GRADE equity guidelines 2: considering health equity in GRADE guideline development: equity extension of the guideline development checklist

Poor reporting limited consideration of EDI in the Australian guidelines for the clinical care of people with COVID-19

OBJECTIVES

Actively addressing issues of equity, diversity, and inclusion (EDI) in healthcare guidelines provides an important avenue ensure that individuals and communities receive high-quality healthcare that meets their needs. In 2020, the National Clinical Evidence Taskforce was charged with developing Australian living guidelines for COVID-19 (the Guidelines). It was intended that the Guidelines would consider the biological and social determinants of health (BSDH) underpinning evidence-based recommendations for of the treatment of COVID-19. The objective of this paper is to describe the evidence available on BSDH that is reported in published trials of disease-modifying therapies for COVID-19.

STUDY DESIGN AND SETTING

Published papers of randomized controlled trials that informed clinical recommendations (for and against drug therapies for COVID-19) in the Guidelines were reviewed retrospectively using a case series design. We extracted reported characteristics relating to BSDH. These included age, sex, gender, geographical location, ethnicity (including indigenous), disability, migrant status, income, education, employment, and social support. A descriptive analysis was conducted to illustrate the characteristics available for use in guideline development.

RESULTS

A total of 115 peer-reviewed papers describing randomized control trials of drug interventions for the treatment of COVID-19 were included. BSDH characteristics were poorly reported. Geographical location of the study was the only category reported in all papers. While age and sex were reported in most papers (n = 109 and 108, respectively), ethnicity was reported in only one-third of papers (n = 40), social support was reported in only three papers, and employment in one paper. No paper reported on gender, disability, migrant status, income, or education.

CONCLUSION

Consideration of EDI issues is a crucial component of guideline development. Although these issues were widely recognized to impact on health outcomes from COVID-19, reporting of these characteristics was poor in COVID trials. Urgent action is needed to improve reporting of EDI characteristics if they are to be meaningfully considered in guideline processes, and health inequity is overcome.

Under-representation of Diversity on American Urological Association and European Association of Urology Guideline Panels

OBJECTIVE

To assess the panel composition of the 2 most important guideline developers in urology as equity and acceptability, important domains in clinical guideline development, require broad stakeholder representation.

METHODS

Following a predefined protocol, we identified all current AUA and EAU guideline documents. Two authors independently abstracted data including guideline topic, number and roles of panel members, voting status, and academic rank. We determined panel member's gender (woman, man, or nonbinary) and racialization (White or non-White) status based on name, internet picture, pronouns used, bios available, and gender listed on their profile.

RESULTS

We identified 31 AUA and 20 EAU guidelines for inclusion. Median panel size was 19 (interquartile range [IQR]: 17; 21) with 12 (IQR: 10; 14) voting members. The average composition of voting panels was predominantly male (81.8%) and White (86.8%). Eleven guideline panels (21.6%) did not include any women, and 9 (17.6%) panels had no representation of individuals from non-White groups. While gender distribution was similar among guidelines of the 2 organizations, the AUA included more voting members from non-White groups (14.3% vs 8.0%; P = .010). Analysis of the AUA panel composition over time revealed stable proportions of female and non-White individuals.

CONCLUSION

Both AUA and EAU guidelines exhibit insufficient representation of females and non-White individuals, with no evident improvement observed over time. Implementing more transparent processes that advocate for diverse panel representation may enhance the incorporation of stakeholder values and preferences, thereby improving the dissemination and adoption of guidelines.

The American Society of Addiction Medicine Clinical Practice Guideline Development Methodology

ABSTRACT

The American Society of Addiction Medicine (ASAM) has published clinical practice guidelines (CPGs) since 2015. As ASAM's CPG work continues to develop, it maintains an organizational priority to establish rigorous standards for the trustworthy production of these important documents. In keeping with ASAM's mission to define and promote evidence-based best practices in addiction prevention, treatment, and recovery, ASAM has rigorously updated its CPG methodology to be in line with evolving international standards. The CPG Methodology and Oversight Subcommittee was formed to establish and publish a methodology for the development of ASAM CPGs and to develop an ASAM CPG strategic plan. This article provides a focused overview of the ASAM CPG methodology.

Society of American Gastrointestinal and Endoscopic Surgeons guidelines development: health equity update to standard operating procedure

INTRODUCTION

The SAGES Guidelines Committee creates evidence-based clinical practice guidelines. Due to existing health disparities, recommendations made in these guidelines may have different impacts on different populations. The updates to our standard operating procedure described herein will allow us to produce well-designed guidelines that take these disparities into account and potentially reduce health inequities.

METHODS

This paper outlines updates to the SAGES Guidelines Committee Standard Operating Procedure in order to incorporate issues of heath equity into our guideline development process with the goal of minimizing downstream health disparities.

RESULTS

SAGES has developed an evidence-based, standardized approach to consider issues of health equity throughout the guideline development process to allow physicians to better counsel patients and make research recommendations to better address disparities.

CONCLUSION

Societies that promote guidelines within their organization must make an intentional effort to prevent the widening of health disparities as a result of their recommendations. The updates to the Guidelines Committee Standard Operating Procedure will hopefully lead to increased attention to these disparities and provide specific recommendations to reduce them.

Development of a Health Equity Framework for the US Preventive Services Task Force

Importance

Clinical practice guidelines can play an important role in mitigating health inequities. The US Preventive Services Task Force (USPSTF) has prioritized addressing health equity and racism in its recommendations.

Objective

To develop a framework that would allow the USPSTF to incorporate a health equity lens that spans the entirety of its recommendation-making process.

Evidence Review

Key guidance, policy, and explanatory frameworks related to health equity were identified, and their recommendations and findings were mapped to current USPSTF methods. USPSTF members as well as staff from multiple entities supporting the USPSTF portfolio were consulted. Based on all the gathered information, a draft health equity framework and checklist were developed; they were then circulated to the USPSTF's key partners for input and review.

Findings

An equity framework was developed that could be applied to all phases of the recommendation process: (1) topic nomination, selection, and prioritization; (2) development of the work plan; (3) evidence review; (4) evidence deliberation; (5) development of the recommendation statement; and (6) dissemination of recommendations. For each phase, several considerations and checklist items to address are presented. These items include using health equity as a prioritization criterion and engaging a diverse group of stakeholders at the earliest phases in identifying topics for recommendations; developing necessary equity-relevant questions (eg, beyond effectiveness and harms) to address during the protocol phase; using methods in synthesizing the evidence and contextual issues in the evidence review related to specific populations experiencing a disproportionate burden of disease; and examining the magnitude and certainty of net benefit, implementation considerations, risk assessment, and evidence gaps through an equity lens when developing evidence-based recommendations.

Conclusions and Relevance

Executing this entire framework and checklist as described will be challenging and will take additional time and resources. Nonetheless, whether adopted in its entirety or in parts, this framework offers guidance to the USPSTF, as well as other evidence-based guideline entities, in its mission to develop a more transparent, consistent, and intentional approach to addressing health equity in its recommendations.

GRADE Concept 7: Issues and Insights Linking Guideline Recommendations to Trustworthy Essential Medicine Lists

OBJECTIVES

Guidelines and essential medicine lists (EMLs) bear similarities and differences in the process that lead to decisions. Access to essential medicines is central to achieve universal health coverage. The World Health Organization (WHO) EML has guided prioritization of essential medicines globally for nearly 50 years, and national EMLs (NEMLs) exist in over 130 countries. Guideline and EML decisions, at WHO or national levels, are not always coordinated and aligned. We sought to explore challenges, and potential solutions, for decision-making to support trustworthy medicine selection for EMLs from a Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group perspective. We primarily focus on the WHO EML; however, our findings may be applicable to NEML decisions as well.

STUDY DESIGN AND SETTING

We identified key challenges in connecting the EML to health guidelines by involving a broad group of stakeholders and assessing case studies including real applications to the WHO EML, South Africa NEML, and a multiple sclerosis guideline connected to a WHO EML application for multiple sclerosis treatments. To address challenges, we utilized the results of a survey and feedback from the stakeholders, and iteratively met as a project group. We drafted a conceptual framework of challenges and potential solutions. We presented a summary of the results for feedback to all attendees of the GRADE Working Group meetings in November 2022 (approximately 120 people) and in May 2023 (approximately 100 people) before finalizing the framework.

