From MARS to MAGIC: The remarkable journey through time and space of the Grading of Recommendations Assessment, Development and Evaluation initiative

Ethics of Mathematical Modeling in Public Health: The Case of Medical Male Circumcision for HIV Prevention in Africa

Mathematical modelling has played an increasingly prominent role in public health responses, for example by offering estimates of how infectious disease incidence over time may be affected by the adoption of certain policies and interventions. In this paper, we call for greater research and reflection into the ethics of mathematical modeling in public health. First, we present some promising ways of framing the ethics of mathematical modeling that have been offered in the very few publications specifically devoted to this subject. Second, to draw out some issues that have not yet been sufficiently considered, we bring in the case of mathematical modeling in voluntary medical male circumcision (VMMC) initiatives for HIV prevention in Africa. We argue that greater attention should be paid to ethical considerations in mathematical modeling, particularly as its use is becoming more widespread and its potential impacts are becoming greater in the 'big data' era, as witnessed during the COVID-19 pandemic.

The impact of an online course on agreement rates of the certainty of evidence assessment using Grading of Recommendations, Assessment, Development, and Evaluation Approach: a before-and-after study

BACKGROUND AND OBJECTIVE

The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach is a systematic method for assessing the certainty of evidence (CoE) and strength of recommendations in health care. We aimed to verify the effects of an online-based GRADE course on multirater consistency in the evaluation of the CoE in systematic reviews (SRs) analysis.

STUDY DESIGN AND SETTINGS

Sixty-five Brazilian methodologists and researchers participated in an online course over 8 weeks. Asynchronous lessons and weekly synchronous meetings addressed the GRADE system in the context of CoE assessment. We asked participants to evaluate the CoE of random SRs (two before and another two after the course). Analyzes focused on the multirater agreement with a standard response, in the interrater agreement, and before-after changes in the proportion of participants that rated down the domains.

RESULTS

48 individuals completed the course. Participants presented improvements in the raters' assessment of the CoE using the GRADE approach after the course. The multirater consistency of indirectness, imprecision, and the overall CoE increased after the course, as well as the agreement between raters and the standard response. Furthermore, interrater reliability increased for risk of bias, inconsistency, indirectness, publication bias, and overall CoE, indicating progress in between-raters consistency. After the course, approximately 78% of individuals rated down the overall CoE to a low/very low degree, and participants presented more explanations for the judgment of each domain.

CONCLUSION

An online GRADE course improved the consistency and agreement of the CoE assessment by Brazilian researchers. Online training courses have the potential to improve skills in guideline methodology development.

Conflicts of Interest in Nutrition: Categorical Thinking and the Stigma of Commercial Collaboration

There is a high level of concern about the possible influence of commercial organizations on food-related research and professional bodies, including regulatory and advisory panels. This has contributed to an increased emphasis on the declaration and management of conflicts of interest (CoI) in the reporting, evaluation, and application of research in nutrition science. However, common perceptions of CoI in nutrition, and procedures for declaring and managing these, often lack intellectual rigor and consistency. This commentary highlights 3 main issues related to CoI in nutrition, particularly the emphasis on industry-related CoI relative to other sources of conflict and bias. 1) Considerations of CoI in nutrition are largely limited to financial or collaborative links to the food industry, disregarding other important sources of influence such as intellectual allegiances or nonindustry financial and professional incentives. 2) Associations with industry incur ad hominem, often punitive stigmatization of individuals and their research, and inappropriate downgrading or exclusion of evidence. This disproportionately affects expertise in the food and agricultural sciences, in which commercial collaborations are widely encouraged. 3) These practices and related approaches to managing CoI are applied without due consideration of the nature of the conflicts and activities involved, the qualifications of individuals, or the availability of other, objective methods and guidance for assessing research quality and risks of bias. Overall, recognition of the nature and range of CoI in nutrition and approaches to their identification and management lack consistency and balance. A singular and strict focus specifically on industry-related CoI may paradoxically exacerbate rather than mitigate imbalance and bias in the field. This commentary outlines the underlying issues and the need for more comprehensive and nuanced approaches to the assessment, reporting, and management of CoI in nutrition.

Systems for rating bodies of evidence used in systematic reviews of air pollution exposure and reproductive and children's health: a methodological survey

BACKGROUND

Translating findings from systematic reviews assessing associations between environmental exposures and reproductive and children's health into policy recommendations requires valid and transparent evidence grading.

METHODS

We aimed to evaluate systems for grading bodies of evidence used in systematic reviews of environmental exposures and reproductive/ children's health outcomes, by conducting a methodological survey of air pollution research, comprising a comprehensive search for and assessment of all relevant systematic reviews. To evaluate the frameworks used for rating the internal validity of primary studies and for grading bodies of evidence (multiple studies), we considered whether and how specific criteria or domains were operationalized to address reproductive/children's environmental health, e.g., whether the timing of exposure assessment was evaluated with regard to vulnerable developmental stages.

