCT of good quality,
however, data on symptom improvement is lacking. The
strength of recommendation in favor of using this drug is?
a)SOR A
b)SOR B
c)SOR C
SOR Example 3 – Assign the SOR
Recommendation: “Drug A increases the forced
expiratory volume in 1 second (FEV1) and peak
flow rate in patients with an acute asthma
exacerbation.”
This recommendation is based on a RCT of good quality,
however, data on symptom improvement is lacking. The
strength of recommendation in favor of using this drug is?
a)SOR A
b)SOR B
c)SOR C – Disease oriented evidence
SOR example 4 - Assign the SOR
Recommendation: “Vitamin E should not routinely
be used to prevent heart disease”
An observational study suggested cardiovascular benefit
from vitamin E, but this recommendation against using
vitamin E is from 2 separate large, well-designed RCT
with a diverse patient population which showed no
benefit, and actually showed more harm. The strength
of this recommendation would be?
a) SOR A
b) SOR B
c) SOR C
SOR example 4 - Assign the SOR
Recommendation: “Vitamin E should not routinely
be used to prevent heart disease”
An observational study suggested cardiovascular benefit
from vitamin E, but this recommendation against using
vitamin E is from 2 separate large, well-designed RCT
with a diverse patient population which showed no
benefit, and actually showed more harm. The strength
of this recommendation would be?
a) SOR A- based on 2 RCTs with consistent findings
b) SOR B
c) SOR C
Summary
 Assigning a SOR to a recommendation guides
readers on the strength of the recommendation
based on the body of evidence
 An A recommendation is based on consistent, good
quality patient oriented evidence
 A B recommendation is based one inconsistent, or
limited quality patient oriented evidence
 A C recommendation is based on consensus, diseaseoriented evidence, or opinion
Summary (cont.)
 All Help Desk Answers need a SOR grade, with an
explanatory phrase explaining why the grade was
given

For example; (SOR A, based on a systematic review of RCT)
 The SOR can be assigned by using the SOR
algorithm based on a body of evidence
Reference
 Ebell M, Siwek J, Weiss B, Woolf S, Susman J, Ewigman B, Bowman M.
Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach
to Grading Evidence in the Medical Literature. American Family Physician, Feb
2004;69(3); 548-556