RESULTS

We prioritized issues and insights/solutions that addressed the connections between the EML and health guidelines. Our suggested solutions include early planning alignment of guideline groups and EMLs, considering shared participation to strengthen linkage, further clarity on price/cost considerations, and using explicit shared criteria to make guideline and EML decisions. We also provide recommendations to strengthen the connection between WHO EML and NEMLs including through contextualization methods.

CONCLUSION

This GRADE concept article, jointly developed by key stakeholders from the guidelines and EMLs field, identified key conceptual issues and potential solutions to support the continued advancement of trustworthy EMLs. Adopting structured decision criteria that can be linked to guideline recommendations bears the potential to advance health equity and gaps in availability of essential medicines within and between countries.

Clinical practice guidelines for the diagnosis and management of Duchenne muscular dystrophy: a scoping review

Introduction

Our objective was to identify recent CPGs for the diagnosis and management of DMD and summarize their characteristics and reliability.

Methods

We conducted a scoping review of CPGs using MEDLINE, the Turning Research Into Practice (TRIP) database, Google Scholar, guidelines created by organizations, and other repositories to identify CPGs published in the last 5 years. Our protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses for scoping reviews. To assess the reliability of the CPGs, we used all the domains included in the Appraisal of Guidelines Research and Evaluation II.

Results

We selected three CPGs published or updated between 2015 and 2020. All the guidelines showed good or adequate methodological rigor but presented pitfalls in stakeholder involvement and applicability domains. Recommendations were coherent across CPGs on steroid treatment, except for minor differences in dosing regimens. However, the recommendations were different for new drugs.

Discussion

There is a need for current and reliable CPGs that develop broad topics on the management of DMD and consider the challenges of developing recommendations for RDs.

Operationalizing the GRADE-equity criterion to inform guideline recommendations: application to a medical cannabis guideline

OBJECTIVES

Incorporating health equity considerations into guideline development often requires information beyond that gathered through traditional evidence synthesis methodology. This article outlines an operationalization plan for the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-equity criterion to gather and assess evidence from primary studies within systematic reviews, enhancing guideline recommendations to promote equity. We demonstrate its use in a clinical guideline on medical cannabis for chronic pain.

STUDY DESIGN AND SETTING

We reviewed GRADE guidance and resources recommended by team members regarding the use of evidence for equity considerations, drafted an operationalization plan, and iteratively refined it through team discussion and feedback and piloted it on a medicinal cannabis guideline.

RESULTS

We propose a seven-step approach: 1) identify disadvantaged populations, 2) examine available data for specific populations, 3) evaluate population baseline risk for primary outcomes, 4) assess representation of these populations in primary studies, 5) appraise analyses, 6) note barriers to implementation of effective interventions for these populations, and 7) suggest supportive strategies to facilitate implementation of effective interventions.

CONCLUSION

Our approach assists guideline developers in recognizing equity considerations, particularly in resource-constrained settings. Its application across various guideline topics can verify its feasibility and necessary adjustments.

Equity issues rarely addressed in the development of COVID-19 formal recommendations and good practice statements: a cross-sectional study

BACKGROUND AND OBJECTIVE

To identify COVID-19 actionable statements (e.g., recommendations) focused on specific disadvantaged populations in the living map of COVID-19 recommendations (eCOVIDRecMap) and describe how health equity was assessed in the development of the formal recommendations.

METHODS

We employed the place of residence, race or ethnicity or culture, occupation, gender or sex, religion, education, socio-economic status, and social capital-Plus framework to identify statements focused on specific disadvantaged populations. We assessed health equity considerations in the evidence to decision frameworks (EtD) of formal recommendations for certainty of evidence and impact on health equity criteria according to the Grading of Recommendations, Assessment, Development, and Evaluations criteria.

RESULTS

We identified 16% (124/758) formal recommendations and 24% (186/819) good practice statements (GPS) that were focused on specific disadvantaged populations. Formal recommendations (40%, 50/124) and GPS (25%, 47/186) most frequently focused on children. Seventy-six percent (94/124) of the recommendations were accompanied with EtDs. Over half (55%, 52/94) of those considered indirectness of the evidence for disadvantaged populations. Considerations in impact on health equity criterion most frequently involved implementation of the recommendation for disadvantaged populations (17%, 16/94).

CONCLUSION

Equity issues were rarely explicitly considered in the development COVID-19 formal recommendations focused on specific disadvantaged populations. Guidance is needed to support the consideration of health equity in guideline development during health emergencies.

A scoping review establishes need for consensus guidance on reporting health equity in observational studies

OBJECTIVES

To evaluate the support from the available guidance on reporting of health equity in research for our candidate items and to identify additional items for the Strengthening Reporting of Observational studies in Epidemiology-Equity extension.

STUDY DESIGN AND SETTING

We conducted a scoping review by searching Embase, MEDLINE, CINAHL, Cochrane Methodology Register, LILACS, and Caribbean Center on Health Sciences Information up to January 2022. We also searched reference lists and gray literature for additional resources. We included guidance and assessments (hereafter termed "resources") related to conduct and/or reporting for any type of health research with or about people experiencing health inequity.

RESULTS

We included 34 resources, which supported one or more candidate items or contributed to new items about health equity reporting in observational research. Each candidate item was supported by a median of six (range: 1-15) resources. In addition, 12 resources suggested 13 new items, such as "report the background of investigators".

CONCLUSION

Existing resources for reporting health equity in observational studies aligned with our interim checklist of candidate items. We also identified additional items that will be considered in the development of a consensus-based and evidence-based guideline for reporting health equity in observational studies.

Representations of clinical practice guidelines and health equity in healthcare literature: An integrative review

AIM

This paper reports an integrative review of international health literature that discusses health equity in relation to clinical practice guidelines (CPGs).

BACKGROUND

Healthcare professionals (HCPs), policy makers, and decision makers rely on sound empirical evidence to make fiscally responsible and appropriate decisions about the allocation of health resources and health service delivery. CPGs provide statements and recommendations that aim to standardize care with an implicit goal of achieving equity of care among diverse populations. Developers of CPGs must be careful not to exacerbate inequity when making recommendations. As such, it is important to determine how equity is discussed within the context of CPGs.

DESIGN

This integrative review was conducted according to integrative review methods as outlined by Whittemore and Knafl (2005), and Toronto and Remington (2020). These authors outlined a systematic process for the identification of relevant literature across health disciplines to examine the state of knowledge pertaining to a phenomenon such as health equity.

SEARCH METHODS

The computerized databases PubMed, CINAHL, Cochrane, Embase, Medline, and Web of Science were searched using a combination of keywords. Search parameters included international peer-reviewed published, full-text, English language articles, editorials, and reports over the last decade (January 2011 to February 2022). A reference search of included articles was conducted to identify any additional articles. Dissertations and theses were not included.

SEARCH OUTCOME

A total of 139 peer-reviewed English language articles were identified.

RESULTS

The findings of this review revealed five main ways in which health equity is in context of CPGs including if they target or exacerbate inequity among disadvantaged populations, equity and CPG development, implementation, and evaluation, and checklists and tools to assist developers and users of CPG to consider equity. Although critical appraisal tools exist to assist users of CPGs assess and to evaluate how well CPGs address issues of equity, the definition of equity and how CPG development panels should incorporate and articulate it remains unclear and haphazard. As such, recommendations intended to be implemented by HCPs to optimize health equity remains diverse and unclear.

CONCLUSION

The way equity is discussed within the reviewed health literature has implications for their uptake by and utility for HCPs. The ability of HCPs to implement CPGs may be hindered without an appreciation and integration of equity considerations across the various phases of CPG conceptualization, development, implementation, and evaluation, and their relevance and appropriateness to diverse geographic and socioeconomic contexts with variable access to health human resources and services. This situation could be improved if equity were more clearly articulated within all aspects of the CPG process.

