II. Background

  1. Structured approach to healthcare recommendations established in 2000

III. Criteria: Quality of Evidence (Certainty)

  1. Certainty and confidence
    1. High
      1. Authors have high confidence that the true effect is similar to the estimated effect
    2. Moderate
      1. Authors have moderate confidence that the true effect is similar to the estimated effect
    3. Low
      1. True effect may be significantly different than the estimated effect
    4. Very Low
      1. True effect is likely significantly different than the estimated effect
  2. Factors that decrease certainty
    1. Risk of Study Bias
    2. Imprecision (in relation to the 95% Confidence Interval)
    3. Inconsistency (e.g. overlapping Confidence Intervals, heterogeneity)
    4. Indirectness (e.g. patient population, environment and other factors differ from that of the applied recommendations)
    5. Publication Bias (e.g. missing evidence, e.g. in observational studies, industry funded studies)
  3. Factors that increase certainty
    1. Large magnitude of effect
    2. Consistent dose response gradient
    3. Confounders are likely to increase effect magnitude

IV. Criteria: Strength of Recommendation

  1. Problem
    1. Importance and frequency of the healthcare condition
  2. Values and Preferences
    1. How important are the health outcomes to the affected population?
  3. Quality of Evidence
    1. Quality of evidence (see above)
  4. Benefits and Harms
    1. Degree to which the net benefit exceeds the net harm
  5. Resource Implications
    1. Cost effectiveness and its associated incremental benefit
  6. Equity
    1. Does the recommendation reduce health disparities?
  7. Acceptability
    1. Is the recommendation acceptable to most stakeholders (esp. the target population)
  8. Feasibility
    1. Is the implementation practical given resources and acceptability?

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