Over half of the WHO guidelines published from 2014 to 2019 explicitly considered health equity issues: a cross-sectional survey

GRADE good practice statements: a time to say "good-bye"? A new typology for normative statements on interventions

BACKGROUND

Clinical and public health guidelines include a variety of types of normative statements concerning interventions. "Recommendations" are usually the central focus, and are based on one or more systematic reviews of research evidence. Guidelines may include other types of normative statements, however, including Grading of Recommendations, Assessment, Develoment, and Evaluation (GRADE) good (or best) practice statements (GPS), which represent recommendations that guideline panels feel are important but are not appropriate for formal ratings of quality of evidence because it is sufficiently obvious that desirable effects outweigh undesirable effects. These normative statements are typically supported by a great deal of high-certainty, indirect evidence, which the authors feel would be a waste of time to examine. There are a number of conceptual and methodological issues with GRADE GPS, however, and these are manifested in guidelines, including both inappropriate overuse and underuse, and unclear interpretation and impact among end-users. This situation has arisen in part from lack of clarity in, and misunderstandings of, GRADE guidance, the lumping of many different types of normative statements under one label ("GPS"), from limitations in GRADE's approach to linked bodies of evidence, and because the appropriate basis for many normative statements about interventions is not reviews of research evidence. A new typology is needed for normative statements on interventions and policies that are not optimally based on reviews of research evidence.

PROPOSED TYPOLOGY

This proposed typology differentiates normative statements about interventions by the type or nature of the most appropriate basis for the statement. The typology encompasses the range of statements encompassed by GPS, but provides a more nuanced categorization designed to assist both guideline developers and end-users. This typology encompasses two main types of normative statements about interventions (including policies): (1) statements that indicate when to use (or not) an intervention, which intervention to use, and if, when and how to use it and (2) the principles, practices, or norms that inform or underpin such interventions. These correspond to normative statements based on empirical evidence, and those based on human rights, ethics, or norms, respectively. Normative statements based on empirical evidence include: (1) recommendations based on systematic reviews of human or animal evidence on effectiveness and harms, including linked bodies of evidence; (2) normative statements based on scientific fundamentals (eg, physical/biological/chemical properties, theories, laws, or principles); and (3) implementation guidance based most commonly on experiential evidence such as case studies. Normative statements based on human rights, ethics, or norms include: (1) guiding principles, based on human rights standards and conventions and/or ethics principles; and (2) practice norms and standards, based on clinical and public health norms and/or professional standards.

CONCLUSION

There are conceptual and methodological problems with GRADE GPS, leading to their misapplication, with overuse and underuse. This paper presents a proposal for a new typology for normative statements on interventions, according to the basis for the statement. This typology encompasses and replaces GPS, providing a more nuanced set of statements. Testing of this proposed approach is needed among both guideline developers and end-users.

Operationalizing the GRADE-equity criterion to inform guideline recommendations: application to a medical cannabis guideline

OBJECTIVES

Incorporating health equity considerations into guideline development often requires information beyond that gathered through traditional evidence synthesis methodology. This article outlines an operationalization plan for the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-equity criterion to gather and assess evidence from primary studies within systematic reviews, enhancing guideline recommendations to promote equity. We demonstrate its use in a clinical guideline on medical cannabis for chronic pain.

STUDY DESIGN AND SETTING

We reviewed GRADE guidance and resources recommended by team members regarding the use of evidence for equity considerations, drafted an operationalization plan, and iteratively refined it through team discussion and feedback and piloted it on a medicinal cannabis guideline.

RESULTS

We propose a seven-step approach: 1) identify disadvantaged populations, 2) examine available data for specific populations, 3) evaluate population baseline risk for primary outcomes, 4) assess representation of these populations in primary studies, 5) appraise analyses, 6) note barriers to implementation of effective interventions for these populations, and 7) suggest supportive strategies to facilitate implementation of effective interventions.

CONCLUSION

Our approach assists guideline developers in recognizing equity considerations, particularly in resource-constrained settings. Its application across various guideline topics can verify its feasibility and necessary adjustments.