CLINICAL RELEVANCE

Understanding how equity is discussed in the literature relative to CPGs has implications for their uptake by and utility for HCPs in their goal of providing equitable health care. Successful implementation of CPGs with consideration equity could be improved if equity were more clearly articulated within all aspects of the CPG process including conceptualization, development, implementation, and evaluation.

Health equity considerations in guideline development: a rapid scoping review

BACKGROUND

Systematic guidance for considering health equity in guidelines is lacking. This scoping review aims to synthesize current best practices for integrating health equity into guideline development and the benefits or drawbacks of these practices.

METHODS

We searched Ovid MEDLINE ALL and Embase Classic+Embase on the Ovid platform, CINAHL on EBSCO, and Web of Science (Core Collection) from 2010 to 2022. We searched grey literature from 2015 to 2022, using the Canadian Agency for Drugs and Technologies in Health Grey Matters checklist and searches of potentially relevant websites. Articles were screened independently by 1 reviewer. Proposed best practices, advantages and disadvantages, and tools were extracted independently by 1 reviewer and qualitatively synthesized based on the relevant steps of a comprehensive checklist covering the stages of guideline development.

RESULTS

We included 26 articles that proposed best practices for incorporating health equity within the guideline development process. These practices were organized under different stages of the development process, including guideline planning, evidence review, guideline development and dissemination. Included studies provided best practices from guideline producers, articles discussing health equity in current guidelines, articles addressing strategies to increase equity in the guideline implementation process, and literature reviews of promising health equity practices.

INTERPRETATION

Our scoping review identified best practices to incorporate health equity considerations at each phase of guideline development. Identified practices may be used to inform equity-promoting strategies with the guideline development process; however, guideline producers should carefully consider the advantages and disadvantages of best practices when integrating health equity.

The role of acupuncture and moxibustion in the treatment, prevention, and rehabilitation of patients with COVID-19: A scoping review

Introduction

This study aims to summarize the available evidence and guideline/consensus recommendations for acupuncture and moxibustion in the treatment, prevention and rehabilitation of patients with coronavirus disease 2019 (COVID-19).

Methods

A scoping review was performed. Eight electronic databases and other related websites were searched. All studies related to acupuncture and moxibustion for COVID-19 were considered. Descriptive analysis was applied to analyze the all included studies and guideline recommendations.

Results

We ultimately included 131 eligible studies. The main topics of the included studies were the treatment (82.4%) and prevention (38.9%) of COVID-19. The most included studies were literature reviews (65, 49.6%), protocols of systematic reviews (20, 15.3%), and guidelines and consensuses (18, 13.7%). The 18 (13.7%) COVID-19 guidelines and consensuses included 47 recommendations on acupuncture and moxibustion, which focused on the treatment (21/47, 44.7%), rehabilitation (17/47, 36.2%) and prevention (6, 12.8%) of COVID-19 patients. Zusanli (ST36), Feishu (BL13), Guanyuan (RN4) were recommended mostly for the treatment, rehabilitation and prevention respectively.

Conclusion

Acupuncture and moxibustion are effective in the treatment of COVID-19 patients to some extent. However, more high-quality of clinical trials still needed to determine the feasibility of acupuncture and moxibustion in COVID-19 patients to better guide clinical practice.

Study registration

Open Science Framework Registries (Registration DOI: 10.17605/OSF.IO/Z35WN; https://osf.io/z35wn).

Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health: A Scientific Statement From the American Heart Association

Background Social isolation, the relative absence of or infrequency of contact with different types of social relationships, and loneliness (perceived isolation) are associated with adverse health outcomes. Objective To review observational and intervention research that examines the impact of social isolation and loneliness on cardiovascular and brain health and discuss proposed mechanisms for observed associations. Methods We conducted a systematic scoping review of available research. We searched 4 databases, PubMed, PsycInfo, Cumulative Index of Nursing and Allied Health, and Scopus. Findings Evidence is most consistent for a direct association between social isolation, loneliness, and coronary heart disease and stroke mortality. However, data on the association between social isolation and loneliness with heart failure, dementia, and cognitive impairment are sparse and less robust. Few studies have empirically tested mediating pathways between social isolation, loneliness, and cardiovascular and brain health outcomes using appropriate methods for explanatory analyses. Notably, the effect estimates are small, and there may be unmeasured confounders of the associations. Research in groups that may be at higher risk or more vulnerable to the effects of social isolation is limited. We did not find any intervention studies that sought to reduce the adverse impact of social isolation or loneliness on cardiovascular or brain health outcomes. Conclusions Social isolation and loneliness are common and appear to be independent risk factors for worse cardiovascular and brain health; however, consistency of the associations varies by outcome. There is a need to develop, implement, and test interventions to improve cardiovascular and brain health for individuals who are socially isolated or lonely.

A systematic review protocol for assessing equity in clinical practice guidelines for traumatic brain injury and homelessness

Background

When used optimally, clinical practice guidelines (CPGs) can reduce inappropriate variations in practice, improve application of research to practice, and enhance the quality of healthcare. However, a common criticism, despite its potential, is the lack of consideration for equity and disadvantaged populations.

Objectives

This protocol is for a systematic review of CPGs for traumatic brain injury (TBI) and homelessness that aims to assess (1) the extent to which evidence regarding TBI and homelessness is integrated in CPGs for homelessness and TBI, respectively, and (2) equity considerations in CPGs for TBI and homelessness.

Methods and analysis

The methodology for this review is guided by the PRISMA-P, validated search filters for CPGs, and methodological guides to searching systematic reviews and gray literature. CPGs will be identified from (a) databases for peer-reviewed literature (MEDLINE, Embase, CINAHL, and PsycInfo), (b) targeted websites and Google Search for gray literature, and (c) reference lists of peer-reviewed and gray literature that meet the eligibility criteria. Searching for gray literature, including from guideline-specific resources, is a critical component of this review and is considered an efficient approach to identifying CPGs, given the low precision of searching peer-reviewed databases. Two independent reviewers will screen all articles based on pre-determined eligibility criteria. A narrative synthesis will be conducted to identify the proportion of CPGs that integrate evidence about TBI and homelessness and how TBI and homelessness is or is not integrated in CPGs. Quality appraisal will take the form of an equity assessment of CPGs and will be completed independently by two reviewers.

Conclusion

This protocol outlines the methodology for a systematic review of CPGs for TBI and homelessness. The resulting systematic review from this protocol will form an evidence-based foundation to advance CPGs for individuals with lived experience of TBI and homelessness.

Systematic review registration

identifier: CRD42021287696.

Broadening the diversity of consumers engaged in guidelines: a scoping review

BACKGROUND

Guideline developers are encouraged to engage patients, carers and their representatives ('consumers') from diverse backgrounds in guideline development to produce more widely applicable guidelines. However, consumers from diverse backgrounds are infrequently included in guidelines and there is scant research to support guideline developers to do this.

OBJECTIVES

To identify principles and approaches to broaden the diversity of consumers engaged in guideline development.

DESIGN

Scoping review and semi-structured interviews.

METHODS

We conducted comprehensive searches to March 2020 for studies, reports and guidance documents. Inclusion criteria included the terms 'consumer' (patients, carers and their representatives), 'diversity' (defined using the PROGRESS-PLUS mnemonic) and 'consumer engagement' (the active involvement of consumers at any stage of guideline development). We also conducted four interviews with consumers and guideline developers. We used descriptive synthesis to identify themes, and summarised information about implemented approaches used to broaden diversity of consumers in guidelines.

RESULTS

From 10 included documents, we identified eight themes. Themes covered general engagement concepts (Respectful partnerships; Recruitment; Expectations, process and review); specific concepts about guideline development group (GDG) engagement (Characteristics of guideline personnel; Consumers' role, characteristics and prominence; Preparing and supporting consumers); and other (non-GDG) approaches (Online methods; Consultations and research-based approaches). The most commonly included PROGRESS-PLUS categories were Disability, Race/culture/ethnicity/language, Place of residence and Other vulnerable (eg, 'disadvantaged groups'). Each theme included the views of both consumers and guideline developers. We found descriptions of 12 implemented engagement approaches to broaden diversity of consumers in guidelines.

