Using GRADEpro to create Evidence Profiles and Summary of Findings Tables Wednesday 19 January to 1330 (PT) Nancy Santesso McMaster University

Evidence profiles Guideline panels are working from the – same evidence – transparently provided Recommendations can be based on – the quality of the evidence – the summarised effects of an intervention – Estimated effects of an intervention

Evidence profiles Is a summary of the key findings of the evidence Presents – the quality of the evidence – the effects – reasons behind decisions

Format of evidence profiles PICO Outcomes Results – Participants and studies – Relative effects – Absolute effects Quality of the Evidence Comments and Footnotes

Question: Should self management vs usual care be used for chronic obstructive pulmonary disease? 1 Settings: primary care, community, outpatient Bibliography: Effing TTW, Monninkhof EEM, van der Valk PP.D.L.P.M., van der Palen JJ, van Herwaarden CLA, Partidge MR, Walters HEH, Walters EH, Zielhuis GG.A.. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, Issue 4. Quality assessmentNo of patientsEffect QualityImportance No of studies DesignLimitationsInconsistencyIndirectnessImprecisionOtherSelf managementUsual care Relative (95% CI) Absolute Quality of Life (follow-up 3 to 12 months; measured with: St George's Respiratory Questionnaire; range of scores: (worse); Better indicated by lower values) 7randomised trials no serious limitations no serious inconsistency no serious indirectness no serious imprecision reporting bias MD 2.58 lower (5.14 to 0.02 lower)  MODERATE CRITICAL Dyspnoea (follow-up 3 to 6 months; measured with: Borg Scale; range of scores: 0-10 (worse); Better indicated by lower values) 2randomised trials serious 3 no serious inconsistency no serious indirectness serious 4 none MD 0.53 lower (0.96 to 0.1 lower)  LOW CRITICAL Number and severity of exacerbations 5 (Better indicated by lower values) 3randomised trials no serious limitations no serious inconsistency no serious indirectness very serious imprecision 5 none not pooled 5  LOW CRITICAL Respiratory-related hospital admissions (follow-up 3 to 12 months) 8randomised trials no serious limitations no serious inconsistency serious 6 no serious imprecision none 95/528 (18%) 10% 7 OR 0.64 (0.47 to 0.89) 3 fewer per 100 (from 1 fewer to 5 fewer)  MODERATE CRITICAL 50% 7 11 fewer per 100 (from 3 fewer to 18 fewer) Emergency department visits for lung diseases (follow-up 6 to 12 months; Better indicated by lower values) 4randomised trials no serious limitations no serious inconsistency no serious indirectness serious 4 none MD 0.1 higher (0.2 lower to 0.3 higher)  MODERATE IMPORTANT Doctor and nurse visits (follow-up 6 to 12 months; Better indicated by lower values) 8randomised trials no serious limitations serious 8 no serious indirectness no serious imprecision none MD 0.02 higher (1 lower to 1 higher)  MODERATE IMPORTANT 1 Self-management is a term applied to any formalized patient education programme aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. Of the 14 studies, there were four in which the education delivery mode consisted of group education; nine which were individual education and one study which was written education material only. In six studies the use of an action plan for self-treatment of exacerbations was assessed. 2 Seven other studies were not pooled and some showed non-significant effects. 3 No allocation concealment in 1 study. Incomplete follow-up. 4 Sparse data. 5 Different definitions of exacerbations used and studies could not be pooled. 6 Two studies with very severe COPD patients weighted heavily in meta-analysis. Therefore, there is some uncertainty with the applicability of effect to all risk groups. 7 The low and high risk values are the two extreme numbers of admissions in the control groups from two studies (8% was rounded to 10% and 51% to 50%). 8 Unexplained heterogeneity.

