It is not uncommon for a health guideline to compare two or more interventions against one another. However, while sophisticated statistical approaches such as network meta-analyses allow us to compare these interventions head-to-head in terms of specified health outcomes, they do not take other important aspects of clinical decision-making into account, such as patient values and preferences, resource use, and equity considerations. A new paper from Piggott and colleagues aims to provide initial suggestions for using the GRADE evidence to decision (EtD) framework when choosing which of multiple interventions to recommend.
The authors identified a need for more direction when undertaking a multiple intervention comparison (MC) approach while working on recently released guidelines for the European Commission Initiative on Breast Cancer in which multiple screening intervals were compared against one another. Based on this experience, the group drafted a flexible yet transparency-minded framework to help guide similar efforts in the future, which was then added as a module in GRADE's official guideline development software, GRADEpro.
The new module was pilot-tested for feasibility with several additional guidelines. The module allows the user to select and then compare multiple pairwise comparisons against one another (for instance, with one column for "Intervention 1 vs. Comparator 1" and "Intervention 2 vs. Comparator 2"). A five-star system is used to judge various components of the EtD, such as cost effectiveness, for each individual intervention and comparator, whereas a column on the right-hand side allows the user to input the relative importance of these components in decision-making.
Finally, the user can review all judgments across interventions and summatively recommend the most favorable intervention(s) overall.
Piggott T, Brozek J, Nowak A, et al. (2021). Using GRADE evidence to decision frameworks to choose from multiple interventions. J Clin Epidemiol 130:117-124.
Manuscript available from the publisher's website here.