USGN Congratulates Fall 2024 Scholar Michelle Hannum

The U.S. GRADE Network, in partnership with the Evidence Foundation, is proud to be able to offer scholarships for deserving applicants to attend our semi-annual GRADE Guideline Development Workshop with a waived registration fee. 

The scholarship allows workshop participants of all disciplines, fields, career stages, and backgrounds to learn about the GRADE framework for assessing certainty of evidence and formulating guideline recommendations. 

The fall 2024 scholarship recipient, Michelle Hannum, was chosen due to her proposed project on "The Promising Future of Evidence-Based Clinical Pathways in Reducing Healthcare Bias," undertaken as part of her work as a Guideline Development Project Manager at the Value Institute at the Medical University of South Carolina (MUSC) Health. The role of clinical pathways is to provide the right information (guideline recommendations) to the right people (electronic health record end-users) at the right time (based on patient data) in the right formats and using the right channels. Hannum presented data on pathway utilization at MUSC Health, which demonstrated that Heart Failure pathway utilization was approximately 16-18% and that utilization was equal across patient race/ethnicity and sex among this population. Furthermore, pathway utilization coincided with lower mortality rates, fewer 30-day readmissions and ICU days, and overall lower cost. 

When asked about her experience as a scholar, Hannum stated,

"The workshop does an outstanding job meeting individuals with where they are at in their GRADE journey, whether it be for career roles or personal goals. The information was presented in an engaging manner with plenty of opportunities for discussion and question-answering. The workshop provides an excellent foundation for understanding GRADE and its application."

Interested in being a scholar at the Spring 2025 GRADE Workshop in Washington, DC, May 7-9, 2025? Applications are due January 31. See details at www.evidencefoundation.org/scholarships/html.

EF Scholar Success Story: Nirjhar Ruth Ghosh

 New publication alert!

Nirjhar Ruth Ghosh, who attended the winter 2022 Systematic Review workshop as an Evidence Foundation scholar, recently published the results of her hard work in The Journal of Nutrition! The project, "Evidence-Based Practice Competencies Among Nutrition Professionals and Students: A Systematic Review" was originally presented by Ghosh to her fellow attendees of the virtual workshop. The results of the systematic review are now able to be read in detail at this link. 

In an accompanying editorial lauding the publication, Francene M. Steinberg wrote that "Ghosh et al. have provided a foundation for further consideration of steps to advance interprofessional competencies in EBP to optimize clinical nutrition decision making and patient care outcomes. Improved clarity about core competencies, innovative EBP curriculum and pedagogic approaches, and more rigorous research evaluations of EBP application and outcomes are all necessary components of the path forward."

Congratulations, Ruth!

Interested in being our next scholar success story? Applications for scholarships to attend our fully virtual GRADE Guideline Development Workshop are now open (deadline: August 31). Learn more at https://evidencefoundation.org/scholarships. 

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Three's a Crowd: How to Deal with More than Two Arms in a Meta-Analysis

It is not uncommon to come across the following scenario: when conducting a meta-analysis between two arms (e.g., an active therapy vs. a placebo), the meta-analyst includes a study that actually included two active arms (e.g., two different doses of the same experimental drug vs. placebo, two different routes of administration, etc.) Let's say that both of these arms were relevant to the clinical question. How should meta-analysis be undertaken in this case? A new tutorial article published in Cochrane Evidence Synthesis and Methods gives a primer on how to approach this common conundrum. 

Including the study twice in the forest plot – for instance, with one dose versus placebo and the other versus the same placebo group – is statistically problematic. It leads to a "unit of analysis" error by essentially "double-counting" the participants in the control group and violating the assumption that every individual participant is only counted twice. (Aside: this is also a common error in meta-analyses combining multiple similar outcomes – e.g., including the handgrip strength of both the dominant and non-dominant hand in the same forest plot – and risks committing the same violation unless advanced multi-level statistical techniques are used to account for this). 

