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Evidence to Decision Framework for Public Health: Opportunity for Collaboration

Michele Hilton BoonMiloslav Klugar @MKlugarklugar@med.muni.cz

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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.