One of the major tenets of GRADE is that certainty of the evidence is just one component of decision-making. Ultimately, decision-makers also need to take into account important factors such as values and preferences, feasibility, and considerations of the impact of a decision on health equity and resource utilization. These factors and others are part of the Evidence-to-Decision (EtD) framework that guides the process from the assessment of certainty of evidence to the final formulation of recommendations in a structured, transparent manner.
Often, multiple teams and individuals involved in the development of a guideline will need to work together to compete the EtD process, which can be a source of confusion. Additionally, until now, no official guidance existed for the use of standardized wording when considering and reporting each EtD framework component. Earlier this year, Piggott and colleagues aimed to address this issue with an article published in the Journal of Clinical Epidemiology.
The project, comprising ten guideline development groups and over 250 recommendations, set out to develop a standardized framework for clear, transparent, and efficient wording when reporting Evidence-to-Decision components within a guideline. This template was then used in two guidelines in development - the European Commission Initiative on Breast Cancer (ECIBC) and the Endocrine Society guidelines on hyperglycemia, hypoglycemia and hypercalcemia. During this process, the authors were able to pilot the wording, receive feedback, and refine the template. The real-life guidelines were also used to provide examples of wording recommendations.
The article includes suggested wording structure and examples for reporting the magnitude and certainty of effect estimates, for conclusions of each portion of the EtD framework, and for justification of recommendations as well as notes on implementation considerations, monitoring and evaluation, and research priorities.
The authors note that these suggestions are preliminary and may require further refinement. Additionally, current examples of consistent and clear wording of EtDs continues to be lacking, though the dissemination of this guidance may improve future publications. While the suggestions within the article are focused on clinical decisions related to management of conditions, future efforts may expand this to guidelines for diagnostic testing, coverage, and other important areas.
Piggott, T., Baldeh, T., Dietl, B., Wiercoch, W., Nieuwlaat, R., Santesso, N., ... & Schünemann, H. (2022). Standardized wording to improve efficiency and clarity of GRADE EtD frameworks in health guidelines. J Clin Epidemiol (online ahead of print). Manuscript available at the publisher's website here.