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

Vivian A Welch; Elie A Akl; Kevin Pottie; Mohammed T Ansari; Matthias Briel; Robin Christensen; Antonio Dans; Leonila Dans; Javier Eslava-Schmalbach; Gordon Guyatt; Monica Hultcrantz; Janet Jull; Srinivasa Vittal Katikireddi; Eddy Lang; Elizabeth Matovinovic; Joerg J Meerpohl; Rachael L Morton; Annhild Mosdol; M Hassan Murad; Jennifer Petkovic; Holger Schünemann; Ravi Sharaf; Bev Shea; Jasvinder A Singh; Ivan Solà; Roger Stanev; Airton Stein; Lehana Thabaneii; Thomy Tonia; Mario Tristan; Sigurd Vitols; Joseph Watine; Peter Tugwell

doi:10.1016/j.jclinepi.2017.01.015

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

J Clin Epidemiol. 2017 Oct:90:76-83. doi: 10.1016/j.jclinepi.2017.01.015. Epub 2017 Apr 4.

Authors

Vivian A Welch¹, Elie A Akl², Kevin Pottie³, Mohammed T Ansari⁴, Matthias Briel⁵, Robin Christensen⁶, Antonio Dans⁷, Leonila Dans⁸, Javier Eslava-Schmalbach⁹, Gordon Guyatt¹⁰, Monica Hultcrantz¹¹, Janet Jull¹², Srinivasa Vittal Katikireddi¹³, Eddy Lang¹⁴, Elizabeth Matovinovic¹⁵, Joerg J Meerpohl¹⁶, Rachael L Morton¹⁷, Annhild Mosdol¹⁸, M Hassan Murad¹⁹, Jennifer Petkovic²⁰, Holger Schünemann²¹, Ravi Sharaf²², Bev Shea²³, Jasvinder A Singh²⁴, Ivan Solà²⁵, Roger Stanev²⁶, Airton Stein²⁷, Lehana Thabaneii²⁸, Thomy Tonia²⁹, Mario Tristan³⁰, Sigurd Vitols³¹, Joseph Watine³², Peter Tugwell³³

Affiliations

¹ Bruyère Research Institute, University of Ottawa and Bruyère Continuing Care, 85 Primrose Ave, Ottawa K1R 7G5, Canada. Electronic address: [email protected].
² Department of Internal Medicine, American University of Beirut, P.O. Box: 11-0236, Riad-El-Solh Beirut, 1107 2020 Beirut, Lebanon; Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada.
³ Bruyère Research Institute, University of Ottawa and Bruyère Continuing Care, 85 Primrose Ave, Ottawa K1R 7G5, Canada; Departments of Family Medicine and Epidemiology and Community Medicine, Bruyère Research Institute, University of Ottawa, WHO and EU ECDC Consultant.
⁴ School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, Room 101, 600 Peter Morand Crescent, Ottawa ON K1G 5Z3 Canada.
⁵ Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel, Spitalstrasse 12, Basel 4031, Switzerland; Department of Health Research Methods, Evidence and Impact, McMaster University Health Sciences Centre, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada.
⁶ Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.
⁷ Department of Medicine, University of the Philippines-Manila, Manila 1000, Philippines.
⁸ Department of Pediatrics, University of the Philippines-Manila, Taft Ave, Manila 1000, Philippines.
⁹ Group of Equity in Health, Hospital Universitario Nacional de Colombia, Faculty of Medicine, Universidad Nacional de Colombia; Technology Development Center, Sociedad Colombiana de Anestesiologia y Reanimacion -S.C.A.R.E. Cra 30 45-03, Bogota 111321, Colombia.
¹⁰ Department of Clinical Epidemiology & Biostatistics and Department of Medicine, McMaster University Health Sciences Centre, McMaster University, 1280 Main Street West, Room HSC-2C12, Hamilton, Ontario L8S 4K1, Canada.
¹¹ Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), S:t Eriksgatan 117, Stockholm SE-102 33, Sweden; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, Stockholm SE-171 77, Sweden.
¹² Bruyère Research Institute, University of Ottawa, 85 Primrose Avenue, Room 312, Ottawa, Ontario K1R 7G5.
¹³ MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, Glasgow, Scotland, UK.
¹⁴ Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta.
¹⁵ Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
¹⁶ Cochrane Germany, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Strasse 153, Freiburg 79110, Germany; Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité - U1153, Inserm / Université Paris Descartes, Cochrane France, Hôpital Hôtel-Dieu, 1, place du Parvis Notre-Dame, Paris 75004, France.
¹⁷ NHMRC Clinical Trials Centre, The University of Sydney, Medical Foundation Building Level 6, 92-94 Parramatta Road, Camperdown, NSW 2050, Australia.
¹⁸ Knowledge Centre for the Health Services, Norwegian Institute of Public Health, PO Box 4404, Nydalen, N-0403 Oslo, Norway.
¹⁹ Mayo Clinic Evidence-Based Practice Center, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
²⁰ Bruyère Research Institute & University of Ottawa, 85 Primrose Avenue, Ottawa, Ontario K1R 7G5.
²¹ Department of Health Research Methods, Evidence and Impact, McMaster University Health Sciences Centre, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
²² Division of Gastroenterology, Northwell Health/Hofstra University School of Medicine, Long Island Jewish Medical Center, Research Building B202, 270-05 76th Avenue, New Hyde Park, NY 11040, USA.
²³ Bruyère Research Institute and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada.
²⁴ Medicine Service, Birmingham Veterans Affairs Medical Center, 700, 19th Street South, Birmingham, AL 35233, USA; Department of Medicine at School of Medicine and the Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, 1720 Second Avenue South, Birmingham, AL 35294-0022, USA; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905, USA.
²⁵ Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau, CIBER of Epidemiology and Public Health (CIBERESP-IIB Sant Pau), Barcelona, Spain.
²⁶ Institute of Technology, University of Washington, 1900 Commerce St., Tacoma, WA 98402, USA.
²⁷ Public Health Department - Universidade Federal de Ciencias da Saude de Porto Alegre (Ufcspa), Rua Sarmento Leite, 245, CEP - CEP 90050-170 and HTA of Conceicao Hospital, Porto Alegre, Brazil.
²⁸ Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
²⁹ Institute of Social and Preventive Medicine, University of Bern, Niesenweg 6, Bern 3012, Switzerland.
³⁰ IHCAI Foundation & Cochrane Central America & Spanish speaking Caribbean, Av 7. calles 35 y 37, No 35 30, Codigo Postal 10106, San Jose, Costa Rica.
³¹ Clinical Pharmacology Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
³² Laboratory Medicine, Hôpital La Chartreuse, avenue Caylet, F-12200, Villefranche-de-Rouergue, France.
³³ Department of Medicine, Faculty of Medicine, University of Ottawa, K1H 8M5, Ottawa, Canada.

Abstract

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.

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.

Keywords: Applicability; GRADE; Guidelines; Health; Indirectness; Meta-analysis; Subgroup analysis; Systematic review; equity.

MeSH terms

Evidence-Based Practice
Health Equity*
Humans
Meta-Analysis as Topic
Practice Guidelines as Topic / standards*
Research Design
Review Literature as Topic*
Vulnerable Populations*

Abstract

MeSH terms

Grants and funding