TY - JOUR
T1 - A number of factors explain why WHO guideline developers make strong recommendations inconsistent with GRADE guidance
AU - Alexander, Paul E.
AU - Gionfriddo, Michael R.
AU - Li, Shelly Anne
AU - Bero, Lisa
AU - Stoltzfus, Rebecca J.
AU - Neumann, Ignacio
AU - Brito, Juan P.
AU - Djulbegovic, Benjamin
AU - Montori, Victor M.
AU - Norris, Susan L.
AU - Schünemann, Holger J.
AU - Thabane, Lehana
AU - Guyatt, Gordon H.
N1 - Publisher Copyright:
© 2016 Elsevier Inc.
PY - 2016/2/1
Y1 - 2016/2/1
N2 - Objective Many strong recommendations issued by the World Health Organization (WHO) are based on low- or very low-quality (low certainty) evidence (discordant recommendations). Many such discordant recommendations are inconsistent with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance. We sought to understand why WHO makes discordant recommendations inconsistent with GRADE guidance. Study Design and Setting We interviewed panel members involved in guidelines approved by WHO (2007-2012) that included discordant recommendations. Interviews, recorded and transcribed, focused on use of GRADE including the reasoning underlying, and factors contributing to, discordant recommendations. Results Four themes emerged: strengths of GRADE, challenges and barriers to GRADE, strategies to improve GRADE application, and explanations for discordant recommendations. Reasons for discordant recommendations included skepticism about the value of making conditional recommendations; political considerations; high certainty in benefits (sometimes warranted, sometimes not) despite assessing evidence as low certainty; and concerns that conditional recommendations will be ignored. Conclusion WHO panelists make discordant recommendations inconsistent with GRADE guidance for reasons that include limitations in their understanding of GRADE. Ensuring optimal application of GRADE at WHO and elsewhere likely requires selecting panelists who have a commitment to GRADE principles, additional training of panelists, and formal processes to maximize adherence to GRADE principles.
AB - Objective Many strong recommendations issued by the World Health Organization (WHO) are based on low- or very low-quality (low certainty) evidence (discordant recommendations). Many such discordant recommendations are inconsistent with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance. We sought to understand why WHO makes discordant recommendations inconsistent with GRADE guidance. Study Design and Setting We interviewed panel members involved in guidelines approved by WHO (2007-2012) that included discordant recommendations. Interviews, recorded and transcribed, focused on use of GRADE including the reasoning underlying, and factors contributing to, discordant recommendations. Results Four themes emerged: strengths of GRADE, challenges and barriers to GRADE, strategies to improve GRADE application, and explanations for discordant recommendations. Reasons for discordant recommendations included skepticism about the value of making conditional recommendations; political considerations; high certainty in benefits (sometimes warranted, sometimes not) despite assessing evidence as low certainty; and concerns that conditional recommendations will be ignored. Conclusion WHO panelists make discordant recommendations inconsistent with GRADE guidance for reasons that include limitations in their understanding of GRADE. Ensuring optimal application of GRADE at WHO and elsewhere likely requires selecting panelists who have a commitment to GRADE principles, additional training of panelists, and formal processes to maximize adherence to GRADE principles.
KW - Discordant recommendations
KW - GRADE methods
KW - Inconsistent with GRADE guidance
KW - Interviews
KW - Qualitative descriptive study
KW - Strong recommendations low-quality evidence
KW - World Health Organization
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U2 - 10.1016/j.jclinepi.2015.09.006
DO - 10.1016/j.jclinepi.2015.09.006
M3 - Article
C2 - 26399903
AN - SCOPUS:84957434754
SN - 0895-4356
VL - 70
SP - 111
EP - 122
JO - Journal of Clinical Epidemiology
JF - Journal of Clinical Epidemiology
ER -