Clinical practice, public health, and policy guidelines should be developed based on a systematic approach that uses the best available evidence. The advent of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework has facilitated this, resulting in a transparent approach to guideline development.
GRADE suggests that guideline developers seldom make strong recommendations based on low or very low confidence in effect estimates (strong l/vl).
The World Health Organization (WHO) produces recommendations that guide public health policy and, in 2003, WHO adopted the GRADE approach to guideline development. Initial anecdotal evidence suggested that WHO issues a large number of strong recommendations and particularly strong l/vl.
Our research team evaluated the nature of WHO recommendations and conducted a qualitative study using interviews of guideline panel members. Key findings included: i) WHO makes a large proportion of recommendations as strong l/vl ii) many strong l/vl are inconsistent with GRADE guidance iii) reasons guideline panel members offered for strong l/vl included skepticism about the value of making conditional recommendations; political considerations; a high confidence in benefits despite formal ratings of low confidence; and long-standing practices, funding, and policy; iv) methodologist interviewees indicated panelists’ lack of commitment to conditional recommendations; a perceived tension between methodologists and panelists due to resistance to adhering to GRADE guidance; both financial and non-financial conflicts of interest among panel members as explanations of strong l/vl; and the need for greater clarity of, and support for, the role of methodologists as co-chairs of panels.
The understanding of when and why strong l/vl are formulated at WHO is an important methodological issue that has implications not just for WHO, but for a wide range of guideline developers elsewhere. Our findings offer insights that may guide interventions to enhance trustworthiness of practice guidelines. / Thesis / Doctor of Philosophy (PhD)
| Identifer | oai:union.ndltd.org:mcmaster.ca/oai:macsphere.mcmaster.ca:11375/16804 |
| Date | January 2015 |
| Creators | Alexander, Paul |
| Contributors | Guyatt, Gordon, Health Research Methodology |
| Source Sets | McMaster University |
| Language | English |
| Detected Language | English |
| Type | Thesis |
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