CONCLUSIONS

Relationship-building, mitigating power imbalances and meeting consumers where they are at underpin our findings. Engaging with diverse groups may require greater attention to building formal, respectful partnerships and employing inclusive engagement methods.

PROTOCOL: Barriers and facilitators to stakeholder engagement in health guideline development: A qualitative evidence synthesis

BACKGROUND

There is a need for the development of comprehensive, global, evidence-based guidance for stakeholder engagement in guideline development. Stakeholders are any individual or group who is responsible for or affected by health- and healthcare-related decisions. This includes patients, the public, providers of health care and policymakers for example. As part of the guidance development process, Multi-Stakeholder Engagement (MuSE) Consortium set out to conduct four concurrent systematic reviews to summarise the evidence on: (1) existing guidance for stakeholder engagement in guideline development, (2) barriers and facilitators to stakeholder engagement in guideline development, (3) managing conflicts of interest in stakeholder engagement in guideline development and (4) measuring the impact of stakeholder engagement in guideline development. This protocol addresses the second systematic review in the series.

OBJECTIVES

The objective of this review is to identify and synthesise the existing evidence on barriers and facilitators to stakeholder engagement in health guideline development. We will address this objective through two research questions: (1) What are the barriers to multi-stakeholder engagement in health guideline development across any of the 18 steps of the GIN-McMaster checklist? (2) What are the facilitators to multi-stakeholder engagement in health guideline development across any of the 18 steps of the GIN-McMaster checklist?

SEARCH METHODS

A comprehensive search strategy will be developed and peer-reviewed in consultation with a medical librarian. We will search the following databases: MEDLINE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), EMBASE, PsycInfo, Scopus, and Sociological Abstracts. To identify grey literature, we will search the websites of agencies who actively engage stakeholder groups such as the AHRQ, Canadian Institutes of Health Research (CIHR) Strategy for Patient-Oriented Research (SPOR), INVOLVE, the National Institute for Health and Care Excellence (NICE) and the PCORI. We will also search the websites of guideline-producing agencies, such as the American Academy of Pediatrics, Australia's National Health Medical Research Council (NHMRC) and the WHO. We will invite members of the team to suggest grey literature sources and we plan to broaden the search by soliciting suggestions via social media, such as Twitter.

SELECTION CRITERIA

We will include empirical qualitative and mixed-method primary research studies which qualitatively report on the barriers or facilitators to stakeholder engagement in health guideline development. The population of interest is stakeholders in health guideline development. Building on previous work, we have identified 13 types of stakeholders whose input can enhance the relevance and uptake of guidelines: Patients, caregivers and patient advocates; Public; Providers of health care; Payers of health services; Payers of research; Policy makers; Program managers; Product makers; Purchasers; Principal investigators and their research teams; and Peer-review editors/publishers. Eligible studies must describe stakeholder engagement at any of the following steps of the GIN-McMaster Checklist for Guideline Development.

DATA COLLECTION AND ANALYSIS

All identified citations from electronic databases will be imported into Covidence software for screening and selection. Documents identified through our grey literature search will be managed and screened using an Excel spreadsheet. A two-part study selection process will be used for all identified citations: (1) a title and abstract review and (2) full-text review. At each stage, teams of two review authors will independently assess all potential studies in duplicate using a priori inclusion and exclusion criteria. Data will be extracted by two review authors independently and in duplicate according to a standardised data extraction form.

MAIN RESULTS

The results of this review will be used to inform the development of guidance for multi-stakeholder engagement in guideline development and implementation. This guidance will be official GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group guidance. The GRADE system is internationally recognised as a standard for guideline development. The findings of this review will assist organisations who develop healthcare, public health and health policy guidelines, such as the World Health Organization, to involve multiple stakeholders in the guideline development process to ensure the development of relevant, high quality and transparent guidelines.

Actions to Transform US Preventive Services Task Force Methods to Mitigate Systemic Racism in Clinical Preventive Services

IMPORTANCE

US life expectancy and health outcomes for preventable causes of disease have continued to lag in many populations that experience racism.

OBJECTIVE

To propose iterative changes to US Preventive Services Task Force (USPSTF) processes, methods, and recommendations and enact a commitment to eliminate health inequities for people affected by systemic racism.

DESIGN AND EVIDENCE

In February 2021, the USPSTF began operational steps in its work to create preventive care recommendations to address the harmful effects of racism. A commissioned methods report was conducted to inform this process. Key findings of the report informed proposed updates to the USPSTF methods to address populations adversely affected by systemic racism and proposed pilots on implementation of the proposed changes.

FINDINGS

The USPSTF proposes to consider the opportunity to reduce health inequities when selecting new preventive care topics and prioritizing current topics; seek evidence about the effects of systemic racism and health inequities in all research plans and public comments requested, and integrate available evidence into evidence reviews; and summarize the likely effects of systemic racism and health inequities on clinical preventive services in USPSTF recommendations. The USPSTF will elicit feedback from its partners and experts and proposed changes will be piloted on selected USPSTF topics.

CONCLUSIONS AND RELEVANCE

The USPSTF has developed strategies intended to mitigate the influence of systemic racism in its recommendations. The USPSTF seeks to reduce health inequities and other effects of systemic racism through iterative changes in methods of developing evidence-based recommendations, with partner and public input in the activities to implement the advancements.

Addressing Racism in Preventive Services: Methods Report to Support the US Preventive Services Task Force

IMPORTANCE

In January 2021, the US Preventive Services Task Force (USPSTF) issued a values statement that acknowledged systemic racism and included a commitment to address racism and health equity in recommendations for clinical preventive services.

OBJECTIVES

To articulate the definitional and conceptual issues around racism and health inequity and to describe how racism and health inequities are currently addressed in preventive health.

METHODS

An audit was conducted assessing (1) published literature on frameworks or policy and position statements addressing racism, (2) a subset of cancer and cardiovascular topics in USPSTF reports, (3) recent systematic reviews on interventions to reduce health inequities in preventive health or to prevent racism in health care, and (4) health care-relevant professional societies, guideline-making organizations, agencies, and funding bodies to gather information about how they are addressing racism and health equity.

FINDINGS

Race as a social category does not have biological underpinnings but has biological consequences through racism. Racism is complex and pervasive, operates at multiple interrelated levels, and exerts negative effects on other social determinants and health and well-being through multiple pathways. In its reports, the USPSTF has addressed racial and ethnic disparities, but not racism explicitly. The systematic reviews to support the USPSTF include interventions that may mitigate health disparities through cultural tailoring of behavioral interventions, but reviews have not explicitly addressed other commonly studied interventions to increase the uptake of preventive services or foster the implementation of preventive services. Many organizations have issued recent statements and commitments around racism in health care, but few have provided substantive guidance on operational steps to address the effects of racism. Where guidance is unavailable regarding the proposed actions, it is principally because work to achieve them is in very early stages. The most directly relevant and immediately useful guidance identified is that from the GRADE working group.

CONCLUSIONS AND RELEVANCE

This methods report provides a summary of issues around racism and health inequity, including the status of how these are being addressed in preventive health.

Transparency, health equity, and strategies in state-based protocols for remdesivir allocation and use

Background

The Emergency Use Authorization (EUA) of remdesivir for coronavirus disease 2019 raised questions on transparency of applied strategy, and how to equitably allocate and prioritize eligible patients given limited supply of the medication. The absence of federal oversight highlighted the critical role by states in health policymaking during a pandemic.

Objective

To identify public state-based protocols for remdesivir allocation and clinical guidance for prioritizing remdesivir use and assess approaches and inclusion of language promoting equitable access or mitigating health disparities.

Methods

We identified remdesivir allocation strategies and clinical use guidelines for all 50 states in the U.S. and the District of Columbia accessible on state health department websites or via internet searches. Public protocols dated between May 1, 2020 and September 30, 2020 were included in the study. We reviewed strategies for allocation and clinical use, including whether protocols contained explicit language on equitable access to remdesivir or mitigating health disparities.

