Transcript No Slide Title

This sessions will be
interactive. So please sit
with people with whom
you will enjoy a
conversation
Plan
• GRADE background
• two steps
– confidence in estimates (quality of
evidence)
– strength of recommendation
• evidence profiles
Grading good idea, but which
grading system to use?
• many available
–
–
–
–
–
Australian National and MRC
Oxford Center for Evidence-based Medicine
Scottish Intercollegiate Guidelines (SIGN)
US Preventative Services Task Force
American professional organizations
• AHA/ACC, ACCP, AAP, Endocrine society, etc....
• cause of confusion, dismay
Dilemma: proliferation of systems
Solution: common international
grading system?
• GRADE (Grades of recommendation,
assessment, development and evaluation)
• international group
– Australian NMRC, SIGN, USPSTF, WHO, NICE,
Oxford CEBM, CDC, CC
• ~ 30 meetings over last eleven years
• (~10 – 50 attendants)
Grading system – for what?
• interventions
– management strategy 1 versus 2
• what grade is not about
– individual studies (body of eidence)
– prognostic questions
• in patients with heart failure is high uric
acid associated with increased risk
– diagnostic accuracy questions
• in lung cancer, what is the accuracy of CT
scanning of the mediastinum
GRADE Uptake
Agencia sanitaria regionale, Bologna, Italia
Agency for Health Care Research and Quality (AHRQ)
Allergic Rhinitis and Group - Independent Expert Panel
American Association for the study of liver diseases
American College of Cardiology Foundation
American College of Chest Physicians
American College of Emergency Physicians
American College of Physicians
American Endocrine Society
American Gastroenterology Association
American Society for Colposcopy and Cervical Pathology
American Society of Gastrointestinal Endoscopy
American Society of Interventional Pain Physicians
American Thoracic Society (ATS)
Ärztliches Zentrum für Qualität in der Medizin - Germany
Austrian Ludwig Boltzmann Institute for HTA
BMJ Clinical Evidence
British Medical Journal
Canadian Agency for Drugs and Technology in Health
Canadian Cardiovascular Society
Canadian Society of Nephrology
Canadian Task Force on Preventive Health Care
Centre for Disease Control Committee on Immunization Practices
COMPUS at CADTH - Canada
Centers for Disease Control
Cochrane Collaboration
Critical Ultrasound Journal
Dutch Institute for Healthcare Improvement CBO
EBM Guidelines Finland
Emergency Medical Services for Children National Resource Center
European Association for the Study of the Liver
European Monitoring Centre for Drugs and Drug Addicaton
European Respiratory Society
European Society of Thoracic Surgeons
Evidence-based Nursing Sudtirol, Alta Adiga, Italy
Evidence-Based Tuberculosis Diagnosis (tbevidence.org) - Canada
Finnish Office of Health Technology Assessment
German Agency for Quality in Medicine
German Center for Evidence-based Nursing "sapere aude" - Germany
Heelth Inspectorate for Scotland
Infectious Disease Society of America
Institute for Clinical Systems Improvement
Japanese Society of Oral and Maxillofacial Radiology
Japanese Society for Temporomandibular Joint
Joslin Diabetes Center
Journal of Infection in Developing Countries
Kaiser Permanente
Kidney Disease International Guidelines Organization
Ministry of Health and Long-term Care, Ontario
National and Gulf Centre for Evidence-based Medicine
National Board of Health and Welfare - Sweden
National Institute for Clinical Excellence (NICE)
National Kidney Foundation
NHS Quality Improvement Scotland - UK
Norwegian Knowledge Centre for the Health Services
Ontario MOH Medical Advisory Secretariat
Panama and Costa Rica National Clinical Guidelines Program
Polish Institute for EBM
Scottish Intercollegiate Guideline Network (SIGN)
Society of Critical Care Medicine
Society of Pediatric Endocrinology
Society of Vascular Surgery
Spanish Society of Family Practice (SEMFYC)
Stop TB Diagnostic Working Group
Surviving sepsis campaign
Swedish Council on Technology Assessment in Health Care
Swedish National Board of Health and Welfare
University of Pennsylvania Health System for EB Practice
UpToDate
WINFOCUS
World Allergy Organization
World Health Organization (WHO)
GRADE uptake
What are we grading?
• two components
• confidence in estimate of effect
adequate to support decision (quality
of body of evidence)
• high, moderate, low, very low
• strength of recommendation
• strong and weak
Confidence in estimate
(quality of evidence)
Very Low
no
confidence
Moderate
Low
High
totally
confident
Determinants of confidence
• RCTs start high
• observational studies start low
• what can lower confidence?
•
•
•
•
•
risk of bias
inconsistency
indirectness
imprecision
publication bias
What can raise confidence?
• large magnitude can rate up one level
– very large two levels
• common criteria
– everyone used to do badly
– almost everyone does well
– quick action
• hip replacement for hip osteoarthritis
Dose-response gradient
• childhood lymphoblastic leukemia
• risk for CNS malignancies 15 years after
cranial irradiation
• no radiation: 1% (95% CI 0% to 2.1%)
• 12 Gy: 1.6% (95% CI 0% to 3.4%)
• 18 Gy: 3.3% (95% CI 0.9% to 5.6%).
Confidence assessment criteria
Beta blockers in non-cardiac surgery
Summary of Findings
Quality Assessment
Quality
Relative
Effect
(95% CI)
Outcome
Number of
participants
(studies)
Risk of
Bias
Consistency
Directness
Precision
Publication
Bias
Myocardial
infarction
10,125
(9)
No serious
limitations
No serious
imitations
No serious
limitations
No serious
limitations
Not
detected
High
0.71
(0.57 to 0.86)
Mortality
10,205
(7)
No serious
limitations
Possiblly
inconsistent
No serious
limitations
Imprecise
Not
detected
Moderate
or low
1.23
(0.98 – 1.55)
Stroke
10,889
(5)
No serious
limitaions
No serious
limitations
No serious
limitations
No serious
limitations
Not
detected
High
2.21
(1.37 – 3.55)
Absolute risk
difference
1.5% fewer
(0.7% fewer to
2.1% fewer)
0.5% more
(0.1% fewer
to 1.3% more)
0.5% more
(0.2% more to
1.3% more0
Strength of Recommendation
• strong recommendation
– benefits clearly outweigh risks/hassle/cost
– risk/hassle/cost clearly outweighs benefit
• what can downgrade strength?
• low confidence in estimates
• close balance between up and downsides
Significance of strong vs weak
• variability in patient preference
– strong, almost all same choice (> 90%)
– weak, choice varies appreciably
• interaction with patient
– strong, just inform patient
– weak, ensure choice reflects values
• use of decision aid
– strong, don’t bother
– weak, use the aid
• quality of care criterion
– strong, consider
– weak, don’t consider
Conclusion
• clinicians, policy makers need summaries
– confidence in estimates
– strength of recommendations
• explicit rules
– transparent, informative
• GRADE
– transparent, systematic
– increasing wide adoption