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

[Social inequality in home care: A scoping review on the impact of socio-economic resources on home care arrangements]

INTRODUCTION

Inequalities in long-term home care are still rarely considered in the discourse on health inequalities, although there is reason to assume that opportunities for a successful home care arrangement are not equally distributed among those in need of it. This paper pursues the question how socio-economic resources of people in need of care and their family caregivers are influencing the utilization of care services in Germany.

METHODS

A scoping review has been conducted to analyse the current state of research. To identify relevant papers the online databases CINAHL including MEDLINE, PubMed, LIVIVO and Web of Science were searched and supplemented by internet research. According to Bourdieu, the research studies included were arranged in economic, educational and social resources.

RESULTS

29 qualitative and quantitative research papers were included in the analysis. 14 papers represent quantitative research results, nine papers are based on qualitative research. Six further papers are analyses based on an international data record. The utilization of care services increases with the level of income and wealth as well as education. On closer examination of individual care services, however, the evidence is inconsistent and only the so-called 24-hour care service is distinguishable as a care arrangement for high-status groups. A compensation of the lower utilization of professional care by informal support cannot be described in quantitative terms. Caregivers with low income and education levels seem to be more likely to not only provide care but also to provide higher-intensity care.

DISCUSSION

Despite increasing research reflected in the literature, the evidence remains incomplete and shows inconsistencies so that a valid statement on the degree of inequalities in care provision is not possible. A conceptual basis for the definition of social inequality in the context of long-term home care is lacking as well as a common understanding of equity in care provision. The perspective of people in need of care and their caregivers has hardly been addressed.

CONCLUSION

Home care is not only determined by individual need but seems to be decisively influenced by socio-economic restrictions. For a more targeted approach, further research on the use of care services depending on socio-economic resources is needed, explicitly taking into account the user perspective.

Caring for Australians and New Zealanders With Kidney Impairment Guidelines: Rapid Development of Urate Lowering Therapy Guidelines for People With CKD

Introduction

The slow transformation of new research findings into clinical guidelines is a barrier to providing evidence-based care. The Caring for Australians and New Zealanders with Kidney Impairment (CARI) guidelines are developing models to improve guideline production, one methodology involves more functional concordance between trial groups, such as the Australian Kidney Trials Network (AKTN) and CARI. The objective of this project was to rapidly produce an evidence-based guideline on urate-lowering therapy in patients with chronic kidney disease (CKD), in response to new clinical trial publications on the topic by the AKTN.

Methods

To produce a guideline as rapidly as possible, an existing systematic review was utilized as the evidence base, and then updated with the inclusion of clinical trials that had been published subsequently. A Work Group was convened to review the evidence and compose an appropriate guideline using CARI/GRADE methodology. The group met 3 times over 45 days to formulate the guideline.

Results

The result was a strong recommendation against the use urate-lowering therapies in individuals with CKD (not receiving dialysis) and asymptomatic hyperuricemia. The process of identifying an appropriate existing systematic review, updating the literature search, and synthesizing the evidence, was done by 2 individuals over 15 days. The Work Group was formulated and composed the guideline over 45 days. In all, a new guideline incorporating the most up-to-date evidence was formulated in 60 days.

Conclusion

This method of guideline development represents a potentially new way of releasing guidelines that encapsulates all available evidence in a time-efficient manner.

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.