Results

A total of 38 states had a remdesivir allocation strategy, with 33 states (87%) making these public. States used diverse allocation strategies, and only 10 (30%) of the 33 states included language on equitable allocation. A total of 30 states had remdesivir clinical use guidelines, where all were publicly accessible. All guidelines referenced recommendations by federal agencies but varied in their presentation format. Of the 30 states, 12 (40%) had guidelines that included language on equitable use. Neither an allocation strategy or clinical use guideline were identified (public or non-public) for 10 states and the District of Columbia during the study period.

Conclusions

The experience with the remdesivir EUA presents an opportunity for federal and state governments to develop transparent protocols promoting fair and equal access to treatments for future pandemics.

Informing the GRADE evidence to decision process with health equity considerations: demonstration from the Canadian rheumatoid arthritis care context

OBJECTIVES

Health equity is a priority for clinical and public health practice and promoted in GRADE's Evidence to Decision (EtD) Framework, yet there is still limited integration of specific equity considerations in chronic disease guideline development and implementation. Our objective was to embed equity considerations for upcoming Canadian Rheumatoid Arthritis treatment guidelines.

STUDY DESIGN AND SETTING

In parallel with the Guidelines Committee process, considerations for six population groups (rural and remote residents, Indigenous Peoples, elderly persons with frailty, minority populations of first-generation immigrants and refugees, persons with low socioeconomic status or who are vulnerably housed, and sex and gender populations) based on literature reviews and key informant interviews were identified and contextualized to each step in the GRADE EtD framework.

RESULTS

The EtD Framework domains relevant to rheumatoid arthritis treatment and management were analyzed through patient-centric, social determinant and economic lenses, while considering implementation feasibility. This determined tailored considerations relevant to recommendations for the priority populations to mitigate potential intervention-generated inequities.

CONCLUSION

This approach provides a demonstration of the process of incorporating equity in the evidence to decision process and can be applied in future rheumatic disease guidelines while also informing a research agenda for equity in rheumatology outcomes.

Supporting Equity in Rheumatoid Arthritis Outcomes in Canada: Population-specific Factors in Patient-centered Care

OBJECTIVE

Health equity considerations have not been incorporated into prior Canadian Rheumatology Association guidelines. Our objective was to identify the challenges and possible solutions to mitigate threats to health equity in rheumatoid arthritis (RA) care in Canada.

METHODS

A consultation process informed selection of priority populations, determined to be rural and remote, Indigenous, elderly with frailty, first-generation immigrant and refugee, low income and vulnerably housed, and diverse gender and sex populations. Semistructured interviews were completed with patients with lived experience, healthcare providers, and equity-oriented researchers. These interviews probed on population factors, initial and ongoing healthcare access issues, and therapeutic considerations influencing RA care. Known or proposed solutions to mitigate inequities during implementation of service models for the population group were requested. The research team used a phenomenological thematic analysis model and mapped the data into a logic model. Solutions applicable to several population groups were proposed.

RESULTS

Thirty-five interviews were completed to identify realities for each population in accessing RA care. Five themes emerged as primary solutions to population-based inequities, including actively improving the patient-practitioner relationship, increasing accessibility and coordination of care through alternative models of care, upholding autonomy in treatment selection while actively addressing logistical barriers and individualized therapy needs, collaborating with health supports valued by the patient, and being advocates for policy change and health system restructuring to ensure appropriate resource redistribution.

CONCLUSION

The challenges for populations facing inequities in rheumatology care and promising solutions should inform guideline development and implementation, policy change, and health system restructuring.

International clinical practice guidelines for gender minority/trans people: systematic review and quality assessment

OBJECTIVES

To identify and critically appraise published clinical practice guidelines (CPGs) regarding healthcare of gender minority/trans people.

DESIGN

Systematic review and quality appraisal using AGREE II (Appraisal of Guidelines for Research and Evaluation tool), including stakeholder domain prioritisation.

SETTING

Six databases and six CPG websites were searched, and international key opinion leaders approached.

PARTICIPANTS

CPGs relating to adults and/or children who are gender minority/trans with no exclusions due to comorbidities, except differences in sex development.

INTERVENTION

Any health-related intervention connected to the care of gender minority/trans people.

MAIN OUTCOME MEASURES

Number and quality of international CPGs addressing the health of gender minority/trans people, information on estimated changes in mortality or quality of life (QoL), consistency of recommended interventions across CPGs, and appraisal of key messages for patients.

RESULTS

Twelve international CPGs address gender minority/trans people's healthcare as complete (n=5), partial (n=4) or marginal (n=3) focus of guidance. The quality scores have a wide range and heterogeneity whichever AGREE II domain is prioritised. Five higher-quality CPGs focus on HIV and other blood-borne infections (overall assessment scores 69%-94%). Six lower-quality CPGs concern transition-specific interventions (overall assessment scores 11%-56%). None deal with primary care, mental health or longer-term medical issues. Sparse information on estimated changes in mortality and QoL is conflicting. Consistency between CPGs could not be examined due to unclear recommendations within the World Professional Association for Transgender Health Standards of Care Version 7 and a lack of overlap between other CPGs. None provide key messages for patients.

CONCLUSIONS

A paucity of high-quality guidance for gender minority/trans people exists, largely limited to HIV and transition, but not wider aspects of healthcare, mortality or QoL. Reference to AGREE II, use of systematic reviews, independent external review, stakeholder participation and patient facing material might improve future CPG quality.

PROSPERO REGISTRATION NUMBER

CRD42019154361.

Challenges in applying the GRADE approach in public health guidelines and systematic reviews: a concept article from the GRADE Public Health Group

BACKGROUND AND OBJECTIVE

This article explores the need for conceptual advances and practical guidance in the application of the GRADE approach within public health contexts.

METHODS

We convened an expert workshop and conducted a scoping review to identify challenges experienced by GRADE users in public health contexts. We developed this concept article through thematic analysis and an iterative process of consultation and discussion conducted with members electronically and at three GRADE Working Group meetings.

RESULTS

Five priority issues can pose challenges for public health guideline developers and systematic reviewers when applying GRADE: (1) incorporating the perspectives of diverse stakeholders; (2) selecting and prioritizing health and "nonhealth" outcomes; (3) interpreting outcomes and identifying a threshold for decision-making; (4) assessing certainty of evidence from diverse sources, including nonrandomized studies; and (5) addressing implications for decision makers, including concerns about conditional recommendations. We illustrate these challenges with examples from public health guidelines and systematic reviews, identifying gaps where conceptual advances may facilitate the consistent application or further development of the methodology and provide solutions.

CONCLUSION

The GRADE Public Health Group will respond to these challenges with solutions that are coherent with existing guidance and can be consistently implemented across public health decision-making contexts.

Removing Unnecessary Medical Barriers to Contraception: Celebrating a Decade of the U.S. Medical Eligibility Criteria for Contraceptive Use

In 2010, the Centers for Disease Control and Prevention (CDC) released the U.S. Medical Eligibility Criteria for Contraceptive Use, providing recommendations for health care providers on safe use of contraception for people with certain characteristics or medical conditions. Adapted from World Health Organization guidance, the goal of the recommendations is to remove unnecessary medical barriers to contraception. Over the past decade, CDC has updated recommendations based on new evidence, collaborated with national partners to disseminate and implement the guidelines, and conducted provider surveys to assess changes in attitudes and practices around contraception safety and provision. CDC remains committed to supporting evidence-based guidelines for safe use of contraception, as the basis for improving access to contraception and high-quality family planning services, reducing unintended pregnancy, and improving reproductive health in the United States.

GRADE Concept Paper 1: Validating the "F.A.C.E" instrument using stakeholder perceptions of feasibility, acceptability, cost, and equity in guideline implement

BACKGROUND AND OBJECTIVE

To present a structured approach for assessing stakeholder perceptions and implementing the approach in guideline development.

METHODS

This work was carried out by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Equity and Stakeholder Engagement Project Groups through brainstorming and iterative frameworks, stakeholder engagement, pilot testing, refinement of ideas, using input from workshops, and discussions at GRADE Working Group meetings to produce this document, which constitutes a GRADE conceptual article on implementation.

