Medical Researchers’ Ancillary Clinical Care Responsibilities Essay

Medical Researchers’ Ancillary Clinical Care Responsibilities Essay

Healthcare workers using clinical practice guidelines
and other recommendations need to know how much
confidence they can place in the recommendations.
Systematic and explicit methods of making judgments
can reduce errors and improve communication. We
have developed a system for grading the quality of evidence and the strength of recommendations that can
be applied across a wide range of interventions and
contexts. In this article we present a summary of our
approach from the perspective of users of guidelines.
What makes a good guideline?Medical Researchers’ Ancillary Clinical Care Responsibilities Essay

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Judgments about evidence and recommendations are
complex. Consider, for example, the choice between
selective serotonin reuptake inhibitors and tricyclic
antidepressants for the treatment of moderate depression. Clinicians must decide which outcomes to
consider, which evidence to include for each outcome,
how to assess the quality of that evidence, and how to
determine if selective serotonin reuptake inhibitors do
more good than harm compared with tricyclics.
Because resources are always limited and money that is
spent on serotonin reuptake inhibitors cannot be used
elsewhere, they may also need to decide whether any
incremental health benefits are worth the additional
costs.
It is not practical for individual clinicians and
patients to make unaided judgments for each clinical
decision. Clinicians and patients commonly use clinical
practice guidelines as a source of support. Users of
guidelines need to know how much confidence they
can place in the evidence and recommendations. We
describe the factors on which our confidence should
be based and a systematic approach for making the
complex judgments that go into clinical practice
guidelines, either implicitly or explicitly. To achieve
simplicity in our presentation we do not discuss all the
nuances, some of which are discussed in the longer
version of this article on bmj.com.Medical Researchers’ Ancillary Clinical Care Responsibilities Essay
The GRADE Working Group began as an informal
collaboration of people with an interest in tackling the
shortcomings of present grading systems. Table 1 summarises these shortcomings and the ways in which we
have overcome them. The GRADE system enables
more consistent judgments, and communication of
such judgments can support better-informed choices
in health care. Box 1 shows the steps in developing and
implementing guidelines from prioritising problems
through evaluating their implementation. We focus
here on grading the quality of evidence and strength of
recommendations.
Definitions
We have used the following definitions: the quality of
evidence indicates the extent to which we can be confident that an estimate of effect is correct; the strength of
a recommendation indicates the extent to which we
can be confident that adherence to the recommendation will do more good than harm.
The steps in our approach are to make sequential
judgments about:
x The quality of evidence across studies for each
important outcome
x Which outcomes are critical to a decision
x The overall quality of evidence across these critical
outcomes
x The balance between benefits and harms
x The strength of recommendations
All of these judgments depend on having a clearly
defined question and considering all of the outcomes
that are likely to be important to those affected. The
question should identify which options are being comThis is an abridged version; the full version is on bmj.com
Correspondence to:Medical Researchers’ Ancillary Clinical Care Responsibilities Essay
Andrew D Oxman,
Informed Choice
Research
Department,
Norwegian Health
Services, PO Box
7004, St Olavs plass,
0130 Oslo, Norway
oxman@online.no
BMJ 2004;328:1490–4
1490 BMJ VOLUME 328 19 JUNE 2004 bmj.com
pared (for example, selective serotonin reuptake
inhibitors and tricyclic antidepressants), for whom
(moderately depressed adult patients), and in what setting (primary care in England).
Quality of evidence
Judgments about quality of evidence should be guided
by a systematic review of available evidence. Reviewers
should consider four key elements: study design, study
quality, consistency, and directness (box 2). Study
design refers to the basic s