Grading the quality of evidence and the strength of recommendations Equity.
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Transcript of Grading the quality of evidence and the strength of recommendations Equity.
![Page 1: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/1.jpg)
Grading the quality of evidence and the strength of recommendations
Equity
![Page 2: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/2.jpg)
Equity
For disadvantaged groups are there different
1. Effects?
2. Values?
3. Thresholds for costs?
4. Distributions of disease?
5. Settings?
6. Baseline risks?
![Page 3: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/3.jpg)
Different effects
• Quality across studies for specific outcomes
1. Are there different effects?
• Overall quality of evidence across outcomes
• Balance of benefits and harms
• Balance of net benefits and costs
• Recommendations
![Page 4: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/4.jpg)
1. Are there different effects for disadvantaged groups?
• If there are inconsistent results that can be explained by social inequalities
Different balance sheets for different groups– Tobacco taxation
• If there is uncertainty about the directness of evidence for disadvantaged groups
Lower quality of evidence– Pneumococcal vaccine
![Page 5: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/5.jpg)
Different values
• Quality across studies for specific outcomes
• Overall quality of evidence across outcomes
2. Are there different values?
• Balance of benefits and harms
2. Are there different values?
• Balance of net benefits and costs
• Recommendations
![Page 6: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/6.jpg)
2. Are there differences in the relative importance of the health outcomes for disadvantaged groups?
• If an outcome is critical for a disadvantaged group and not for others
This may change the overall quality of evidence– If evidence regarding return to work is critical for disadvantaged
groups and there is lower quality evidence for this outcome, the overall quality of evidence might be lowered
• If there are differences in the relative importance of health outcomes
This may change the balance of benefits and harms– Giving more weight to returning more quickly to work may shift
the balance in favour of ARVs for HIV
![Page 7: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/7.jpg)
Different thresholds for costs or distributions of disease
• Quality across studies for specific outcomes• Overall quality of evidence across outcomes• Balance of benefits and harms• Balance of net benefits and costs
3. Are there different thresholds for costs?
4. Are there differences in the distribution of disease?
• Recommendations
![Page 8: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/8.jpg)
3. Is the cost of an intervention high for disadvantaged groups?
• If the cost of an intervention is high for disadvantaged groups
This may change the balance of net benefits and costs– Cholesterol screening
![Page 9: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/9.jpg)
4. Are there differences in the distribution of the burden of illness that might affect judgements about whether the intervention is worth the costs?
• Differences in the distribution of the burden of illness
May change the balance of net benefits and costs– It may be more important to use resources for HIV
than for screening for colorectal cancer
![Page 10: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/10.jpg)
Differences in settings or baseline risks
• Quality across studies for specific outcomes
• Overall quality of evidence across outcomes
• Balance of benefits and harms
• Balance of net benefits and costs
• Recommendations
5. Are there differences in settings?
6. Are there different baseline risks?
![Page 11: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/11.jpg)
5. Are there factors that would affect the translation of the evidence into practice in disadvantaged settings?
• If there are important factors that could be expected to modify the size of the expected effects, such as proximity to a hospital or available expertise
This may change a recommendation– Magnesium sulphate
![Page 12: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/12.jpg)
6. Are there differences in baseline risk for disadvantaged groups?
• If disadvantaged groups are at higher riskThis will increase the benefits
– Penicillin for strept throat to prevent Rheumatic fever
• If there is uncertainty about the baseline risk for disadvantaged groups
This may change a recommendation– BCG for tuberculosis
![Page 13: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/13.jpg)
How do judgements about equity affect recommendations?
For disadvantaged groups different1. Effects
– Inconsistant results (tobacco taxation) – explicit value judgment– Uncertainty about directness (pneumococcal vaccine) – recommend evaluation
2. Values– Different values (ARV) – different recommendation
3. Thresholds for costs– Different thresholds (cholesterol screening) – different recommendation
4. Distributions of disease– Different distribution (colorectal cancer screening) – different priorities
5. Settings– Different settings (magnesium sulphate) – different recommendations
6. Baseline risks– Different baseline risks (BCG) – different recommendations
7. People may choose to recommend interventions that are less cost-effective because of equity
![Page 14: Grading the quality of evidence and the strength of recommendations Equity.](https://reader036.fdocuments.us/reader036/viewer/2022083009/5697bfa51a28abf838c97f26/html5/thumbnails/14.jpg)
Equity should also be considered in formulating questions, implementing recommendations and
evaluating the implementation of recommendations
• Formulating and prioratising questions• Quality of studies for specific outcomes• Quality across studies for specific outcomes• Overall quality of evidence across outcomes• Balance of benefits and harms• Balance of net benefits and costs• Recommendations• Implementing recommendations• Evaluation