RESULTS

We introduce the FACE implementation criteria, feasibility, acceptability, cost, and equity; priority; and "intent to implement" criterion. We outline the implementation importance of networks and approaches to patient and other stakeholder engagement. Implementation is often highly contextual and can benefit from stakeholder engagement and other assessments. Our FACE approach provides stakeholder questions and language to inform guideline implementation and tools.

CONCLUSION

The FACE criteria propose a series of knowledge translation questions to guide the assessment of implementation for evidence-based guidelines. It is desirable for guideline developers to use a conceptual approach, such as FACE, to tailor implementation and inform end of guideline dissemination and knowledge translation activities.

Working towards inclusive and equitable trauma treatment guidelines: a child-centered reflection

Clinical practice guidelines, such as those focusing on traumatic stress treatment, can play an important role in promoting inclusion and equity. Based on a review of 14 international trauma treatment guidance documents that explicitly mentioned children, we reflect on two areas in which these guidelines can become more inclusive and equitable; a) representation of children's cultural background and b) children's opportunity to have their voice heard. While a few guidelines mentioned that treatment should be tailored to children's cultural needs, there was little guidance on how this could be done. Moreover, there still appears to be a strong white Western lens across all stages of producing and evaluating the international evidence base. The available documentation also suggested that no young people under the age of 18 had been consulted in the guideline development processes. To contribute to inclusion and equity, we suggest five elements for future national guideline development endeavours. Promoting research and guideline development with, by, and for currently under-represented communities should be a high priority for our field. Our national, regional and global professional associations are in an excellent position to (continue to) stimulate conversation and action in this domain.

Bridging the Gap between Theory, Practice, and Policy: A Decision-Making Process Based on Public Health Evidence Feasible in Multi-Stage Research on Biological Risk Factors in Poland

Stakeholder input into the decision-making process when developing public health programs and policies is crucial. This article presents an innovative approach, involving online participation with a wide group of stakeholders located in different geographic locations for policy consensus. The results of the project have been used to propose assumptions regarding a strategy for preventing blood-borne diseases in Poland. The research was conducted iteratively using a multi-stage qualitative methodology to explore risk assessment involving blood-borne infections. The final output of the study is a list of key problems/challenges and potential solutions associated with medical and nonmedical services that are connected to the breakage of tissue continuity. Qualitative research is rare in risk assessment, as priority is generally given to statistical data and endpoints. In addition to policy preparation for blood-borne illnesses, the methodology employed in the study can also be used to successfully explore other areas of public health.

GRADE-Leitlinien zu Gerechtigkeit 4. Berücksichtigung der Gerechtigkeit im Gesundheitswesen bei der Entwicklung von GRADE-Leitlinien: von der Evidenz zur Empfehlung

OBJECTIVES

The aim of this paper is to provide detailed guidance on how to incorporate health equity within the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evidence to decision process.

STUDY DESIGN AND SETTING

We developed this guidance based on the GRADE evidence to decision frame-work, iteratively reviewing and modifying draft documents, in person discussion of project group members and input from other GRADE members. This is a German translation of the original paper published in English.

RESULTS

Considering the impact on health equity may be required, both in general guidelines and guide-lines that focus on disadvantaged populations. We suggest two approaches to incorporate equity considerations: (1) assessing the potential impact of interventions on equity and (2) incorporating equity considerations when judging or weighing each of the evidence to decision criteria. We provide guidance and include illustrative examples.

CONCLUSION

Guideline panels should consider the impact of recommendations on health equity with attention to remote and underserviced settings and disadvantaged populations. Guideline panels may wish to incorporate equity judgments across the evidence to decision framework. This is the fourth and final paper in a series about considering equity in the GRADE guideline development process. This series is coming from the GRADE equity subgroup.

[GRADE equity guidelines 3: considering health equity in GRADE guideline development: rating the certainty of synthesized evidence]

OBJECTIVES

The aim of this paper is to describe a conceptual framework for how to consider health equity in the Grading Recommendations Assessment and Development Evidence (GRADE) guideline development process.

STUDY DESIGN AND SETTING

Consensus-based guidance developed by the GRADE working group members and other methodologists. This is a German translation of the original paper published in English.

RESULTS

We developed consensus-based guidance to help address health equity when rating the certainty of synthesized evidence (i.e., quality of evidence). When health inequity is determined to be a concern by stakeholders, we propose five methods for explicitly assessing health equity: (1) include health equity as an outcome; (2) consider patient-important outcomes relevant to health equity; (3) assess differences in the relative effect size of the treatment; (4) assess differences in baseline risk and the differing impacts on absolute effects; and (5) assess indirectness of evidence to disadvantaged populations and/or settings.

CONCLUSION

The most important priority for research on health inequity and guidelines is to identify and document examples where health equity has been considered explicitly in guidelines. Although there is a weak scientific evidence base for assessing health equity, this should not discourage the explicit consideration of how guidelines and recommendations affect the most vulnerable members of society.

Over half of the WHO guidelines published from 2014 to 2019 explicitly considered health equity issues: a cross-sectional survey

OBJECTIVE

To evaluate how and to what extent health equity considerations are assessed in World Health Organization (WHO) guidelines.

STUDY DESIGN AND SETTING

We evaluated WHO guidelines published between January 2014 and May 2019. Health equity considerations were assessed in relation to differences in baseline risk, importance of outcomes for socially disadvantaged populations, inclusion of health inequity as an outcome, equity-related subgroup analysis, and indirectness in each recommendation.

RESULTS

We identified 111 WHO guidelines, and 54% (60 of 111) of these used the Evidence to Decision (EtD) framework. For the 60 guidelines using an EtD framework, the likely impact on health equity was supported by research evidence in 28% of the recommendations (94 of 332). Research evidence was mostly provided as differences in baseline risk (23%, 78/332). Research evidence less frequently addressed the importance of outcomes for socially disadvantaged populations (11%, 36/332), considered indirectness of the evidence for socially disadvantaged populations (2%, 5/332), considered health inequities as an outcome (2%, 5/332) and considered differences in the magnitude of effect in relative terms between disadvantaged and more advantaged populations (1%, 3/332).

CONCLUSION

The provision of research evidence to support equity judgements in WHO guidelines is still suboptimal, suggesting the need for better guidance and more training.

Targeted bone density testing for optimizing fracture prevention in Canada

The Canadian FRAX® tool used without bone mineral density (BMD) is highly sensitive for identifying individuals qualifying for pharmacotherapy based upon an intervention threshold of 20% for major osteoporotic fracture risk (MOF) computed with BMD.

INTRODUCTION

This analysis was performed to inform initial BMD testing as part of Osteoporosis Canada's Guidelines Update for women and men at average risk, assuming a pharmacotherapy intervention threshold of 20% for FRAX® MOF computed with BMD.

METHODS

Women and men age 50 + without previous low-trauma fracture or high-risk medication use were identified in a BMD registry for the province of Manitoba, Canada. Fracture probability assessments with the Canadian FRAX® tool were computed without and with BMD (denoted MOF-clinical and MOF-BMD, respectively).

RESULTS

The study population consisted of 50,700 women (mean age 65.5 ± 9.4 years) and 4152 men (69.2 ± 10.0 years). FRAX MOF-clinical score was > 10% in 33.8% of women and 13.3% of men (P < 0.001). The median (interquartile range [IQR]) age for MOF-clinical to reach 10% in women was 70 (69-72) and 65 years (62-67) years in the absence and presence of additional FRAX clinical risk factors, respectively. In men, comparable ages were 83 years [82-86] and 76 [70-78] years. Using MOF-BMD of 20% as the intervention threshold, 4.3% of women and 0.7% of men qualified for treatment. MOF-clinical > 10% had high sensitivity to identify those qualifying for treatment (99.3% in women and 99.1% in men). An age-based rule ("BMD testing is indicated at age 70 if no additional FRAX clinical risk factors are present, or at age 65 if one or more clinical risk factors exists") gave similarly high sensitivity (women 99.9% and men > 99.9%).

