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Plan

Plan. GRADE background confidence in estimates (quality of evidence) evidence profiles confidence in estimates and recommendations. 60+ Organizations. 2008. 2010. 2006. 2005. 2007. 2009. 2011. GRADE uptake. Confidence in estimate (quality of evidence).

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Plan

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  1. Plan GRADE background confidence in estimates (quality of evidence) evidence profiles confidence in estimates and recommendations

  2. 60+ Organizations 2008 2010 2006 2005 2007 2009 2011

  3. GRADE uptake

  4. Confidence in estimate(quality of evidence) Randomized trials start high confidence Very Low Moderate totally confident no confidence Low High Observational studies start low confidence

  5. Determinants of confidence risk of bias concealment blinding loss to follow-up imprecision wide confidence intervals publication bias

  6. Relative Risk with 95% CI for Vitamin D Non-vertebral Fractures

  7. 75% 50% 25% Why are we Pooling? Serious concern Some concern No worries

  8. Relative Risk with 95% CI for Vitamin D Non-vertebral Fractures

  9. Quality judgments: Directness • populations • older, sicker or more co-morbidity • interventions • warfarin in trials and community • outcomes • important versus surrogate outcomes • glucose control versus CV events

  10. What can raise confidence? • large magnitude can upgrade one level • very large two levels • common criteria • everyone used to do badly • almost everyone does well • quick action • hip replacement for hip osteoarthritis • mechanical ventilation in respiratory failure

  11. Quality assessment criteria

  12. Nonfatal MI – Fixed Effects

  13. Beta blockers in non-cardiac surgery

  14. Mortality – Fixed Effects

  15. Beta blockers in non-cardiac surgery

  16. Stroke – Fixed Effects Total events 75/10,290

  17. Beta blockers in non-cardiac surgery

  18. Significance of strong vs weak • variability in patient preference • strong, almost all same choice (> 90%) • weak, choice varies appreciably • interaction with patient • strong, just inform patient • weak, ensure choice reflects values • use of decision aid • strong, don’t bother • weak, use the aid • quality of care criterion • strong, consider • weak, don’t consider

  19. Strength of Recommendation • strong recommendation • benefits clearly outweigh risks/hassle/cost • risk/hassle/cost clearly outweighs benefit • what can downgrade strength? • low confidence in estimates • close balance between up and downsides

  20. Conclusion • clinicians, policy makers need summaries • quality of evidence • explicit rules • transparent, informative • GRADE • simple, transparent, systematic

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