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Guidelines for guideline developers: a systematic review of grading systems for medical tests.

Gopalakrishna G, Langendam MW, Scholten RJ, Bossuyt PM, Leeflang MM - Implement Sci (2013)

Bottom Line: However, development of guidelines for medical tests is especially challenging given the typical indirectness of the evidence; direct evidence of the effects of testing on patient important outcomes is usually absent.We compared grading systems for medical tests on how they use evidence in guideline development.At present, no one system addressed the full complexity of gathering, assessing and linking different bodies of evidence.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. g.gopalakrishna@amc.uva.nl

ABSTRACT

Background: A variety of systems have been developed to grade evidence and develop recommendations based on the available evidence. However, development of guidelines for medical tests is especially challenging given the typical indirectness of the evidence; direct evidence of the effects of testing on patient important outcomes is usually absent. We compared grading systems for medical tests on how they use evidence in guideline development.

Methods: We used a systematic strategy to look for grading systems specific to medical tests in PubMed, professional guideline websites, via personal correspondence, and handsearching back references of key articles. Using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument as a starting point, we defined two sets of characteristics to describe these systems: methodological and process ones. Methodological characteristics are features relating to how evidence is gathered, appraised, and used in recommendations. Process characteristics are those relating to the guideline development process. Data were extracted in duplicate and differences resolved through discussion.

Results: Twelve grading systems could be included. All varied in the degree to which methodological and process characteristics were addressed. Having a clinical scenario, identifying the care pathway and/or developing an analytical framework, having explicit criteria for appraising and linking indirect evidence, and having explicit methodologies for translating evidence into recommendations were least frequently addressed. Five systems at most addressed these, to varying degrees of explicitness and completeness. Process wise, features most frequently addressed included involvement of relevant professional groups (8/12), external peer review of completed guidelines (9/12), and recommendations on methods for dissemination (8/12). Characteristics least often addressed were whether the system was piloted (3/12) and funder information (3/12).

Conclusions: Five systems for grading evidence about medical tests in guideline development addressed to differing degrees of explicitness the need for and appraisal of different bodies of evidence, the linking of such evidence, and its translation into recommendations. At present, no one system addressed the full complexity of gathering, assessing and linking different bodies of evidence.

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Main steps in guideline development.
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Figure 1: Main steps in guideline development.

Mentions: For the purposes of this review, we defined an evidence-grading system to be a subset of the overall guideline development process. We defined a guideline development process to be one that begins by defining a topic of interest, then conducting a scoping of the literature in order to assess feasibility of the chosen topic. Once feasibility is ascertained, specific key questions that the guideline will address should be explicitly defined. This is followed by systematically gathering the available evidence and evaluating its quality; then formulating recommendations based on a number of factors such as the quality of the gathered evidence, applicability, resource issues, benefits versus harm, etc. We defined a grading system to be the subset of this series of processes: those that address aspects concerned with formulating a key question, systematically searching and gathering the related evidence, then assessing its quality and formulating recommendations (FigureĀ 1).


Guidelines for guideline developers: a systematic review of grading systems for medical tests.

Gopalakrishna G, Langendam MW, Scholten RJ, Bossuyt PM, Leeflang MM - Implement Sci (2013)

Main steps in guideline development.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3716938&req=5

Figure 1: Main steps in guideline development.
Mentions: For the purposes of this review, we defined an evidence-grading system to be a subset of the overall guideline development process. We defined a guideline development process to be one that begins by defining a topic of interest, then conducting a scoping of the literature in order to assess feasibility of the chosen topic. Once feasibility is ascertained, specific key questions that the guideline will address should be explicitly defined. This is followed by systematically gathering the available evidence and evaluating its quality; then formulating recommendations based on a number of factors such as the quality of the gathered evidence, applicability, resource issues, benefits versus harm, etc. We defined a grading system to be the subset of this series of processes: those that address aspects concerned with formulating a key question, systematically searching and gathering the related evidence, then assessing its quality and formulating recommendations (FigureĀ 1).

Bottom Line: However, development of guidelines for medical tests is especially challenging given the typical indirectness of the evidence; direct evidence of the effects of testing on patient important outcomes is usually absent.We compared grading systems for medical tests on how they use evidence in guideline development.At present, no one system addressed the full complexity of gathering, assessing and linking different bodies of evidence.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. g.gopalakrishna@amc.uva.nl

ABSTRACT

Background: A variety of systems have been developed to grade evidence and develop recommendations based on the available evidence. However, development of guidelines for medical tests is especially challenging given the typical indirectness of the evidence; direct evidence of the effects of testing on patient important outcomes is usually absent. We compared grading systems for medical tests on how they use evidence in guideline development.

Methods: We used a systematic strategy to look for grading systems specific to medical tests in PubMed, professional guideline websites, via personal correspondence, and handsearching back references of key articles. Using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument as a starting point, we defined two sets of characteristics to describe these systems: methodological and process ones. Methodological characteristics are features relating to how evidence is gathered, appraised, and used in recommendations. Process characteristics are those relating to the guideline development process. Data were extracted in duplicate and differences resolved through discussion.

Results: Twelve grading systems could be included. All varied in the degree to which methodological and process characteristics were addressed. Having a clinical scenario, identifying the care pathway and/or developing an analytical framework, having explicit criteria for appraising and linking indirect evidence, and having explicit methodologies for translating evidence into recommendations were least frequently addressed. Five systems at most addressed these, to varying degrees of explicitness and completeness. Process wise, features most frequently addressed included involvement of relevant professional groups (8/12), external peer review of completed guidelines (9/12), and recommendations on methods for dissemination (8/12). Characteristics least often addressed were whether the system was piloted (3/12) and funder information (3/12).

Conclusions: Five systems for grading evidence about medical tests in guideline development addressed to differing degrees of explicitness the need for and appraisal of different bodies of evidence, the linking of such evidence, and its translation into recommendations. At present, no one system addressed the full complexity of gathering, assessing and linking different bodies of evidence.

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