1 / 19

Plan

This sessions will be interactive. So please sit with people with whom you will enjoy a conversation. Plan. GRADE background two steps confidence in estimates (quality of evidence) strength of recommendation evidence profiles. Grading good idea, but which grading system to use?.

nikkos
Download Presentation

Plan

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. This sessions will be interactive. So please sit with people with whom you will enjoy a conversation

  2. Plan GRADE background two steps confidence in estimates (quality of evidence) strength of recommendation evidence profiles

  3. Grading good idea, but which grading system to use? • many available • Australian National and MRC • Oxford Center for Evidence-based Medicine • Scottish Intercollegiate Guidelines (SIGN) • US Preventative Services Task Force • American professional organizations • AHA/ACC, ACCP, AAP, Endocrine society, etc.... • cause of confusion, dismay

  4. Dilemma: proliferation of systemsSolution: common international grading system? • GRADE (Grades of recommendation, assessment, development and evaluation) • international group • Australian NMRC, SIGN, USPSTF, WHO, NICE, Oxford CEBM, CDC, CC • ~ 30 meetings over last eleven years • (~10 – 50 attendants)

  5. Grading system – for what? • interventions • management strategy 1 versus 2 • what grade is not about • individual studies (body of eidence) • prognostic questions • in patients with heart failure is high uric acid associated with increased risk • diagnostic accuracy questions • in lung cancer, what is the accuracy of CT scanning of the mediastinum

  6. GRADE Uptake

  7. GRADE uptake

  8. What are we grading? • two components • confidence in estimate of effect adequate to support decision (quality of body of evidence) • high, moderate, low, very low • strength of recommendation • strong and weak

  9. Confidence in estimate(quality of evidence) Very Low Moderate totally confident no confidence Low High

  10. Determinants of confidence RCTs start high observational studies start low what can lower confidence? risk of bias inconsistency indirectness imprecision publication bias

  11. What can raise confidence? large magnitude can rate up one level very large two levels common criteria everyone used to do badly almost everyone does well quick action hip replacement for hip osteoarthritis

  12. Dose-response gradient • childhood lymphoblastic leukemia • risk for CNS malignancies 15 years after cranial irradiation • no radiation: 1% (95% CI 0% to 2.1%) • 12 Gy: 1.6% (95% CI 0% to 3.4%) • 18 Gy: 3.3% (95% CI 0.9% to 5.6%).

  13. Confidence assessment criteria

  14. Beta blockers in non-cardiac surgery

  15. 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

  16. 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

  17. Conclusion • clinicians, policy makers need summaries • confidence in estimates • strength of recommendations • explicit rules • transparent, informative • GRADE • transparent, systematic • increasing wide adoption

More Related