Evidence to Decision framework provides a structured "roadmap" for making GRADE guidelines recommendations.

Li SA1, Alexander PE2, Reljic T3, Cuker A4, Nieuwlaat R2, Wiercioch W2, Guyatt G2, Schünemann HJ2, Djulbegovic B5.

Author information

1: Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Toronto, Ontario M5T 1P8, Canada. Electronic address: shellyanne.li@mail.utoronto.ca.
2: Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street W, Hamilton, Ontario L8S 4K1, Canada.
3: Comparative Effectiveness Research Program, Morsani College of Medicine, University of South Florida, 3515 E. Fletcher Avenue, MDT 1212, Tampa, FL 33612, USA.
4: Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
5: Department of Supportive Care Medicine, Department of Hematology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA.

Abstract

OBJECTIVES:

It is unclear how guidelines panelists discuss and consider factors (criteria) that are formally and not formally included in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. To describe the use of decision criteria, we explored how panelists adhered to GRADE criteria and sought to identify any emerging non-GRADE criteria when the panelists used the Evidence to Decision (EtD) framework as part of GRADE application.

STUDY DESIGN AND SETTING:

We used conventional and summative qualitative analyses to identify themes emerging from face-to-face, panel meeting discussions. Forty-eight members from 12 countries participated in the development of five guidelines for the management of venous thromboembolism by the American Society of Hematology.

RESULTS:

Ten themes corresponded to the GRADE approach and represented all panel discussions. Over half (53%) of the total panel discussions concerned the use of research evidence. When evidence was considered sufficient and clear, the decision-making process proved rapid.

CONCLUSION:

The GRADE EtD framework provides structure to guidelines panel meetings, and ensures that the panelists consider all established formal GRADE criteria as they decide on the recommendation text, strength, and direction (for or against an intervention). This is the first study assessing the use of GRADE's EtD framework during real-time guidelines development using panel discussions. Given the widespread use of GRADE, this study provides important information for practice recommendations generated when guidelines panels explicitly follow, in a transparent and systematic manner, the structured GRADE EtD framework. By recognizing the extent to which panels discuss and consider GRADE and other (non-GRADE) criteria for producing guideline recommendations, we are one step closer to understanding the decision-making process in panels that use a structured framework such as the GRADE EtD framework.