GDG Meeting

Wednesday November 9, 2011 9:30 – 11:30 am

Time Agenda Lead

9:30 - 9:35 Review objectives for the teleconference Jess Rogers

9:35 - 9:45 Business rising from previous meeting:• Conflict of interest• Analytic framework• Literature research and review

Jess Rogers

9:45 - 10:00 Review of guideline methods Jess Rogers

10:00 - 10:20 Confirming Outcomes Valerie Palda

10:20 - 11:15 GRADE:• What does GRADE offer?• Review GRADE process/methodology• Walk though GRADE tables• How do you combine evidence?

Valerie Palda Dave Hallett

11:15 - 11:30 • Questions• Overview of training session agenda Dec 6-7• Action items

All

Agenda

Objectives Confirm outcomes for analytic framework Review Guideline Development Process Review rationale and purpose of GRADE Review a sample GRADE table to ensure

everyone is comfortable using them

GRADE: An OverviewGrading of RecommendationsAssessment, Development and

Evaluation

Agenda What is GRADE? Importance of Evidence Determining Quality of Evidence Methods for Summarizing Evidence

• Evidence Profile Tables• Summary of Findings Tables

Determining Strength of Recommendations

What is GRADE? A transparent and structured process for

developing and presenting evidence summaries for systematic reviews and guidelines in health care and for carrying out the steps involved in developing recommendations.

The GRADE Approach Considers

• All factors to determine how confident we are in the results (quality of evidence)

• The evidence for each outcome• Magnitude of the effect

Ensures• Systematic process• Transparency

Importance of EvidenceWhen making guideline recommendations: The quality of evidence reflects the extent to

which our confidence in an estimate of the effect is adequate to support a particular recommendation.

Quality of the Body of Evidence

Determining Quality RCTs start (high) Observational studies start at (low)

Determining Quality

5 factors that can lower quality1. Limitations in detailed design and execution (risk

of bias criteria)2. Inconsistency (or heterogeneity)3. Indirectness (PICO and applicability)4. Imprecision (number of events and confidence

intervals)5. Publication bias

Summarizing Evidence Evidence Profiles and Summary of Findings

Tables• An EP includes a detailed quality assessment in

addition to a SoFs. • The SoF table includes an assessment of the

quality of evidence for each outcome but not the detailed judgments on which that assessment is based.

Evidence Profile Table

Summary of Findings Table

Determining Strength of Recommendations

4 key Factors Influence the Strength of a Recommendation

1. Quality of the evidence The higher the quality of evidence, the more likely is a strong

recommendation.2. Balance between desirable and undesirable effects The larger the difference between the desirable and undesirable

consequences, the more likely a strong recommendation warranted. The smaller the net benefit and the lower certainty for that benefit, the more likely weak recommendation warranted.

3. Values and preferences The greater the variability in values and preferences, or uncertainty in

values and preferences, the more likely weak recommendation warranted.

4. Costs (resource allocation) The higher the costs of an intervention – that is, the more resources

consumed – the less likely is a strong recommendation warranted