Developing a Best Practice Guideline for Clinical Practice in a Digital Health Environment: Systematic Reviews Based on the Grading of Recommendations, Assessment, Development, and Evaluation Approach

Estimating benefits and harms of screening across subgroups: the Canadian Task Force on Preventive Health Care integrates the GRADE approach and overcomes minor challenges

Chronic constipation is a prevalent disorder representing a significant public health problem. The management of chronic constipation remains challenging, with people reporting dissatisfaction with available treatment options (1). Current clinical guidelines offer limited dietary recommendations only, and there is a lack of comprehensive evidence-based guidelines for the dietary management of chronic constipation. The aim of this project was to develop the first comprehensive evidence-based dietary guidelines for the management of chronic constipation in adults via a systematic literature review and a Delphi consensus process among an expert steering committee.The scope of the guidelines included dietary supplements, foods and drinks, and whole diets in adults with chronic constipation. Four systematic reviews and meta-analyses were performed to identify eligible randomised controlled trials (RCTs)(2-5). The findings generated from the meta-analysis of RCTs were then used to develop guideline statements using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach and a Delphi consensus survey among a multi-disciplinary expert steering committee. Recommendation statements were produced for treatment response, stool output, gut symptoms, adverse events, and quality of life. Statements were generated based on the findings only where ≥2 RCTs contributed to the meta-analysis (2-5). The “strength of recommendation” was assessed using the GRADE approach. Once statements were generated, they underwent consensus voting amongst the expert steering committee using a modified Delphi survey approach. Recommendation statements with ≥85% agreement were accepted.The four systematic reviews included a total of 75 RCTs (2-5). Based upon these, 59 dietary recommendation statements were generated and accepted through the Delphi survey. In terms of dietary supplements, 15 recommendation statements related to fibre supplements (overall and specific types), 20 related to probiotics (overall and specific species or strains), 2 to synbiotics (overall), 5 to magnesium oxide, 2 to senna, and 3 to kiwifruit supplements. In terms of foods, 3 recommendation statements related to kiwifruits, 2 to prunes, and 2 to rye bread. In terms of drinks, 5 recommendation statements related to high mineral-containing water. No recommendations were made for whole diet approaches due to lack of evidence. Ten statements had a very low level of evidence, 41 had low level of evidence, and 8 had moderate evidence. Twenty-seven statements were strong recommendations and 32 were qualified recommendations.These are the first ever comprehensive evidence-based dietary guidelines for the management of constipation. Recommendations were made for several dietary supplements, foods and drinks that have never been previously included in clinical guidelines. These guidelines offer new evidence-based dietary recommendations that can be rapidly implemented into clinical practice, thereby improving clinical care and patient outcomes.

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach is the de facto standard framework for summarising evidence in systematic reviews and developing recommendations in clinical practice guidelines. We describe how the GRADE approach is used in clinical practice guidelines, including key points and examples. The intended audience of this overview of GRADE is clinicians and researchers who are, or plan to be, involved in the development or assessment of clinical practice guidelines. We cover guideline endorsement and adaptation; guideline panels and sponsors; conflicts of interest; guideline questions and outcome prioritisation; systematic review creation, updating and re-use; rating the overall certainty of evidence; development of recommendations and implications; and peer review, publication, implementation and updating of guidelines. This overview aims to help developers, assessors and users of clinical practice guidelines understand how trustworthy, high-quality guidelines are developed using the GRADE approach.

Objective: To identify and describe the certainty of evidence of gynecology and obstetrics systematic reviews (SRs) using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Method: Database searches of SRs using GRADE, published between 1 January 2016 to 31 December 2020, in the 10 “gynecology and obstetrics” journals with the highest impact factor, according to the Journal Citation Report 2019. Selected studies included those SRs using the GRADE approach, used to determine the certainty of evidence. Results: Out of 952 SRs, ninety-six SRs of randomized control trials (RCTs) and/or nonrandomized studies (NRSs) used GRADE. Sixty-seven SRs (7.04%) rated the certainty of evidence for specific outcomes. In total, we identified 946 certainty of evidence outcome ratings (n = 614 RCT ratings), ranging from very-low (42.28%) to low (28.44%), moderate (17.65%), and high (11.63%). High and very low certainty of evidence ratings accounted for 2.16% and 71.60% in the SRs of NRSs, respectively, compared with 16.78% and 26.55% in the SRs of RCTs. In the SRs of RCTs and NRSs, certainty of evidence was mainly downgraded due to imprecision and bias risks. Conclusions: More attention needs to be paid to strengthening GRADE acceptance and building knowledge of GRADE methods in gynecology and obstetrics evidence synthesis.