Question: Should self management vs usual care be used for chronic obstructive pulmonary disease? 1 Settings: primary care, community, outpatient Bibliography: Effing TTW, Monninkhof EEM, van der Valk PP.D.L.P.M., van der Palen JJ, van Herwaarden CLA, Partidge MR, Walters HEH, Walters EH, Zielhuis GG.A.. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, Issue 4. Quality assessmentNo of patientsEffect QualityImportance No of studies DesignLimitationsInconsistencyIndirectnessImprecisionOtherSelf managementUsual care Relative (95% CI) Absolute Quality of Life (follow-up 3 to 12 months; measured with: St George's Respiratory Questionnaire; range of scores: (worse); Better indicated by lower values) 7randomised trials no serious limitations no serious inconsistency no serious indirectness no serious imprecision reporting bias MD 2.58 lower (5.14 to 0.02 lower)  MODERATE CRITICAL Dyspnoea (follow-up 3 to 6 months; measured with: Borg Scale; range of scores: 0-10 (worse); Better indicated by lower values) 2randomised trials serious 3 no serious inconsistency no serious indirectness serious 4 none MD 0.53 lower (0.96 to 0.1 lower)  LOW CRITICAL Number and severity of exacerbations 5 (Better indicated by lower values) 3randomised trials no serious limitations no serious inconsistency no serious indirectness very serious imprecision 5 none not pooled 5  LOW CRITICAL Respiratory-related hospital admissions (follow-up 3 to 12 months) 8randomised trials no serious limitations no serious inconsistency serious 6 no serious imprecision none 95/528 (18%) 10% 7 OR 0.64 (0.47 to 0.89) 3 fewer per 100 (from 1 fewer to 5 fewer)  MODERATE CRITICAL 50% 7 11 fewer per 100 (from 3 fewer to 18 fewer) Emergency department visits for lung diseases (follow-up 6 to 12 months; Better indicated by lower values) 4randomised trials no serious limitations no serious inconsistency no serious indirectness serious 4 none MD 0.1 higher (0.2 lower to 0.3 higher)  MODERATE IMPORTANT Doctor and nurse visits (follow-up 6 to 12 months; Better indicated by lower values) 8randomised trials no serious limitations serious 8 no serious indirectness no serious imprecision none MD 0.02 higher (1 lower to 1 higher)  MODERATE IMPORTANT 1 Self-management is a term applied to any formalized patient education programme aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. Of the 14 studies, there were four in which the education delivery mode consisted of group education; nine which were individual education and one study which was written education material only. In six studies the use of an action plan for self-treatment of exacerbations was assessed. 2 Seven other studies were not pooled and some showed non-significant effects. 3 No allocation concealment in 1 study. Incomplete follow-up. 4 Sparse data. 5 Different definitions of exacerbations used and studies could not be pooled. 6 Two studies with very severe COPD patients weighted heavily in meta-analysis. Therefore, there is some uncertainty with the applicability of effect to all risk groups. 7 The low and high risk values are the two extreme numbers of admissions in the control groups from two studies (8% was rounded to 10% and 51% to 50%). 8 Unexplained heterogeneity.

Question: Should self management vs usual care be used for chronic obstructive pulmonary disease? 1 Settings: primary care, community, outpatient Bibliography: Effing TTW, Monninkhof EEM, van der Valk PP.D.L.P.M., van der Palen JJ, van Herwaarden CLA, Partidge MR, Walters HEH, Walters EH, Zielhuis GG.A.. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, Issue 4. Quality assessmentNo of patientsEffect QualityImportance No of studies DesignLimitationsInconsistencyIndirectnessImprecisionOtherSelf managementUsual care Relative (95% CI) Absolute Quality of Life (follow-up 3 to 12 months; measured with: St George's Respiratory Questionnaire; range of scores: (worse); Better indicated by lower values) 7randomised trials no serious limitations no serious inconsistency no serious indirectness no serious imprecision reporting bias MD 2.58 lower (5.14 to 0.02 lower)  MODERATE CRITICAL Dyspnoea (follow-up 3 to 6 months; measured with: Borg Scale; range of scores: 0-10 (worse); Better indicated by lower values) 2randomised trials serious 3 no serious inconsistency no serious indirectness serious 4 none MD 0.53 lower (0.96 to 0.1 lower)  LOW CRITICAL Number and severity of exacerbations 5 (Better indicated by lower values) 3randomised trials no serious limitations no serious inconsistency no serious indirectness very serious imprecision 5 none not pooled 5  LOW CRITICAL Respiratory-related hospital admissions (follow-up 3 to 12 months) 8randomised trials no serious limitations no serious inconsistency serious 6 no serious imprecision none 95/528 (18%) 10% 7 OR 0.64 (0.47 to 0.89) 3 fewer per 100 (from 1 fewer to 5 fewer)  MODERATE CRITICAL 50% 7 11 fewer per 100 (from 3 fewer to 18 fewer) Emergency department visits for lung diseases (follow-up 6 to 12 months; Better indicated by lower values) 4randomised trials no serious limitations no serious inconsistency no serious indirectness serious 4 none MD 0.1 higher (0.2 lower to 0.3 higher)  MODERATE IMPORTANT Doctor and nurse visits (follow-up 6 to 12 months; Better indicated by lower values) 8randomised trials no serious limitations serious 8 no serious indirectness no serious imprecision none MD 0.02 higher (1 lower to 1 higher)  MODERATE IMPORTANT 1 Self-management is a term applied to any formalized patient education programme aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. Of the 14 studies, there were four in which the education delivery mode consisted of group education; nine which were individual education and one study which was written education material only. In six studies the use of an action plan for self-treatment of exacerbations was assessed. 2 Seven other studies were not pooled and some showed non-significant effects. 3 No allocation concealment in 1 study. Incomplete follow-up. 4 Sparse data. 5 Different definitions of exacerbations used and studies could not be pooled. 6 Two studies with very severe COPD patients weighted heavily in meta-analysis. Therefore, there is some uncertainty with the applicability of effect to all risk groups. 7 The low and high risk values are the two extreme numbers of admissions in the control groups from two studies (8% was rounded to 10% and 51% to 50%). 8 Unexplained heterogeneity.

