EAST GRADE course 2019 Creating Recommendations John R. Lunde, DNP, AGACNP-BC, TCRN, FCCM George Kasotakis, MD MPH FACS FCCM

Defined The strength of a recommendation reflects the extent to which we can be confident that the desirable effects of an intervention outweigh the undesirable effects.” The implications of recommendations have clinical and medico-legal effects.

Making a Recommendation Determining the strength of a recommendation is separate and different from rating the quality of the evidence.

The Primary Rating Determinants: The overall quality of the evidence across outcomes (critical outcomes first) The balance between benefits and harms and burden Patient values and preferences Resource considerations Acceptability / feasibility

Grade Level of Action Strength Strong Recommendation Used when the desirable effects of adherence to a recommendation clearly outweighs the undesirable effects, or clearly do not We recommend using the phrase “we recommend” or “we recommend against”

Weak (conditional) recommendation Used when the tradeoffs are less certain either because of low-quality evidence or when the available evidence suggests that the desirable and undesirable effects are closely balanced; or patients values and preferences vary widely or are uncertain; or the resource used involved may bot be worth in relation to the benefit achieved.

Weak cont. We recommend using the phrase “we conditionally recommend” or “we conditionally recommend against” when a weak recommendation is warrented

Tips on Making Recommendations Covert the PICO Question into an affirmative statement For strong- use “recommend” or ”recommend against” For weak- use “conditionally recommend” or “conditionally recommend against”

What contributes to the strength of a recommendation Quality of the evidence Uncertainty or variability in the values and preferences Uncertainty about whether the intervention represents a wise use of resources Balance between desirable and undesirable effects

Implications of Recommendation The implication of a strong recommendation are: Patients Clinicians Policy Makers It essentially dictates the new standard of care

The implications of a weak recommendation are: Patients Clinicians Policy Makers It implies the intervention should be considered in the majority of clinically applicable situations

Questions

EAST GRADE course 2019 Drafting the Manuscript John R. Lunde, DNP, AGACNP-BC, TCRN, FCCM George Kasotakis, MD MPH FACS FCCM

Overall Approach JOT limits manuscripts to 5000 words Structured abstract is limited to 300 words Limited to 8 figures and tables which include “Summary of Recommendations” figure

Format Title Abstract Introduction: Discuss the magnitude of the problem; known data; knowledge gap; aim of the project Objectives: What you set out to accomplish

Methods Identification of Resources – Literature Search: How the lit search was conducted, what engines, what terms Include Prisma flow chart! Outcome Measure Types What Outcomes were considered, how they were rated Data Extraction and Methodology How abstracts/full manuscripts were reviewed, how conflicts were adjudicated, how data points were extracted

Results for PICO #1 Qualitative Synthesis Quantitative Synthesis: Discuss differences across analyzed manuscripts, how these may affect your recommendation. Comment on notable observations, specific subpopulations that may benefit more or less from the proposed intervention. Quantitative Synthesis: Review / Discuss the Meta-Analysis results, present the GRADE Pro table findings.

Results for PICO #1 Grading the Evidence Present Grade Pro table, discuss results, evaluate overall quality of evidence. Recommendation: State the final recommendation as an answer to your PICO. ”Based on ____ quality of evidence”. Discuss positive outcomes that improve, and adverse outcomes that may decrease Discuss specific circumstances, pt populations where it may be more or less applicable.

Repeat Results for PICO #2 Qualitative Synthesis Quantitative Synthesis Grading the Evidence Recommendation

Summary of Recommendations Using These Guidelines in Clinical Practice: Discuss in more detail what benefits are to be expected from application of the recommendations. Reiterate any exclusions/populations that may benefit more or less from the proposed intervention Conclusion Reiterate your recommendations & the clinical setting where they may most be applicable Summary of Recommendations Table with recommendations per PICO

Questions