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Illustrating the GRADE Methodology: The Cather Associated-UTI Case Study

Illustrating the GRADE Methodology: The Cather Associated-UTI Case Study. Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice University of Pennsylvania. TEACH Level II Workshop 5 NYAM August 9 th , 2013.

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Illustrating the GRADE Methodology: The Cather Associated-UTI Case Study

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  1. Illustrating the GRADE Methodology: The Cather Associated-UTI Case Study Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice University of Pennsylvania TEACH Level II Workshop 5 NYAM August 9th, 2013

  2. CDC Guideline on Preventing CAUTI Full guideline at http://www.cdc.gov/hicpac/index.html

  3. GRADE Working Group Grades of Recommendation Assessment, Development and Evaluation

  4. The GRADE Working Group Since 2000 Researchers/guideline developers with interest in methodology Goal to develop one worldwide system of rating quality of evidence and strength of recommendations Clear separation of 2 elements: Quality of evidence: very low, low, moderate, or high quality Strength of recommendation: weak or strong www.GradeWorking-Group.org

  5. GRADE Uptake World Health Organization National Institute Clinical Excellence (NICE) British Medical Journal Infectious Disease Society of America Centers for Disease Control and Prevention (HICPAC and ACIP) American College of Chest Physicians UpToDate American College of Physicians Cochrane Collaboration Agency for Healthcare Research and Quality (AHRQ) Over 20 other major organizations

  6. Example key question in guideline: Do Texas catheters impact UTI outcomes differently than Foley catheters? VS.

  7. Risks and benefits associated with Texas vs. Foley catheters?

  8. Determinants of quality RCTs start high Observational studies start low 5 factors lower the quality of evidence 3 factors can increase the quality of evidence

  9. Grading the Evidence

  10. Overall Quality Grades High further research is very unlikely to change confidence in the estimate of effect Moderate further research is likely to impact confidence in the estimate and may change the estimate Low further research is very likely to impact confidence in the estimate and is likely to change the estimate Very low any estimate is very uncertain

  11. Grading the Evidence for Each Outcome

  12. Grading the Evidence for Each Outcome * = CRITICAL OUTCOMES

  13. Grading the Evidence for Each Outcome * = CRITICAL OUTCOMES

  14. Narrative Evidence Summary Q2A1. Condom versus indwelling urethral There was moderate quality evidence to support the use of condom catheters over indwelling urethral catheters in male patients. This was based on decreased risk of symptomatic UTI as well as increased patient satisfaction with condom catheters.

  15. Formulating Recommendations • Three key inputs: • Values and preferences used to determine the “critical” outcomes • Overall GRADE of the evidence for the “critical” outcomes • Net benefits, net harms, or trade-offs that result from weighing the "critical" outcomes

  16. Grading the Evidence for Each Outcome * = CRITICAL OUTCOMES

  17. CDC Recommendation Scheme

  18. Recommendation Example: Condom catheter drainage should be used in cooperative male patients without urinary retention or bladder outlet obstruction. (Category IA)

  19. Questions?

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