Grade Equity Guidelines 4: Considering Health Equity in Grade Guideline Development: Evidence to Decision Process

Pottie K, Welch V, Morton R, Akl EA, Eslava-Schmalbach JH, Katikireddi V, Singh J, Moja L, Lang E, Magrini N, Thabane L, Stanev R, Matovinovic E, Snellman A, Briel M, Shea B, Tugwell P, Schunemann H, Guyatt G, Alonso-Coello P
Source: J Clin Epidemiol
Publication Year: 2017
Population Focus: Vulnerable/disadvantaged
Intervention Type: Best practices
Study Design: Other Study Design
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/28802675
Abstract

OBJECTIVES:
The aim of this paper is to provide detailed guidance on how to incorporate health equity within the GRADE (Grading Recommendations Assessment and Development Evidence) evidence to decision process.

STUDY DESIGN AND SETTING:
We developed this guidance based on the GRADE evidence to decision framework, iteratively reviewing and modifying draft documents, in person discussion of project group members and input from other GRADE members.

RESULTS:
Considering the impact on health equity may be required, both in general guidelines and guidelines that focus on disadvantaged populations. We suggest two approaches to incorporate equity considerations: (1) assessing the potential impact of interventions on equity and (2) incorporating equity considerations when judging or weighing each of the evidence to decision criteria. We provide guidance and include illustrative examples.

CONCLUSION:
Guideline panels should consider the impact of recommendations on health equity with attention to remote and underserviced settings and disadvantaged populations. Guideline panels may wish to incorporate equity judgments across the evidence to decision framework. This is the fourth and final paper in a series about considering equity in the GRADE guideline development process. This series is coming from the GRADE equity subgroup.

Insights Results

Overview of article

  • This paper is the fourth in a 4-part series about considering equity in the Grading Recommendations Assessment and Development Evidence (GRADE) guideline development process. Specifically, this paper provides detailed guidance on how to incorporate health equity within the GRADE evidence to decision process

Methods of article

  • Development of this guidance is based on the GRADE evidence to decision (EtD) framework. Process of development includes iteratively reviewing and modifying draft documents, in person discussion of project group members and input from other GRADE members

Results

  • 3 types of recommendations are proposed to be used by guideline panels to determine how best to integrate health equity into guidelines using GRADE’s Evidence to Decision framework: 1) General recommendation applicable to different populations and settings; 2) General recommendation to be accompanied with a smaller group; and 3) Separate recommendation for a specific disadvantaged population
  • Identified challenges in determining the potential impact of health equity is the heterogeneity in experience of health inequity across different social determinants (e.g., race, ethnicity), and the step-wise, potentially redundant, nature of the Evidence to Development process outlined by GRADE

Key takeaways/implications

  • Researchers could monitor the use of Evidence to Decision frameworks to see if health equity impacts of considerations are being reported. This evaluation could also be compared to other guideline development processes to identify ways to advance equity related methods in other guideline development processes
  • There are 3 key points that span the entire GRADE workgroup session: 1) Panels should consider the potential for an intervention to have unwanted effects on equity when moving from evidence to decision making; 2) Incorporating health equity judgments into other evidence to decision criteria should be considered, both in general guidelines and in disadvantaged population specific guidelines; and 3) Panels may wish to point out these potential adverse effects such that decision makers could take mitigating actions in their implementation and monitoring of the recommendation
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