CONCLUSIONS

FRAX without BMD offers an effective strategy to identify individuals meeting the current Canadian treatment threshold based upon FRAX® with BMD (≥ 20%). Moreover, this can be operationalized using simple age cutoffs of 70 years in the absence of additional clinical risk factors and 65 years in the presence of additional clinical risk factors.

Reporting quality of chronic kidney disease practice guidelines according to the RIGHT statement: a systematic analysis

Aim:

The aim of this study was to evaluate the reporting quality of chronic kidney disease (CKD) guidelines.

Methods:

PubMed, EMBASE, and guideline-related websites were searched from 2008 to 2019. The CKD guidelines were included. Two reviewers used the RIGHT (Reporting Items for Practice Guidelines in Healthcare) checklist to assess the quality of guidelines and calculate the reporting proportion of each guideline.

Results:

We included 13 guidelines, of which 30.8% (4/13) were developed in Europe and about two-thirds (8/13) were published on their own website. The average quality of the 13 guidelines was 68.57%. The reporting proportion of the seven domains (i.e. basic information; background; evidence; recommendations; review and quality assurance; funding and declaration and management of interests; other information) were 65.39%, 81.73%, 63.08%, 69.23%, 53.85%, 63.46%, and 61.54%, respectively.

Conclusion:

CKD guidelines had moderate reporting quality in some domains, but guideline developers should increase the reporting items in basic information, guideline evidence, and recommendations. The RIGHT checklist would be a useful tool to improve the reporting quality of guidelines.

Targeted vertebral fracture assessment for optimizing fracture prevention in Canada

Vertebral fracture assessment (VFA) provides incremental information in identifying women and men aged 70 years and older qualifying for anti-osteoporosis treatment compared with FRAX^® major osteoporotic fracture (MOF) probability computed with bone mineral density (BMD).

PURPOSE

This analysis was performed to inform appropriate use of VFA testing as part of Osteoporosis Canada's Guidelines Update, assuming vertebral fracture is an indication for pharmacotherapy in women and men.

METHODS

Women and men aged 70 years and older without previous high-risk fracture (i.e., hip, spine, or multiple fractures) were identified in a BMD registry for the province of Manitoba, Canada. MOF probability with BMD was computed using the Canadian FRAX^® tool. VFA was performed in those with a minimum BMD T-score of -1.5 or lower.

RESULTS

The study population consisted of 7289 women (mean age 76.7 ± 5.6 years) and 1323 men (77.9 ± 5.8 years). More women than men qualified for VFA testing (48.7% vs 25.4%, respectively, p < 0.001). Among those undergoing VFA, a vertebral fracture was more commonly detected among men than women (22.9% vs 13.3%, p < 0.001), and vertebral fracture prevalence increased with lower BMD T-score (both p trend <0.001). The number needed to screen with VFA to detect a vertebral fracture was 8 for women and 4 for men. MOF probability was substantially lower in men than in women, and fewer men than women (3.3% vs 20.2%, p < 0.001) met a treatment threshold of MOF 20% or greater. In those with MOF probability <20%, VFA identified an incremental 5.4% of men and 3.4% of women for treatment based upon vertebral fracture.

CONCLUSIONS

The number needed to screen to identify a previously unappreciated vertebral fracture is low and further improves with lower BMD T-score. VFA identified more men as qualifying for treatment than MOF probability. In women, treatment qualification was predominantly from MOF probability.

Protocol for the development of guidance for stakeholder engagement in health and healthcare guideline development and implementation

BACKGROUND

Stakeholder engagement has become widely accepted as a necessary component of guideline development and implementation. While frameworks for developing guidelines express the need for those potentially affected by guideline recommendations to be involved in their development, there is a lack of consensus on how this should be done in practice. Further, there is a lack of guidance on how to equitably and meaningfully engage multiple stakeholders. We aim to develop guidance for the meaningful and equitable engagement of multiple stakeholders in guideline development and implementation.

METHODS

This will be a multi-stage project. The first stage is to conduct a series of four systematic reviews. These will (1) describe existing guidance and methods for stakeholder engagement in guideline development and implementation, (2) characterize barriers and facilitators to stakeholder engagement in guideline development and implementation, (3) explore the impact of stakeholder engagement on guideline development and implementation, and (4) identify issues related to conflicts of interest when engaging multiple stakeholders in guideline development and implementation.

DISCUSSION

We will collaborate with our multiple and diverse stakeholders to develop guidance for multi-stakeholder engagement in guideline development and implementation. We will use the results of the systematic reviews to develop a candidate list of draft guidance recommendations and will seek broad feedback on the draft guidance via an online survey of guideline developers and external stakeholders. An invited group of representatives from all stakeholder groups will discuss the results of the survey at a consensus meeting which will inform the development of the final guidance papers. Our overall goal is to improve the development of guidelines through meaningful and equitable multi-stakeholder engagement, and subsequently to improve health outcomes and reduce inequities in health.

[GRADE equity guidelines 1: Considering health equity in GRADE guideline development - introduction and rationale]

OBJECTIVES

This article introduces the rationale and methods for explicitly considering health equity in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology for developing clinical, public health, and health system guidelines. This article is a German translation of the original version published in English.

STUDY DESIGN AND SETTING

We searched for guideline methodology articles, conceptual articles about health equity, and examples of guidelines that considered health equity explicitly. We held three meetings with GRADE Working Group members and invited comments from the GRADE Working Group listserve.

RESULTS

We developed three articles on incorporating equity considerations into the overall approach to guideline development, rating certainty, and assembling the evidence base and evidence to decision and/or recommendation.

CONCLUSION

Clinical and public health guidelines have a role to play in promoting health equity by explicitly considering equity in the process of guideline development.

Conceptual framework of equity-focused implementation research for health programs (EquIR)

BACKGROUND

Implementation research is increasingly used to identify common implementation problems and key barriers and facilitators influencing efficient access to health interventions.

OBJECTIVE

To develop and propose an equity-based framework for Implementation Research (EquIR) of health programs, policies and systems.

METHODS

A systematic search of models and conceptual frameworks involving equity in the implementation of health programs, policies and systems was conducted in Medline (PubMed), Embase, LILACS, Scopus and grey literature. Key characteristics of models and conceptual frameworks were summarized. We identified key aspects of equity in the context of seven Latin American countries-focused health programs We gathered information related to the awareness of inequalities in health policy, systems and programs, the potential negative impact of increasing inequalities in disadvantaged populations, and the strategies used to reduce them.

RESULTS

A conceptual framework of EquIR was developed. It includes elements of equity-focused implementation research, but it also links the population health status before and after the implementation, including relevant aspects of health equity before, during and after the implementation. Additionally, health sectors were included, linked with social determinants of health through the "health in all policies" proposal affecting universal health and the potential impact of the public health and public policies.

CONCLUSION

EquIR is a conceptual framework that is proposed for use by decision makers and researchers during the implementation of programs, policies or health interventions, with a focus on equity, which aims to reduce or prevent the increase of existing inequalities during implementation.

Reporting, presentation and wording of recommendations in clinical practice guideline for gout: a systematic analysis

OBJECTIVES

We systematically analysed recommendations from gout guidelines as an example, to provide a basis for developing a reporting standard of recommendations in clinical practice guidelines (CPGs).

DESIGN

Systematic review without meta-analysis.

METHODS

We systematically searched MEDLINE and all relevant guideline websites (National Institute for Health and Care Excellence, National Guideline Clearinghouse, Scottish Intercollegiate Guidelines Network, WHO, Guidelines International Network, DynaMed, UpTodate, Best Practice) from their inception to January 2017 to identify and select gout CPGs. We used search terms such as 'gout', 'hyperuricemia' and 'guideline'. We included the eligible CPGs of gout according to the predefined inclusion and exclusion criteria after screening titles, abstracts and full texts. The characteristics of recommendations reported in the included guidelines were extracted and analysed.

