Wednesday, January 30, 2019

Stating the “Obvious”: A Primer on Good Practice Statements in GRADE Guidelines

Contributed by Madelin Siedler, 2018/2019 U.S. GRADE Network Research Fellow

Stating the “Obvious”: A Primer on Good Practice Statements in GRADE Guidelines

One of the benefits of the GRADE approach is that it provides a framework for the development of evidence-based recommendations that are clear and actionable for practicing clinicians even when only lower-quality evidence is available. However, in some particular instances, caution is warranted when developing a recommendation based on low-quality evidence or inference. “Good practice statements” are one such instance. 

The term “good practice statement” is sometimes interchanged for “motherhood statement”.” In either case, the practice being recommended is usually something that is already commonly accepted as beneficial or practical advice. It could even be seen as irrefutably “good” as motherhood and apple pie (hence the term). The nature of these types of statements is such that the action is seen as so obviously beneficial that it would be unduly onerous to conduct a review to demonstrate its efficacy.

An example of a good practice statement is the first recommendation from the American Gastroenterological Association (AGA)’s 2015 guideline on the management of asymptomatic pancreatic cysts, which reads, “The AGA recommends that before starting any pancreatic cyst surveillance program, patients should have a clear understanding of programmatic risks and benefits” (Vege et al., 2015).

How to Spot a Good Practice Statement
An easy way to identify a good practice statement is to restate the recommendation as its inverse: for instance, “patients should not have a clear understanding of programmatic risks and benefits.” If this “unstated alternative” is absurd or clearly does not conform to ethical norms, the original statement is likely a good practice statement (Guyatt et al., 2016).

The Problem with Good Practice Statements
The GRADE Working Group recommends that good practice statements be used sparingly, if at all. Because good practice guidance is typically based on several linked sources of indirect evidence, there is no way to tell whether the benefits of the proposed recommended action are as truly obvious or incontestable as they seem. And if they are (if the inverse of the proposed recommendation would be absurd or unethical) then they are likely unwarranted and can dilute the strength of the guideline as a whole. 

Sometimes, good practice statements may even appear as graded recommendations in a guideline (a decision that’s not recommended by the GRADE working group for the reasons above). In this case, the guideline authors may be tempted to make a strong recommendation based on low-quality evidence, which should ideally be a rare occurrence and based on well-defined criteria (Guyatt et al., 2015). 

Practical Advice for Dealing with Good Practice Statements
The GRADE Working Group recommends using the following checklist to determine whether a good practice statement is warranted:
  1. Is the statement clear and actionable? 
  2. Is the message really necessary in regards to actual health practice? 
  3. After consideration of all relevant health outcomes and potential downstream consequences, will implementing the good practice statement result in large net positive consequences? 
  4. Is collecting and summarizing the evidence a poor use of a guideline panel’s limited time and energy? 
  5. Is there a well-documented clear and explicit rationale connecting the indirect evidence?
If the answer is 'yes' to all five questions, a good practice statement may be warranted for inclusion in a guideline document. When done correctly, good practice advice statements should appear as ungraded recommendations, meaning no formal rating of quality of evidence or strength of recommendation should be given (Guyatt et al., 2015).

However, many potential good practice statements will be eliminated through the use of this checklist. For instance, careful consideration of Question #3 could lead the panel to realize that the assumed net positive of a specific action may not be so obvious after all. In this case, the guideline panel should consider whether a thorough review of the evidence should be conducted and formal grading methods applied.