Level of Evidence/ Grades of Recommendation Teleconference Minutes

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1 ATTENDANCE Level of Evidence/ Grades of Recommendation Teleconference Minutes Wednesday 7th August 2013 at 2.30p.m. (Adelaide) Zachary Munn (Convenor) Craig Lockwood Ed Aromataris Apologies: Suzi Robertson-Malt Kylie Porritt Agenda: Welcome and apologies Collaboration with GRADE Redesign of SUMARI Guidance for systematic reviewers Guidance for BPIS Guidance for evidence summaries Reviewer s manual chapter Convention workshop Any other business? Next steps Any other business Introduction and Formal Business: Welcome: Zac welcomed those present and opened the meeting at 1.00pm Adelaide time. Suzi and Kylie were noted as apologies Collaboration with GRADE Zac updated the group on the progress contacting the GRADE working group. s have been sent to and returned from members of the working group including Prof Gordon Guyatt, Assoc Prof Yngve Falk-Ytter and Prof Holger Schunemann. The crest logo has been sent on to GRADE for upload on their website. Prof Schunemann is attending the

(Adelaide) Zachary Munn (Convenor) Craig Lockwood Ed Aromataris Apologies: Suzi Robertson-Malt Kylie Porritt Agenda: Welcome and apologies Collaboration with GRADE Redesign of SUMARI Guidance for

2 NRMRC Translation conference in October, where he has expressed an interest in meeting with staff. SUMARI Redesign GRADEPro, the software created by Cochrane and the GRADE working group to create summary of findings tables, has been developed in.net. GRADEPro currently can import RevMan files, or can work as a standalone piece of software. When redeveloping SUMARI, a discussion with the GRADE working group regarding compatibility between the two systems may be useful. Guidance for Systematic Reviewers The group discussed whether there needed to be a separate section in the reviewer s manual regarding LoE, GoR and GRADE, or whether this information should be included under each methodological section. After some discussion, it was decided that each section of the reviewer s manual should address LoE, GoR, and GRADE relevant to the evidence in question. Guidance for staff and entities As there will be changes with the new system approved by the School Board, guidance will need to be developed. This can be located on the.org website under a section on the approach to EBHC. This guidance is currently in development. A pilot test of the new LoE and GoR in translation science is drawing to an end, and no changes to the levels have been required. A draft information sheet for the new Grades of Recommendation was discussed by the group (Appendix 1). All guidance will be provided to the scientific committee for approval before uploading to the.org site. Workshop The group are scheduled to present a 2 hour workshop at the upcoming convention in October. All members of the group will be asked to contribute by the convenor if they are available. Any other business: There was no other business. Zac closed the meeting at 3.30pm Action list Item Actions Who ETA Development of Guidance for.org site GRADE in MASTARI reviewer s manual Zac to write a skeleton draft and send to the group for feedback and sci comm for approval Zac to discuss with MASTARI methodology group Zac Zac September 15th September 15th Workshop Zac to draft slides and send to the Zac September 30th

GRADEPro currently can import RevMan files, or can work as a standalone piece of software.

3 group for feedback GRADE collaboratio Meeting with Holger from the GRADE working group Zac, Ed, Craig October 2nd Appendix 1: New Grades of Recommendation The new grades of recommendation are informed by the GRADE working party, which has a binary system for recommendations, with only the two options: strong or weak. The benefit of such a system is its ease of interpretation by both clinicians and patients. When forming a recommendation, GRADE recommends the following four key factors be considered: the balance between desirable and undesirable effects, the quality of the evidence, values and preferences, and costs. 1, 2 Recommendations can be worded for or against particular management approaches. 1, 2 Due to negative connotations associated with the term weak, GRADE have provided the alternative terms of conditional, discretionary or qualified recommendations which can substitute for the term weak. 2 When wording recommendations, the following need to be specified: 1, 2 The population Intervention Any comparator (where applicable) The setting (where applicable) Wording for strong recommendations should be in the active voice. This can be achieved by using phrases such as we recommend/ Health professionals should/ or Do. 1, 2 For weak recommendations, phrases such as we suggest/health professionals might/we conditionally recommend. 1, 2 An example of a strong recommendation is: Health professionals should provide information regarding self-management of blood glucose levels for patients with type 2 diabetes living in the community. An example of a weak recommendation is: Health professionals might consider providing information regarding self-management of blood glucose levels for patients with type 2 diabetes living in the community. GRADE recommend that symbols are used when presenting recommendations. They suggest the symbol for strong recommendations whilst? is used for weak

The benefit of such a system is its ease of interpretation by both clinicians and patients.

4 recommendations. 1, 2 However, will continue using letters to represent the strength of recommendations, with Grade A being a strong recommendation, and Grade B representing a weak recommendation, as this is the approach most familiar to reviewers. Grades of Recommendation Grade A Grade B A strong recommendation for a certain health management strategy where it is clear that desirable benefits outweigh undesirable benefits of the strategy; where there is evidence of sufficient quality supporting its use; there is a benefit or no impact on resource use, and values, preferences and the patient experience have been taken into account. A weak recommendation for a certain health management strategy where desirable benefits appear to outweigh undesirable benefits of the strategy, although this is not as clear; where there is evidence supporting its use, although this may not be of high quality; there is a benefit, no impact or minimal impact on resource use, and values, preferences and the patient experience may or may not have been taken into account. The FAME (Feasibility, Appropriateness, Meaningfulness and Effectiveness) scale may help inform the strength and wording of a recommendation. F Feasibility; specifically: What is the cost effectiveness of the practice? Is the resource/practice available? Is their sufficient experience/levels of competency available? A Appropriateness; specifically: Is it culturally acceptable? Is it transferable to the majority of the population? Is it easily adaptable to a variety of circumstances? M Meaningfulness; specifically: Is it associated with positive experiences? Is it not associated with negative experiences?

5 E Effectiveness; specifically: Was there a beneficial effect? Is there a lack of harm associated with the practice? References 1 Guyatt GH, Oxman AD, Kunz R et al. Going from evidence to recommendations. BMJ. 2008;336(7652): Andrews J, Guyatt G, Oxman AD et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol. 2013;66(7):

Going from evidence to recommendations. BMJ. 2008;336(7652):1049-51.

Supporting Document for the Joanna Briggs Institute Levels of Evidence and Grades of Recommendation

Supporting Document for the Joanna Briggs Institute Levels of Evidence and Grades of Recommendation Developed by the Joanna Briggs Institute Levels of Evidence and Grades of Recommendation Working Party*