Please use this identifier to cite or link to this item:
http://hdl.handle.net/11375/16804
Title: | CLINICAL PRACTICE AND PUBLIC HEALTH GUIDELINES: THE MAKING OF APPROPRIATE STRONG RECOMMENDATIONS WHEN THE CONFIDENCE IN EFFECT ESTIMATES IS LOW OR VERY LOW (DISCORDANT) |
Other Titles: | CLINICAL PRACTICE AND PUBLIC HEALTH GUIDELINES |
Authors: | Alexander, Paul |
Advisor: | Guyatt, Gordon |
Department: | Health Research Methodology |
Keywords: | World Health Organization, clinical practice guidelines, public health guidelines, GRADE, discordant, strong recommendations, low confidence, low quality of evidence |
Publication Date: | 2015 |
Abstract: | 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. |
URI: | http://hdl.handle.net/11375/16804 |
Appears in Collections: | Open Access Dissertations and Theses |
Files in This Item:
File | Description | Size | Format | |
---|---|---|---|---|
FINAL doctoral thesis_P Alexander_revisions March 1_2015.pdf | This file is the pdf version which is the entire (MAIN) thesis and all 9 chapters (all published and submitted studies) | 1.54 MB | Adobe PDF | View/Open |
Items in MacSphere are protected by copyright, with all rights reserved, unless otherwise indicated.