Investigating how the GRADE Evidence to Decision (EtD) framework is used in Clinical Guidelines: a scoping review protocol

Introduction: The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) evidence to decision (EtD) framework provides a structured and transparent approach for clinical guideline developers to use when formulating recommendations. Understanding how stakeholders use the EtD framework will inform how best to provide future training and support. This scoping review objective is to identify the key characteristics of how the GRADE EtD framework is used and identify studies on perception of use by those involved in developing clinical guidelines. Methods: JBI methodology for scoping reviews will be followed. This scoping review will consider both peer review published literature and grey literature. This will include empirical studies on the use of EtDs (including both quantitative, qualitative, and mixed methods primary research articles) and discussion papers/ commentaries on the experience of using the EtD. It will also include a random sample of publicly available populated EtDs identified from databases and repositories of GRADE guidelines. The search strategy will aim to locate both published and unpublished documents. First, we will conduct an exploratory search of MEDLINE and Embase (Elsevier), supplemented with citation analysis of included articles. Populated EtDs will be identified through searches of databases and repositories of GRADE guidelines. Two researchers will independently screen, select, and extract identified documents. Data will be presented in tables and summarized descriptively. Conclusion: This scoping review will identify the key characteristics of how the GRADE EtD framework is currently being used in clinical guidelines. Review findings can be used to inform future guidance and requirements for using GRADE EtD, as well as training on how to consider the criteria in developing recommendations. Results will be disseminated through publications in peer - reviewed journals and conference presentations. We will present our findings to relevant stakeholders via the networks of the co-author team at a one-day workshop.

Equity issues rarely addressed in the development of COVID-19 formal recommendations and good practice statements: a cross-sectional study

BACKGROUND AND OBJECTIVE

To identify COVID-19 actionable statements (e.g., recommendations) focused on specific disadvantaged populations in the living map of COVID-19 recommendations (eCOVIDRecMap) and describe how health equity was assessed in the development of the formal recommendations.

METHODS

We employed the place of residence, race or ethnicity or culture, occupation, gender or sex, religion, education, socio-economic status, and social capital-Plus framework to identify statements focused on specific disadvantaged populations. We assessed health equity considerations in the evidence to decision frameworks (EtD) of formal recommendations for certainty of evidence and impact on health equity criteria according to the Grading of Recommendations, Assessment, Development, and Evaluations criteria.

RESULTS

We identified 16% (124/758) formal recommendations and 24% (186/819) good practice statements (GPS) that were focused on specific disadvantaged populations. Formal recommendations (40%, 50/124) and GPS (25%, 47/186) most frequently focused on children. Seventy-six percent (94/124) of the recommendations were accompanied with EtDs. Over half (55%, 52/94) of those considered indirectness of the evidence for disadvantaged populations. Considerations in impact on health equity criterion most frequently involved implementation of the recommendation for disadvantaged populations (17%, 16/94).

CONCLUSION

Equity issues were rarely explicitly considered in the development COVID-19 formal recommendations focused on specific disadvantaged populations. Guidance is needed to support the consideration of health equity in guideline development during health emergencies.

Health equity considerations in guideline development: a rapid scoping review

BACKGROUND

Systematic guidance for considering health equity in guidelines is lacking. This scoping review aims to synthesize current best practices for integrating health equity into guideline development and the benefits or drawbacks of these practices.

METHODS

We searched Ovid MEDLINE ALL and Embase Classic+Embase on the Ovid platform, CINAHL on EBSCO, and Web of Science (Core Collection) from 2010 to 2022. We searched grey literature from 2015 to 2022, using the Canadian Agency for Drugs and Technologies in Health Grey Matters checklist and searches of potentially relevant websites. Articles were screened independently by 1 reviewer. Proposed best practices, advantages and disadvantages, and tools were extracted independently by 1 reviewer and qualitatively synthesized based on the relevant steps of a comprehensive checklist covering the stages of guideline development.

RESULTS

We included 26 articles that proposed best practices for incorporating health equity within the guideline development process. These practices were organized under different stages of the development process, including guideline planning, evidence review, guideline development and dissemination. Included studies provided best practices from guideline producers, articles discussing health equity in current guidelines, articles addressing strategies to increase equity in the guideline implementation process, and literature reviews of promising health equity practices.

INTERPRETATION

Our scoping review identified best practices to incorporate health equity considerations at each phase of guideline development. Identified practices may be used to inform equity-promoting strategies with the guideline development process; however, guideline producers should carefully consider the advantages and disadvantages of best practices when integrating health equity.

Using the WHO-INTEGRATE evidence-to-decision framework to develop recommendations for induction of labour

BACKGROUND

In 2019, WHO prioritized updating recommendations relating to three labour induction topics: labour induction at or beyond term, mechanical methods for labour induction, and outpatient labour induction. As part of this process, we aimed to review the evidence addressing factors beyond clinical effectiveness (values, human rights and sociocultural acceptability, health equity, and economic and feasibility considerations) to inform WHO Guideline Development Group decision-making using the WHO-INTEGRATE evidence-to-decision framework, and to reflect on how methods for identifying, synthesizing and integrating this evidence could be improved.