This leaves two basic options for including the data from more than two study arms into the same forest plot: combining interventions that are similar, and splitting the control group in half. For instance, if the three groups in question are as such (assuming a dichotomous outcome):

• Experimental group A: 50 participants, 45 of whom had the event.
• Experimental group B: 50 participants, 41 of whom had the event.
• Control group: 50 participants, 22 of whom had the event.

These two experimental groups can either be combined (100 participants, 89 of whom had the event) and compared to the control group as-is, or they can be split out and compared (on separate lines of the forest plot) to half of the control group on each line:

• Experimental group A (45 out of 50) versus control (11 out of 25)
• Experimental group B (41 out of 50) versus control (11 out of 25).

Both approaches will yield very similar pooled results.

In the case of a continuous outcome, the same general approaches can be applied. However, if pooling two or more arms together, a pooled mean and SD will need to be calculated using the following equations from the Cochrane Handbook:

Reference: Axon, E., Dwan, K., & Richardson, R. (2023) Multiarm studies and how to handle them in a meta-analysis: A tutorial. Cochrane Evidence Synthesis and Methods. Available at publisher's website here.

Review of Time-to-Event Outcomes Analyzed in 50 Systematic Reviews Indicates Lack of Rigorous Reporting

Commonly used in the fields of oncology, cardiology, and others, time-to-event (TTE) outcomes assess not only the occurrence of an event but the amount of time that has lapsed leading up to its occurrence. For individuals in which the event did not occur, their time under observation is included.

TTE outcomes can provide useful insight into, for instance, into how long individuals survive when taking a new drug for advanced cancer. Statistical methods of calculating TTE outcomes include the use of curves and probabilities (Kaplan-Meier curves) and hazard ratios (HRs). 

In addition to being more statistically complex than a simple risk ratio, TTE outcomes are often not reported adequately enough in trials to be used in a meta-analysis without some amount of imputation or exclusion of data, which can introduce error.

In an article published in the July 2023 issue of Journal of Clinical Epidemiology, Goldkuhle and colleagues more closely examined the use of TTE outcomes in meta-analyses included in both Cochrane and non-Cochrane systematic reviews between 2017 and 2020. In the 50 included reviews, a median two TTE outcomes were included in meta-analyses, the most common being comparing the use of biologics and drugs in the treatment of neoplasms. 

However, a lack of clear reporting in the 235 trials informing these systematic reviews could easily lead to incomplete data. For instance, only 82% of the trials included a measure of follow-up duration. Information about missing data was only reported for each trial arm in 134 (57%) of the trials, and about one-third of trials reported no information at all in this respect. 

The authors conclude that trial authors using TTE outcomes should more stridently follow the Consolidated Standards of Reporting Trials (CONSORT) extension to trial outcomes, while specific guidance is needed for the reporting of meta-analysis of TTE outcomes. 

Goldkuhle, M. et al. (2023). Meta-epidemiological review identified variable reporting and handling of time-to-event analyses in publications of trials included in meta-analyses of systematic reviews. J Clin Epidemiol 159: 174-189.

The full-text publication can be accessed here.

McMaster and Guidelines International Network launch Collaboration Toolkit for Guideline Developers

Collaboration between medical professional societies and health organizations can increase the efficiency of development efforts, reduce waste, and help share resources, knowledge, and skills within and across disciplines. However, an international needs assessment of guideline developers found that certain aspects of collaboration were specifically challenging, including difficulties reconciling differences in guideline methodology and the time required for establishing collaboration agreements.

Since then, McMaster University and the Guidelines International Network (G-I-N) have worked on developing a toolkit for organizations looking to inspire, guide, and facilitate their own collaborations. The toolkit, launched at this year's G-I-N conference in Glasgow, Scotland, includes access to helpful resources such as a Memorandum of Understanding template for establishing partnerships and a glossary for making sure all parties are on the same page regarding important terms. A list of collaboration-related publications offers further knowledge and guidance for aspiring collaborators.

Check out the toolkit here and stay posted for update and additions!

