كتاب
diagnosis and treatment of functional constipation in infants and children
- Evidence for the guideline
We used the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) for assigning the quality of evidence and strength of recommendations that includes the following definitions [13]. Informed by the evidence required for the GRADE Evidence to Decision (EtD) framework(s) was(were) done while considering changing strength of recommendations according to availability of some resources in the recommendations.
Description of the interpretation of the GRADE four levels of certainty of evidence:
Table 1. Classification of the Quality of Evidence
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High |
We are very confident that the true effect lies close to that of the estimate of the effect. |
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Moderate |
We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. |
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Low |
Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. |
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Very Low |
We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of the effect. |
GRADE EtD’s contextual factors, criteria and considerations that link to the strength of recommendations:
Criteria and Considerations:
1. Benefits and harms: When a new recommendation is developed, desirable effects (benefits) need to be weighed against undesirable effects (risks/harms), considering any previous recommendation or another alternative. The larger the gap or gradient in favor of the desirable effects over the undesirable effects, the more likely that a strong recommendation will be made.
2. Certainty of the evidence about the effects: The higher the certainty of the scientific evidence base, the more likely that a strong will be made.
3. Values and preferences: If there is no important uncertainty or variability in how much people value the main outcomes, it is likely that a strong recommendation will be made. Uncertainty or variability around these values that could likely lead to different decisions, is more likely to lead to a conditional recommendation.
4. Economic implications: Lower costs (monetary, infrastructure, equipment or human resources) or greater cost-effectiveness are more likely to support a strong recommendation.
5. Equity and human rights: If an intervention will reduce inequities, improve equity or contribute to the realization of human rights, the greater the likelihood of a strong recommendation.
6. Feasibility: The greater the feasibility of an intervention to all stakeholders, the greater the likelihood of a strong recommendation.
7. Acceptability: If a recommendation is widely supported by health workers and program managers and there is widespread acceptance for implementation within the health service, the likelihood of a strong recommendation is greater.
Table 2. Classification of the Strengths of Recommendations
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Strong |
The desirable effects of an intervention clearly outweigh the undesirable effects (or vice versa), so most patients should receive the recommended course of action. |
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Conditional |
There is uncertainty about the trade-offs. The clinician and patient need to discuss the patient's values and preferences, and the decision should be individualized. |
Developing good practice statements:
The GDG/ GAG also developed good practice statements for this guideline, which are actionable messages relevant to the guideline questions. The justification for each good practice statement was carefully considered by the GDG/ GAG with an emphasis that they are clearly needed. Good practice statements were developed, guided by the following GRADE criteria:
1- Message is really necessary with regard to actual healthcare practice
2- Have large net positive consequence (relevant outcomes and downstream consequences) (GRADE EtD domains)
3- Collecting and summarizing the evidence is a poor use of time and resources
4- Include a well-documented, clear rationale connecting indirect evidence
5- Are clear and actionable statements.
The GDG/ GAG collectively drafted and finalized good practice statements with relevant justifications and remarks to help with their interpretation, with close support and input from the consultant and guideline methodologists.
We have used the Reporting Items for Practice Guidelines in Healthcare (RIGHT) extension for adapted guidelines (RIGHT-Ad@pt Tool) as a reporting checklist for this guideline adaptation process as recommended by the EQUATOR network.
