Grade Equity Guidelines 3: Considering Health Equity in Grade Guideline Development: Rating the Certainty of Synthesized Evidence
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.
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.
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.
Overview of article
- This paper is the third in a 4-part series about considering equity in the Grading Recommendations Assessment and Development Evidence (GRADE) guideline development process. Specifically, this paper proposes 5 methods for explicitly assessing health equity in guidelines
Methods of article
- Consensus-based guidance developed by the GRADE working group members and other methodologists was used for method development
- Considering health equity is important for 2 main types of guidelines: 1) Universal interventions where health inequity is a concern; and 2) Targeted interventions aims at 1 or more disadvantaged populations
- 5 methods can be used to assess health equity with the GRADE approach: 1) Include health equity as an outcome in summary of finding tables; 2) Consider patient-important outcomes relevant to health equity; 3) Assess differences in the magnitude of effect in relative terms between disadvantaged and more advantaged populations; 4) Assess differences in baseline risk and their differing impacts on absolute effects for disadvantaged populations; and 5) Assess indirectness of evidence to disadvantaged populations
- Guideline panels need to decide early on whether they plan to develop equity-sensitive recommendations
- Considering health equity in rating the certainty in synthesized evidence requires a priori elaboration of the disadvantaged populations and settings of interest, and methods to assess both relative and absolute effects for these populations
- Methodologic challenges may impact the aforementioned methods of assessment including, the evolving nature of health equity (may need to revisit focus of guideline throughout process), and issues with evidence (e.g., poor reporting, lack of evidence)