RESULTS

Eighteen out of 177 (9.8%) systematic reviews used formal systems for rating the body of evidence; 15 distinct internal validity assessment tools for primary studies, and nine different grading systems for bodies of evidence were used, with multiple modifications applied to the cited approaches. The Newcastle Ottawa Scale (NOS) and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework, neither developed specifically for this field, were the most commonly used approaches for rating individual studies and bodies of evidence, respectively. Overall, the identified approaches were highly heterogeneous in both their comprehensiveness and their applicability to reproductive/children's environmental health research.

CONCLUSION

Establishing the wider use of more appropriate evidence grading methods is instrumental both for strengthening systematic review methodologies, and for the effective development and implementation of environmental public health policies, particularly for protecting pregnant persons and children.

The use of GRADE-CERQual in qualitative evidence synthesis: an evaluation of fidelity and reporting

BACKGROUND

GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) is a methodological approach to systematically and transparently assess how much confidence decision makers can place in individual review findings from qualitative evidence syntheses. The number of reviews applying GRADE-CERQual is rapidly expanding in guideline and other decision-making contexts. The objectives of this evaluation were, firstly, to describe the uptake of GRADE-CERQual in qualitative evidence synthesis by review authors and, secondly, to assess both reporting of and fidelity to the approach.

METHODS

The evaluation had two parts. Part 1 was a citation analysis and descriptive overview of the literature citing GRADE-CERQual. Authors worked together to code and chart the citations, first by title and abstract and second by full text. Part 2 was an assessment and analysis of fidelity to, and reporting of, the GRADE-CERQual approach in included reviews. We developed fidelity and reporting questions and answers based on the most recent guidance for GRADE-CERQual and then used NVivo12 to document assessments in a spreadsheet and code full-text PDF articles for any concerns that had been identified. Our assessments were exported to Excel and we applied count formulae to explore patterns in the data. We employed a qualitative content analysis approach in NVivo12 to sub-coding all the data illustrating concerns for each reporting and fidelity criteria.

RESULTS

233 studies have applied the GRADE-CERQual approach, with most (n = 225, 96.5%) in the field of health research. Many studies (n = 97/233, 41.6%) were excluded from full fidelity and reporting assessment because they demonstrated a serious misapplication of GRADE-CERQual, for example interpreting it as a quality appraisal tool for primary studies or reviews. For the remaining studies that applied GRADE-CERQual to assess confidence in review findings, the main areas of reporting concern involved terminology, labelling and completeness. Fidelity concerns were identified in more than half of all studies assessed.

CONCLUSIONS

GRADE-CERQual is being used widely within qualitative evidence syntheses and there are common reporting and fidelity issues. Most of these are avoidable and we highlight these as gaps in knowledge and guidance for applying the GRADE-CERQual approach.

Trends in the development process of clinical practice guidelines: a questionnaire survey for the guideline development groups in Japan

Background

Clinical practice guidelines (CPGs) are representative methods for promoting healthcare standardization and improving its quality. Previous studies on the CPG (published by 2006) development process in Japan reported that the involvement of experts and patients, efficient evidence collection and appraisal, and paucity of evidence on Japanese patients should be improved for the efficient CPG development. This study aimed to clarify the trends of CPG development process in Japan, focusing on the involvement of experts and patients, efficient evidence collection and appraisal, and paucity of Japanese evidence.

Methods

A cross-sectional questionnaire survey was conducted for CPG development groups to collect information on the development activities of the CPGs published from 2012 to 2019. These CPGs were identified from the Japanese guideline clearinghouse. The questionnaire included the questions on composing the group, securing funding sources, collecting and appraising the research evidence, and the difficulties in the CPG development process. The questionnaires were distributed to the chairpersons of the CPG development groups through postal mail from November 2020 to January 2021. Combining the data from the current survey with those of previous studies reporting the development process of CPGs published by 2011, we analyzed the trend in the CPG development process.

Results

Of the total 265 CPGs included in the analysis, 164 (response rate: 41.4%) were from the current survey and 101 (response rate: 44.5%) were from previous studies. Among these, 40 (15.1%) were published by 2005, 47 (17.7%) in 2006–2010, 77 (29.1%) in 2011–2015, and 101 (38.1%) in 2016–2019. The proportion of CPGs involving methodologists did not increase through the publication periods. The proportion of CPGs involving patients almost doubled from the first period (15.9%) to the fourth period (32.4%). The yield rates of the articles did not change through the publication periods. The difficulty in “Coping with the paucity of Japanese evidence” has been improving consistently (69.2% in the first period to 37.4% in the fourth period).

Conclusions

Our results suggest the need for methodological improvement in the efficient collection and appraisal of evidence and in the system assigning experts to the CPG development groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07492-7.

