Background
Methods
The EtD frameworks
Earlier version | Latest version |
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Used on the World Health Organization and Spanish Guidelines program | Used in Kingdom of Saudi Arabia, World Allergy Organization, Colombian guideline program and rare diseases guidelines |
Did not include “prioritization of the problem” | Included a question evaluating the priority of the problem |
Included a single question evaluating the balance between health benefits and harms of the intervention of interest | The original question was disaggregated into 3 questions: (1) the magnitude of the health benefits, (2) the magnitude of the health harms, and (3) the balance between health benefits and harms. |
Included a single question evaluating the variability of patients’ values and preferences | A judgment regarding the uncertainty about patients’ values and preferences was added. |
Included a single question evaluating the cost of the intervention in relation to the benefits | The original question was disaggregated into 2 questions: (1) what is the cost of the intervention and (2) how large is this cost in relation to the benefits. |
Included equity as an additional criterion | Acceptability and feasibility were added to equity |
Guideline panels |
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Kingdom of Saudi Arabia Guideline Programa
|
1. Management of allergic rhinitis in adults and children |
2. Antithrombotic Treatment of Patients with Non-valvular Atrial Fibrillation |
3. Use of Screening Strategies for Detection of Breast Cancer (used interactive EtD in GRADEpro during panel meeting) |
4. Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention |
5. Diagnosis of Suspected First Deep Vein Thrombosis of Lower Extremity |
6. Timing of Initiation of Dialysis |
7. Role of Vitamin D, Calcium and Exercise in Fracture Prevention in Elderly |
8. Use of Thrombolytic Therapy in Acute Stroke |
9. Prevention of Venous Thromboembolism in Stroke |
10. Treatment of Venous Thromboembolism |
World Health Organization Guideline Programb
|
11. The use of bedaquiline in the treatment of multidrug resistant tuberculosis (used interactive EtD in GRADEpro during panel meeting) |
WAO Guideline Programc
|
12. Guidelines for allergic diseases prevention (GLAD-P) (used interactive EtD in GRADEpro during panel meeting) |
Colombian Guidelines programd
|
13. Clinical practice guidelines for evidence-based care of HIV infection in children |
Spanish Guidelines programe
|
14. Spanish Guidelines program: Childhood asthma |
Rare diseasef
|
15. Hemophilia (used interactive EtD in GRADEpro during panel meeting) |
Sample
Data collection
Section in the EtD table | Compiled feedback |
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Order of columns and rows | The order was not a relevant issue for most panels |
Criteria in EtD | One methodologist expressed concerns regarding the overlap between the sections “acceptability” and “feasibility” with “values and preferences” and “resource considerations”. Another methodologist considered the section “priority” redundant. According to another methodologist, the criteria of the table were not easy to apply to recommendations addressing multiple comparisons. |
Judgment column | Two methodologists stated that allowing modifications to the answer options might be needed to accommodate different contexts and scenarios. |
Research evidence | Although for the majority of panels there were no issues with this column, one methodologist stated that the difference between the purposes of the columns “available evidence” and “additional consideration” was not clear. |
Additional considerations | One methodologist suggested using this column to summarize the available evidence as a general narrative statement. |
Background | One methodologist considered this section redundant (with respect to information that is present in the main text of the guideline). |
PICO | Three methodologists expressed concerns regarding how the question is presented, specifically, they suggested making the PICO structure more explicit (and using the exact terms that P-I-C-O stand for). |
Perspective | One methodologist considered this section particularly relevant, as being explicit about the perspective may help to make transparent the decisions made to formulate recommendations. |
Overall certainty of the Evidence | In general, this section was well evaluated by methodologists, with no major suggestion for improvement. Two methodologists made minor wording suggestions. Another methodologist suggested expanding the content to include more information about each particular outcome. |
Values and preferences (“Uncertainty about how much people value the main outcomes”) | This section posed significant difficulties in several panels. Four methodologists suggested differentiating between “variability” and “uncertainty” of patients’ values and preferences. Another methodologist suggested making explicit the source of patients’ values and preferences. The order of presenting and discussing values and preferences was also questioned and subsequently changed in the EtD framework. |
Balance of benefits and harms | There were major difficulties in 6 guideline panels. According to methodologists, panelists had problems answering consistently the questions about the size of the effect. Additionally, two methodologists considered the questions of this section redundant. |
Resource use | Three guideline panels (all without health economists) struggled answering the question about the relationship between incremental cost and benefits. These panels proposed “is the treatment cost-effective?” as a better alternative. The only guideline panel with health economists considered the questions of this section too superficial. |
Equity | Three guideline panels struggled with this question. A more clear definition of health equity and more guidance on how to answer the question were considered necessary. Two methodologists suggested adding the option “no effect on health equity” to the answers options. |
Acceptability | Two methodologists expressed problems when trying to identify the relevant stakeholders. More guidance was considered necessary. |
Feasibility | None |
Panel decisions | One methodologist considered the wording of this section confusing when the recommendation under discussion involved two active treatments. Another methodologist suggested de-emphasizing the option “no recommendation” |
Justification/remarks | Two panels struggled to decide what to include in the remarks. More guidance was considered necessary. |
Subgroup considerations | One methodologist considered that subgroups should be more explicit in the table. |
Implementation considerations | According to methodologists, this section was used in different ways across guideline panels. More guidance in what to include was considered necessary. |
Monitoring and evaluation | None |
Research priorities | In general, there was agreement regarding the importance of this section. |