Optimizing the Presentation of Indirect Evidence for Clinical Practice Guideline Panels That Use the Grade Approach for Decision-Making

Abstract

While many clinical practice guidelines that use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach have ample published evidence to support their recommendations, certain situations (e.g. rare, rapidly emerging, or understudied diseases) may be limiting. As a result, it is common for guideline developers to seek out indirect evidence from other areas to fill in these evidence gaps. The GRADE evidence-to-decision (EtD) framework, which offers a structured and transparent development process for guidelines, includes additional research evidence domains (e.g. feasibility, acceptability, equity) for panels to consider in their decision-making process. This confluence of both considerations of indirect information and increasing literature domain sources to draw from when making decisions weighs on the simplicity of literature presentation. Herein, firstly, we described an example of specific decision-rules for including indirect evidence and the implications of the rules for presenting results to decision-makers. Secondly, we provided a comprehensive overview of how guideline developers currently report economic information across GRADE evidence-to-decision frameworks. Lastly, we ranked the most important study characteristics suggested in the literature by economists to consider as decision-rules when assessing indirectness (transferability) of economic evaluations chosen as research evidence in a GRADE guideline. We conclude that developers, with the help of their panels, should work to establish and report clear decision-rules and the rationale for indirect evidence that they select for their clinical practice guidelines. This has the potential to simplify the presentation of indirect evidence for panels and developers, as well as, to reduce decision-making confusion, time demands and guideline funder costs.