RESULTS

A total of 15 gout guidelines with a range of 5-80 recommendations were retrieved. Several indicators were used in the gout guidelines to facilitate identification of recommendations, including grouping all recommendations in a summary section, formatting recommendations in a particular or special way, using locating words for recommendations and indicating the strength of recommendation and quality of evidence. We found some components commonly used in the recommendations. The wording of recommendations varied across guidelines. Recommendations were detailed and explained in the section of rationale and explanation of recommendations. In some guidelines, recommendations were accompanied with other material to assist their reporting.

CONCLUSIONS

Variability and inconsistency were found on the reporting and presentation of recommendations in gout guidelines. Several points for reporting recommendation can be summarised. First, we suggested summarising and highlighting the core recommendations in a guideline. Second, guideline developers should try to structure and write recommendations reasonably. Third, it was necessary to detail and explain the recommendations and their rationale. Finally, describing and providing other potential useful contents was also a helpful way for clear reporting.

Understanding women's, caregivers', and providers' experiences with home-based records: A systematic review of qualitative studies

Mothers, caregivers, and healthcare providers in 163 countries have used paper and electronic home-based records (HBRs) to facilitate primary care visit. These standardized records have the potential to empower women, improve the quality of care for mothers and children and reduce health inequities. This review examines experiences of women, caregivers and providers with home-based records for maternal and child health and seeks to explore the feasibility, acceptability, affordability and equity of these interventions. We systematically searched MEDLINE, MEDLINE In-Process, MEDLINE Ahead of Print, Embase, CINAHL, ERIC, and PsycINFO for articles that were published between January 1992 and December 2017. We used the CASP checklist to assess study quality, a framework analysis to support synthesis, and GRADE-CERQual to assess the confidence in the key findings. Of 7,904 citations, 19 studies met our inclusion criteria. In these studies, mothers, caregivers and children shared HBR experiences in relation to maternal and child health which facilitated the monitoring of immunisations and child growth and development. Participants' reports of HBRs acting as a point of commonality between patient and provider offer an explanation for their perceptions of improved communication and patient-centered care, and enhanced engagement and empowerment during pregnancy and childcare. Healthcare providers and nurses reported that the home-based record increased their feeling of connection with their patients. Although there were concerns around electronic records and confidentiality, there were no specific concerns reported for paper records. Mothers and other caregivers see home based records as having a pivotal role in facilitating primary care visits and enhancing healthcare for their families. The records' potential could be limited by users concerns over confidentiality of electronic home-based records, or shortcomings in their design. Health systems should seize the opportunity HBRs provide in empowering women, especially in the contexts of lower literacy levels and weak health care delivery systems.

The evolution of GRADE (part 3): A framework built on science or faith?

RATIONALE, AIMS, AND OBJECTIVES

The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework has undergone several modifications since it was first presented as a method for developing clinical practice recommendations. In the previous two articles of this series, we showed that absent, in the first three versions of GRADE, is a justification (theoretical and/or empirical) for why the presented criteria for determining the quality of evidence and the components for determining the strength of a recommendation were included (and others not included) in the framework. Furthermore, it was often not clear how to operationalize and integrate the criteria/components when using the framework. In part 3 of this series, we examine the literature since version 3 to see if the GRADE working group has provided an overall justification scheme for GRADE or clear instruction on how to operationalize and integrate the criteria/components in the framework.

METHODS

Narrative review.

RESULTS

GRADE has undergone further modification since the last version was presented. In the recent literature, we see additional shifts in terminology (eg, "quality of evidence" is now "certainty of evidence"), clarification on the construct of certainty of evidence, continued emphasis on "transparency" and new emphasis on "trustworthiness," the addition of health equity as a component for determining strength of a recommendation, and the development of the Evidence to Decision frameworks. However, these modifications have done little to improve the justification scheme that sustains GRADE or clarify how to operationalize the criteria/components.

CONCLUSIONS

If we desire that our clinical recommendations be based on scientific teaching rather than faith-based preaching, then the GRADE framework should be justified theoretically and/or empirically. Until such time that the working group provides a theoretical justification that the use of the GRADE framework should produce valid recommendations, and/or empirical evidence to support that it does, enthusiasm for the framework should be tempered.

Effectiveness of knowledge translation and knowledge appropriation of clinical practice guidelines for patients and communities, a systematic review

Introduction: Knowledge translation and knowledge appropriation social interventions apply knowledge to improve health services and outcomes. These interventions can be implemented routinely to improve patient adherence to clinical practice guidelines. Objective: To assess the effectiveness of knowledge translation interventions to improve patient and community adherence to clinical practice guidelines. Materials and methods: We performed a systematic review of these interventions compared with classical interventions for patients and/or communities. We searched the following electronic databases up to April 2017: Medline (Ovid), Embase, Scopus, Central (Ovid), Web of Science, LILACS, Academic Search, and Scielo. Two independent raters qualified the relevance, risk of bias, and quality of included studies. Results: Eight studies were included. Patient adherence to recommendations was observed in two studies. There was high heterogeneity due to the variability of the population, types of guidelines, and types of measurement tools. The risk of bias was high: a 60% risk of performance bias, 50% risk of attrition bias, 25% risk of selection and reporting bias, and 15% risk of detection bias. The quality of evidence was moderate for the outcomes of adherence and mortality. The interventions that used a combination of strategies, such as with the group of health professionals, could improve some clinical outcomes in the patients (Average deviation: -3.00; 95% IC: -6.08-0.08). Conclusions: Knowledge translation interventions might have a slight positive effect on patient adherence and some short-term clinical outcomes, particularly within mixed interventions (patients and health professionals). However, future studies with less heterogeneity are necessary to confirm these results.

Considering health equity when moving from evidence-based guideline recommendations to implementation: a case study from an upper-middle income country on the GRADE approach

The availability of evidence-based guidelines does not ensure their implementation and use in clinical practice or policy making. Inequities in health have been defined as those inequalities within or between populations that are avoidable, unnecessary and also unjust and unfair. Evidence-based clinical practice and public health guidelines ('guidelines') can be used to target health inequities experienced by disadvantaged populations, although guidelines may unintentionally increase health inequities. For this reason, there is a need for evidence-based clinical practice and public health guidelines to intentionally target health inequities experienced by disadvantaged populations. Current guideline development processes do not include steps for planned implementation of equity-focused guidelines. This article describes nine steps that provide guidance for consideration of equity during guideline implementation. A critical appraisal of the literature followed by a process to build expert consensus was undertaken to define how to include consideration of equity issues during the specific GRADE guideline development process. Using a case study from Colombia we describe nine steps that were used to implement equity-focused GRADE recommendations: (1) identification of disadvantaged groups, (2) quantification of current health inequities, (3) development of equity-sensitive recommendations, (4) identification of key actors for implementation of equity-focused recommendations, (5) identification of barriers and facilitators to the implementation of equity-focused recommendations, (6) development of an equity strategy to be included in the implementation plan, (7) assessment of resources and incentives, (8) development of a communication strategy to support an equity focus and (9) development of monitoring and evaluation strategies. This case study can be used as model for implementing clinical practice guidelines, taking into account equity issues during guideline development and implementation.

GRADE equity guidelines 4: considering health equity in GRADE guideline development: evidence to decision process

OBJECTIVES

The aim of this paper is to provide detailed guidance on how to incorporate health equity within the GRADE (Grading Recommendations Assessment and Development Evidence) evidence to decision process.

STUDY DESIGN AND SETTING

We developed this guidance based on the GRADE evidence to decision framework, iteratively reviewing and modifying draft documents, in person discussion of project group members and input from other GRADE members.

RESULTS

Considering the impact on health equity may be required, both in general guidelines and guidelines that focus on disadvantaged populations. We suggest two approaches to incorporate equity considerations: (1) assessing the potential impact of interventions on equity and (2) incorporating equity considerations when judging or weighing each of the evidence to decision criteria. We provide guidance and include illustrative examples.

CONCLUSION

Guideline panels should consider the impact of recommendations on health equity with attention to remote and underserviced settings and disadvantaged populations. Guideline panels may wish to incorporate equity judgments across the evidence to decision framework. This is the fourth and final paper in a series about considering equity in the GRADE guideline development process. This series is coming from the GRADE equity subgroup.