Clinical Guidelines Flashcards
What is the order of search strategy when looking for recommendations?
Clinical guidelines Evidence summaries Systematic reviews Primary studies Consults an expert/specialist to help with search design
What are the features of an evidence summary?
Summarises existing evidence and identifies gaps in evidence
Based on current clinical guideline evidence
Uses SR of evidence
What are the features of clinical guidelines?
De novo systematic review of evidence and economic analysis not restricted by evidence type or quality
Multiple clinical questions covering entire disease management pathway
Evaluates confidence of evidence using GRADE
Engages stakeholders i.e. people with invested interest in the output of the guideline
Develops recommendation for clinical practice based on best available evidence and expert option
What does the process of guideline development involve?
Clinical question guideline looking to address
Search strategy to identify presence of evidence
Review strength of evidence of clinical questions
Look at process Guideline Development Group took to move from evidence to recommendations
Look at the recommendations
Who forms part of guideline development group?
Patients
Stake holders
Industry members
I.e. people with vested interest of study outcome
What is used to assess the strength of evidence of guideline?
GRADE
Grading of Recommendations, Assessment, Development and Evaluations
What are the main purposes of GRADE?
Present number, type and quality of studies for each clinical question
Provide transparent frame work for assessing certainty of summaries of evidence
Provides systematic approach for next step of clinical practice recommendations
What are the 5 domains which form part of GRADE? How is each domain assessed?
Risk of bias
-assessed by evidence hierarchy and critical appraisal
Imprecision
-assessed by width of CI
Inconsistency
- assessed by CI overlap
- I squared
Indirectness/applicability
-assessed by applicability to population/setting of interest
Publication bias
-preferential publication of studies due to studies having positive results, large effect sizes or the studies are in English
When assessing for imprecision as part of GRADE, you identify there is a wide CI. What does this suggest?
Statistical heterogeneity due to clinical or methodological heterogeneity
Clinical factors:
- patient characteristics
- variation in intervention
Methodological factors:
-variation in quality of study
What is certainty in the context of GRADE? How can it be calculated?
How close the size of effect estimated by evidence is likely to be to true effect which will be seen in clinical practice
Calculate:
-sum of the downgrading of certainty across the 5 domains
What are the different levels of certainty and what do they mean?
Very low
-true effect probably markedly different from estimated effect
Low:
-true effect might be markedly different from estimated effect
Moderate:
-true effect close to estimated effect
High:
-lot of confidence true effect similar to estimated effect
What are important considerations when developing recommendations?
Strength of GRADE= quality + certainty of evidence
Size of effect compared with adverse effects
Cost
- monetary
- skills to deliver intervention
Patient preference
Evidence of health benefit/cost
Value of different outcomes:
- long term complications
- all-cause mortality
What is the criteria for a strong recommendation? What language would be used in the guideline?
High evidence certainty
Desirable effects > undesirable effects
Low cost or resource implications
Patient preferences + values unlikely to vary
Must or must not
What is the criteria for a weak recommendation? What language would be used in the recommendation?
Low evidence certainty
Close balance between desirable and undesirable effects
High cost/resource implications
Substantial variation or uncertainty in terms of patient preference
Could
What is used to appraise quality of Guidelines? What are you looking for in the Guideline?
AGREE II checklist
Validity= are guidelines up to date and trustworthy
Clinical relevance