This article describes how the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to grading the quality of evidence and strength of recommendations considers the Bradford Hill criteria for...

These Practice Guidelines for the Psychiatric Evaluation of Adults mark a transition in the American Psychiatric Association’s Practice Guidelines. Since the publication of the 2011 Institute of Medicine report Clinical Practice Guidelines We Can Trust, there has been an increasing focus on using clearly defined, transparent processes for rating the quality of evidence and the strength of the overall body of evidence in systematic reviews of the scientific literature. These guidelines were developed using a process intended to be consistent with the recommendations of the Institute of Medicine (2011), the Principles for theDevelopment of Specialty Society Clinical Guidelines of the Council of Medical Specialty Societies (2012), and the requirements of the Agency for Healthcare Research andQuality (AHRQ) for inclusion of a guideline in the National Guideline Clearinghouse. Parameters used for the guidelines’ systematic review are included with the full text of the guidelines; the development process is fully described in a document available on the APA website: http:// www.psychiatry.org/File%20Library/Practice/APA-GuidelineDevelopment-Process–updated-2011-.pdf. To supplement the expertise of members of the guideline work group, we used a “snowball” survey methodology to identify experts on psychiatric evaluation and solicit their input on aspects of the psychiatric evaluation that they saw as likely to improve specific patient outcomes (Yager 2014). Results of this expert survey are included with the full text of the practice guideline.

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

Non-Pharmacological Interventions to Prevent or Treat Delirium in Older Patients: Clinical Practice Recommendations The SENATOR-ONTOP Series.

Keywords: Cochrane reviews; GRADE methodology; implementation; observational studies; randomized clinical trials; WHO guidelines

ObjectivesDespite the uptake of nutrigenetic testing through direct-to-consumer services and healthcare professionals, systematic reviews determining scientific validity are limited in this field. The objective of this review was to: retrieve,...

ASH ISTH NHF WFH 2021 guidelines on the management of von Willebrand disease.

Executive Summary: Diagnosis and Evaluation of Hypersensitivity Pneumonitis: CHEST Guideline and Expert Panel Report

IntroductionUsing the best current evidence to inform clinical decisions remains a challenge for clinicians. Given the scarcity of trustworthy clinical practice guidelines providing recommendations to answer clinicians’ daily questions, clinical...

Chinese Guideline on the Management of Polypoidal Choroidal Vasculopathy (2022)

It is estimated that 1%-2% of women develop cervical intraepithelial neoplasia grade 2-3 (CIN 2-3) annually worldwide. The prevalence among women living with HIV is higher, at 10%. If left untreated, CIN 2-3 can progress to cervical cancer. WHO has previously published guidelines for strategies to screen and treat precancerous cervical lesions and for treatment of histologically confirmed CIN 2-3. Guidelines were developed using the WHO Handbook for Guideline Development and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. A multidisciplinary guideline panel was created. Systematic reviews of randomized controlled trials and observational studies were conducted. Evidence tables and Evidence to Recommendations Tables were prepared and presented to the panel. There are nine recommendations for screen-and-treat strategies to prevent cervical cancer, including the HPV test, cytology, and visual inspection with acetic acid. There are seven for treatment of CIN with cryotherapy, loop electrosurgical excision procedure, and cold knife conization. Recommendations have been produced on the basis of the best available evidence. However, high-quality evidence was not available. Such evidence is needed, in particular for screen-and-treat strategies that are relevant to low- and middle-income countries.