EF Scholars Talk High-Speed Ways to Apply Evidence to Practice at Austin GRADE Workshop

 At the most recent GRADE Guideline Development Workshop held in Austin, Texas, our team was joined by two impressive scholars making moves in the field of evidence synthesis and evidence-based medicine. These scholars, Drs. Syed Arsalan Naqvi and Juan Ruiz, were selected to have their workshop registration fee waived based on their application materials, including a description of a current or proposed project to reduce bias in healthcare. They also had the opportunity to present on these topics and field questions from the other workshop attendees.

Syed Arsalan Ahmed Naqvi, M.B.B.S., presented on a current project to apply machine learning to develop an algorithm to automatically assess certainty of evidence in living systematic reviews within a living interactive evidence (LivE) framework. Certainty of evidence assessment requires "repetitive evaluations whenever new studies or updated reports of previously included studies are incorporated into the existing body of evidence," Dr. Naqvi explained. "The manual efforts required to assess certainty of evidence necessitate considerable time and resources, which become even more cumbersome with periodic updates." Dr. Naqvi's project described the proposal for "an adjudication system which leverages an interactive web-based graphical user interface and rule-based algorithms" for assessing certainty in the context of living systematic reviews of randomized controlled trials.

Of his experience at the workshop, Dr. Naqvi said, "“The GRADE guideline workshop was an enriching experience. It was well organized, and precise, focusing on the most important aspects of clinical guideline development. I really enjoyed the small group sessions with the faculty and the participants."

Dr. Juan Ruiz presented his proposal to implement a rapid review and question-and-answer program for hospitalists applying evidence-based medicine in everyday practice. "Doctors have questions every day at the point of care that are not always [addressed], Dr. Ruiz explained. "Factors associated with unanswered medical questions" include "lack of time" and "lack of knowledge and skills to apply evidence-based medicine tools." By training onco-hospitalists in GRADE and creating an accessible database with clinical questions, answers, and recommendations based on evidence-based methodologies, Ruiz hopes to help bridge this gap in the evidence-to-practice pipeline.

"I had the opportunity to participate as a Scholar of the Evidence Foundation in the US GRADE Network workshop in Austin, TX in May 2023," said Dr. Ruiz. "This workshop was focused on non-RCTs, an area of great interest to me since I work analyzing large national databases and electronic medical records of cancer patients. I presented and received valuable feedback for a project to be implemented in a cancer hospital to develop recommendations for daily practice using the GRADE approach. It was a very constructive three-day experience where I was able to learn new skills and share knowledge."

Interested in becoming a scholar? Applications to attend our next fully virtual fall workshop, held October 25-27, 2023, for free close on August 31. See application details here. 

GRADE Guideline Development Workshop - now with INGUIDE!

We at the U.S. GRADE Network are excited to announce that, for the first time ever, we have partnered with INGUIDE, a credentialing system for guideline developers, to offer free access to their Level 1 online training to participants of our Guideline Development Workshop and Guideline Fundamentals for Panel Members and Organization Staff pre-workshop course. 

This announcement comes just in time for our next workshop, held in Austin, Texas May 17-19, for which there are still spots available at our workshop website.

The INGUIDE program, the result of a collaboration between the Guidelines International Network (G-I-N) and McMaster University, provides certification of individuals involved in guideline development on four successive levels, from a Guideline Panel Member to becoming a Guideline Development Credentialing Instructor themselves. 

To obtain access to the INGUIDE Level 1 course, simply register for and attend our 3-day GRADE guideline development workshop in addition to the pre-workshop course on Guideline Fundamentals for Panel Members and Organization Staff. This 3-hour pre-workshop course will cover all of the necessary information about the practical aspects of guideline development, including:

• the importance of trustworthy guidelines
• checklists for the development of guidelines
• the structure and roles of a guideline panel
• the process of grading evidence and formulating recommendations

The main 3-day workshop will cover important aspects of assessing risk of bias, rating the certainty of evidence, and considering other important factors when using GRADE to develop a guideline.

Our pre-workshop course combined with our main three-day in-person course will provide all of the training required for a breeze-through experience online. You will receive free access to the ~2-3 hour online course, comprising four modules, that you can complete at your convenience after the workshop. Upon completion, you will be officially certified as an INGUIDE Level 1 Guideline Panel Member.