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The recommendation Evidence to Decision

All recommendations have a Evidence to decision tab where you can work through the Evidence to Decision framework.

You can fill in a summary text and set a guiding label for each of the 4 summary/ 7 EtD factors in going from Evidence to Decision in GRADE:

  • Benefits & Harms
  • Quality of Evidence
  • Preferences and values
  • Resources and other considerations
  • Equity (in 7 EtD factors)
  • Acceptability (in 7 EtD factors)
  • Feasibility (in 7 EtD factors)

You can swap between showing 4 summary/ 7 EtD factors during the development process without loosing content.
The setting you set (4 or 7) when you publish will be what the end users see.
However, if you set 4 factors in the published versions, you will still have the text in the 3 extra factors in your continued draft. You never not loose the text written in any factor, regardless. 

Authors have the option of choosing to see only the summary (like usual), or see judgements and additional text fields for Research evidence and Additional considerations.
The intervention judgements are color coded and supports multiple interventions. You can select the comparator you want to use, and select which interventions you want to make judgements for.
You get a summary of the judgements where you can re-arrange the order of the interventions, and thus use it for internal ranking discussions.

You can choose to set the additional text fields and Summary of judgements grid public or not.

Important to know: 
- The judgements are saved, so even if you remove an intervention or PICO from the list, your settings will be there if you add them again.
- Swapping between the view of see only the summary (like usual), or expanded information in draft is only the view you as an author choose to see. If you write anything in the Research evidence and Additional considerations text fields AND set them to be public, they will show in the public guidelines, even if your view in draft are set to see only summary.

For all factors: The level of your confidence/ gist label given the information you have about the factor
You can set the level of confidence you have in each factors ability to bring about benefits. This is both to help the guideline authors in their discussion and final decision of the strength of recommendation, but also to give the end user of the recommendation a visual cue of how the different factors weighted in on the strength.
In our user testing so far not all users understood the color coding, but the ones that did found it helpful. The ones that didn't understand did not find it disturbing, but rather looked at it as decoration. 

Tips on writing the text
Choose your own style of writing these factors, but remember that the end user should be able to read it and feel that it helps their decision-making process.
Be short, but not too short. What you write should be concrete and useful.

You can use this framework a bit different during development, compared to the published versions, e.g:

  • You can write more during the development process but shorten it (or remove it) when you publish. Only factors with text will be shown in the published versions.
  • You can use the 7 EtD factor framework, but set it to 4 factors when you publish, and then summarize Resources, Equity, Acceptability and Feasibility in the 4 factor last factor: Resources and other considerations. 

The Evidence to Decision summary factors (4) 

Benefit and Harms
State absolute numbers of the most important outcomes and differences in Benefit and Harms.
This is perceived as useful for the decision-making and can be used by the end user to convey to their patients or discussions with colleagues.
Remember that the clinicians have easy access to the Evidence profiles where all the expected benefits and harms will be listed, so try to concentrate on the ones which differ the most between given interventions and will likely be the tipping-point of decision-making. 

See full Evidence to Decision guidance 
Also see GRADE handbook: Going from evidence to recommendations

Quality of Evidence/Confidence in effect estimates
We often see people gets confused by the term Quality of Evidence. What we really mean is how confident we are in our effect estimates. That is: if we state that we have low Quality of Evidence, we do not necessarily mean that the studies we look at have been done poorly, they might be great. But they might be non-randomized, or have another patient population than what we would ideally want, or we expect a publication bias. We then get lower confidence in our effect estimates, as the real estimates may differ substantially. It is this message that should be conveyed to the end user.
You can state your overall confidence across all outcomes (which is generally the lowest confidence you have in any of the critical outcomes), or also state the confidence you have for some of the most critical outcomes. E.g If you have High confidence in the effect estimates for mortality and moderate for stroke, you end up with overall moderate confidence in your effect estimates, but it might still be worth mentioning that you have high confidence in the effect on mortality.

Also see GRADE handbook: Going from evidence to recommendations

Preferences and values
This is a hard summary to write as we generally do know little certain about peoples general preferences. State where you take your comments from, is it the panels experience, did you include patients in the authoring process or do you have preference -studies?
Sometimes you would want to include societal values, like keeping antibiotic resistance down vs. highest cure-rate with 1. level antibiotic. 
We suggest you try to highlight the instances where you would expect some patients choosing an alternative to the recommended/suggested strategy.

See full Evidence to Decision guidance 
Also see GRADE handbook: Going from evidence to recommendations

Resources and other considerations
Here you give information about expected resource use, either for the patient or for the institution responsible for the costs that incur. Resources are not only direct money payed, but personnel or time -resources spent.
Do you have a cost-benefit analysis? Should you make one?
Does the suggested strategy affect other aspects of the treatment or health care system?
Included information in 'Resources' will likely differ when moving from an international setting and to a more local setting (national, institution).    

See full Evidence to Decision guidance 
Also see GRADE handbook: Going from evidence to recommendations

For the Equity, Acceptability, Feasibility factors, please See full Evidence to Decision guidance 

Four (4) and Seven (7) Factor Framework (Only Summary Text)

Evidence to Decision (EtD) factors 

Example of confidence/ gist label of a factor 

Choose wanted EtD type 

The 3 additional factors 

Set default EtD type in Guideline customization under the settings menu 

Four (4) and Seven (7) Factor Framework (Full EtD)

Separate text fields for Research evidence and Additional considerations

Color coded judgements

Supports multiple comparisons. You can choose your comparator

Color coded summary of judgements where you can re-arrange order of intervention. It includes a choice to show in public versions or not. 

Decide which elements are public or just internal.

Make recommendation-editing show in the end of the EtD

You can also create polls and Vote on Evidence to Decision (EtD) factors. See help article here

Last Updated: 18 December 2023

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