METHODS

We adapted the framework to consider the key criteria and sub-criteria relevant to our intervention. We searched for qualitative and other evidence across a variety of sources and mapped the eligible evidence to country income setting and perspective. Eligibility assessment and quality appraisal of qualitative evidence syntheses was undertaken using a two-step process informed by the ENTREQ statement. We adopted an iterative approach to interpret the evidence and provided both summary and detailed findings to the decision-makers. We also undertook a review to reflect on opportunities to improve the process of applying the framework and identifying the evidence.

RESULTS

Using the WHO-INTEGRATE framework allowed us to explore health rights and equity in a systematic and transparent way. We identified a lack of qualitative and other evidence from low- and middle-income settings and in populations that are most impacted by structural inequities or traditionally excluded from research. Our process review highlighted opportunities for future improvement, including adopting more systematic evidence mapping methods and working with social science researchers to strengthen theoretical understanding, methods and interpretation of the evidence.

CONCLUSIONS

Using the WHO-INTEGRATE evidence-to-decision framework to inform decision-making in a global guideline for induction of labour, we identified both challenges and opportunities relating to the lack of evidence in populations and settings of need and interest; the theoretical approach informing the development and application of WHO-INTEGRATE; and interpretation of the evidence. We hope these insights will be useful for primary researchers as well as the evidence synthesis and health decision-making communities, and ultimately contribute to a reduction in health inequities.

Standardized wording to improve efficiency and clarity of GRADE EtD frameworks in health guidelines

BACKGROUND

Grading of Recommendations Assessment, Development and Evaluation (GRADE)Evidence-to-Decision (EtDs) frameworks are increasingly applied by health guideline developers to improve the use of evidence and transparency of health recommendations. Typically, EtDs include 12 criteria but these are flexible and EtDs have been adapted to different types of health decisions. However, developers of health recommendations struggle with the content that they should include in the EtD. The goal of this work was to provide a standardized template that facilitate the development of GRADE EtDs in health guidelines and examples for practical training.

METHODS

We began by establishing the need for standardized wording templates in 10 American Society of Hematology guidelines with over 250 recommendations. We drafted template wording, and examples, and sought iterative feedback from methodologists and guideline panels in this guideline and two additional guidelines.

RESULTS

We generated templates for all EtD criteria describing the type of research evidence considered, ideally based on systematic reviews, using standardized reporting of effect size, integrating the certainty of evidence and addition additional considerations. We also produced templates to inform the completion of the EtD conclusions section that includes recommendations, justification, implementation considerations, monitoring and evaluation and research priorities.

CONCLUSION

We have taken an applied approach to develop a pragmatic and useful tool to support clarity, transparency, and efficiency of the guideline GRADE EtD process.

Supporting Equity in Rheumatoid Arthritis Outcomes in Canada: Population-specific Factors in Patient-centered Care

OBJECTIVE

Health equity considerations have not been incorporated into prior Canadian Rheumatology Association guidelines. Our objective was to identify the challenges and possible solutions to mitigate threats to health equity in rheumatoid arthritis (RA) care in Canada.

METHODS

A consultation process informed selection of priority populations, determined to be rural and remote, Indigenous, elderly with frailty, first-generation immigrant and refugee, low income and vulnerably housed, and diverse gender and sex populations. Semistructured interviews were completed with patients with lived experience, healthcare providers, and equity-oriented researchers. These interviews probed on population factors, initial and ongoing healthcare access issues, and therapeutic considerations influencing RA care. Known or proposed solutions to mitigate inequities during implementation of service models for the population group were requested. The research team used a phenomenological thematic analysis model and mapped the data into a logic model. Solutions applicable to several population groups were proposed.

RESULTS

Thirty-five interviews were completed to identify realities for each population in accessing RA care. Five themes emerged as primary solutions to population-based inequities, including actively improving the patient-practitioner relationship, increasing accessibility and coordination of care through alternative models of care, upholding autonomy in treatment selection while actively addressing logistical barriers and individualized therapy needs, collaborating with health supports valued by the patient, and being advocates for policy change and health system restructuring to ensure appropriate resource redistribution.

CONCLUSION

The challenges for populations facing inequities in rheumatology care and promising solutions should inform guideline development and implementation, policy change, and health system restructuring.