Professional judgement in clinical practice (part 2): knowledge into practice

RATIONALE, AIMS, AND OBJECTIVES

Though strong evidence-based medicine is assertive in its claims, an insufficient theoretical basis and patchwork of arguments provide a good case that rather than introducing a new paradigm, EBM is resisting a shift to actually revolutionary complexity theory and other emergent approaches. This refusal to pass beyond discredited positivism is manifest in strong EBM's unsuccessful attempts to continually modify its already inadequate previous modifications, as did the defenders of the Ptolemaic astronomical model who increased the number of circular epicycles until the entire epicycle-deferent system proved untenable.

METHODS

Narrative Review.

RESULTS

The analysis in Part 1 of this three part series showed epistemological confusion as strong EBM plays the discredited positivistic tradition out to the end, thus repeating in a medical sphere and vocabulary the major assumptions and inadequacies that have appeared in the trajectory of modern science. Paper 2 in this series examines application, attending to strong EBM's claim of direct transferability of EBM research findings to clinical settings and its assertion of epistemological normativity. EBM's contention that it provides the "only valid" approach to knowledge and action is questioned by analyzing the troubled story of proposed hierarchies of the quality of research findings (especially of RCTs, with other factors marginalized), which falsely identifies evaluating findings with operationally utilizing them in clinical recommendations and decision-making. Further, its claim of carrying over its normative guidelines to cover the ethical responsibilities of researchers and clinicians is questioned.

The efficacy of Qigong exercises for nonalcoholic fatty liver disease: A protocol for systematic review and meta-analysis

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases in the world that represents an important public health challenge nowadays. Lifestyle changes and exercise can reduce the development of fatty liver. The aim of this systematic review and meta-analysis is to evaluate the treatment efficacy of Qigong for NAFLD.

METHODS

A detailed search for articles up to September 2020 will be performed to identify randomized controlled trials for Qigong in NAFLD. The following database will be used: PUBMED, Embase, Web of Science, Cochrane Library, Sino Med, Chinese National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodicals Database, and Wanfang Databas. Grey literature will be explored and the selection of studies, data extraction and validation will be performed independently by 2 reviewers using predefined selection criteria and quality indicators. Stata V.13.0 and Review manager 5.3 software will be used for data synthesis, sensitivity analysis, subgroup analysis, and risk of bias assessment. We will use the grading of recommendations assessment, development, and evaluation system to assess the quality of evidence.

RESULTS

This research will provide a quantitative and standardized assessment of the treatment efficacy of Qigong for NAFLD.

CONCLUSION

This systematic review will generate the latest evidence for determining whether Qigong has a positive treatment effect for NAFLD.

REGISTRATION NUMBER

INPLASY202090034.

The Qigong Wuqinxi for chronic obstructive pulmonary disease: Protocol for a systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic and progressive disease that represents an important public health challenge nowadays. Despite the growing number of studies assessing the rehabilitation outcome of Wuqinxi for COPD, their many variables and observations are often explored with a relatively small sample size, accordingly maybe lead to potential false-positive results. The aim of this systematic review and meta-analysis is to evaluate the rehabilitation efficacy of Wuqinxi for COPD.

METHODS

A detailed search for articles up to June 2019 will be performed to identify randomized controlled trials for Wuqinxi in COPD. The following database will be used: PUBMED, Embase, Scopus, Web of Science, Google Scholar, Cochrane Library, Sino Med, Chinese National Knowledge Infrastructure, Chinese Science and Technology Periodicals Database, and Wanfang Database. Grey literature will be explored and the selection of studies, data extraction and validation will performed independently by 2 reviewers using predefined selection criteria and quality indicators. Stata V.13.0 and Review manager 5.3 software will be used for data synthesis, sensitivity analysis, subgroup analysis, and risk of bias assessment. We will use the grading of recommendations assessment, development, and evaluation system to assess the quality of evidence.

RESULTS

This research will update previous evidence summaries and provide a quantitative and standardized assessment of the rehabilitation efficacy of Wuqinxi for COPD.

CONCLUSION

This systematic review will generate the latest evidence for determining whether Wuqinxi has a positive rehabilitation effect for COPD.PROSPERO registration number: PROSPERO CRD 42019120960.

Treating real people: Science and humanity

Something important is happening in applied, interdisciplinary research, particularly in the field of applied health research. The vast array of papers in this edition are evidence of a broad change in thinking across an impressive range of practice and academic areas. The problems of complexity, the rise of chronic conditions, overdiagnosis, co-morbidity, and multi-morbidity are serious and challenging, but we are rising to that challenge. Key conceptions regarding science, evidence, disease, clinical judgement, and health and social care are being revised and their relationships reconsidered: Boundaries are indeed being redrawn; reasoning is being made "fit for practice." Ideas like "person-centred care" are no longer phrases with potential to be helpful in some yet-to-be-clarified way: Theorists and practitioners are working in collaboration to give them substantive import and application.