Question: Should self management vs usual care be used for chronic obstructive pulmonary disease? 1 Settings: primary care, community, outpatient Bibliography: Effing TTW, Monninkhof EEM, van der Valk PP.D.L.P.M., van der Palen JJ, van Herwaarden CLA, Partidge MR, Walters HEH, Walters EH, Zielhuis GG.A.. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, Issue 4. Quality assessmentNo of patientsEffect QualityImportance No of studies DesignLimitationsInconsistencyIndirectnessImprecisionOtherSelf managementUsual care Relative (95% CI) Absolute Quality of Life (follow-up 3 to 12 months; measured with: St George's Respiratory Questionnaire; range of scores: (worse); Better indicated by lower values) 7randomised trials no serious limitations no serious inconsistency no serious indirectness no serious imprecision reporting bias MD 2.58 lower (5.14 to 0.02 lower)  MODERATE CRITICAL Dyspnoea (follow-up 3 to 6 months; measured with: Borg Scale; range of scores: 0-10 (worse); Better indicated by lower values) 2randomised trials serious 3 no serious inconsistency no serious indirectness serious 4 none MD 0.53 lower (0.96 to 0.1 lower)  LOW CRITICAL Number and severity of exacerbations 5 (Better indicated by lower values) 3randomised trials no serious limitations no serious inconsistency no serious indirectness very serious imprecision 5 none not pooled 5  LOW CRITICAL Respiratory-related hospital admissions (follow-up 3 to 12 months) 8randomised trials no serious limitations no serious inconsistency serious 6 no serious imprecision none 95/528 (18%) 10% 7 OR 0.64 (0.47 to 0.89) 3 fewer per 100 (from 1 fewer to 5 fewer)  MODERATE CRITICAL 50% 7 11 fewer per 100 (from 3 fewer to 18 fewer) Emergency department visits for lung diseases (follow-up 6 to 12 months; Better indicated by lower values) 4randomised trials no serious limitations no serious inconsistency no serious indirectness serious 4 none MD 0.1 higher (0.2 lower to 0.3 higher)  MODERATE IMPORTANT Doctor and nurse visits (follow-up 6 to 12 months; Better indicated by lower values) 8randomised trials no serious limitations serious 8 no serious indirectness no serious imprecision none MD 0.02 higher (1 lower to 1 higher)  MODERATE IMPORTANT 1 Self-management is a term applied to any formalized patient education programme aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. Of the 14 studies, there were four in which the education delivery mode consisted of group education; nine which were individual education and one study which was written education material only. In six studies the use of an action plan for self-treatment of exacerbations was assessed. 2 Seven other studies were not pooled and some showed non-significant effects. 3 No allocation concealment in 1 study. Incomplete follow-up. 4 Sparse data. 5 Different definitions of exacerbations used and studies could not be pooled. 6 Two studies with very severe COPD patients weighted heavily in meta-analysis. Therefore, there is some uncertainty with the applicability of effect to all risk groups. 7 The low and high risk values are the two extreme numbers of admissions in the control groups from two studies (8% was rounded to 10% and 51% to 50%). 8 Unexplained heterogeneity.

Question: Should self management vs usual care be used for chronic obstructive pulmonary disease? 1 Settings: primary care, community, outpatient Bibliography: Effing TTW, Monninkhof EEM, van der Valk PP.D.L.P.M., van der Palen JJ, van Herwaarden CLA, Partidge MR, Walters HEH, Walters EH, Zielhuis GG.A.. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, Issue 4. Quality assessmentNo of patientsEffect QualityImportance No of studies DesignLimitationsInconsistencyIndirectnessImprecisionOtherSelf managementUsual care Relative (95% CI) Absolute Quality of Life (follow-up 3 to 12 months; measured with: St George's Respiratory Questionnaire; range of scores: (worse); Better indicated by lower values) 7randomised trials no serious limitations no serious inconsistency no serious indirectness no serious imprecision reporting bias MD 2.58 lower (5.14 to 0.02 lower)  MODERATE CRITICAL Dyspnoea (follow-up 3 to 6 months; measured with: Borg Scale; range of scores: 0-10 (worse); Better indicated by lower values) 2randomised trials serious 3 no serious inconsistency no serious indirectness serious 4 none MD 0.53 lower (0.96 to 0.1 lower)  LOW CRITICAL Number and severity of exacerbations 5 (Better indicated by lower values) 3randomised trials no serious limitations no serious inconsistency no serious indirectness very serious imprecision 5 none not pooled 5  LOW CRITICAL Respiratory-related hospital admissions (follow-up 3 to 12 months) 8randomised trials no serious limitations no serious inconsistency serious 6 no serious imprecision none 95/528 (18%) 10% 7 OR 0.64 (0.47 to 0.89) 3 fewer per 100 (from 1 fewer to 5 fewer)  MODERATE CRITICAL 50% 7 11 fewer per 100 (from 3 fewer to 18 fewer) Emergency department visits for lung diseases (follow-up 6 to 12 months; Better indicated by lower values) 4randomised trials no serious limitations no serious inconsistency no serious indirectness serious 4 none MD 0.1 higher (0.2 lower to 0.3 higher)  MODERATE IMPORTANT Doctor and nurse visits (follow-up 6 to 12 months; Better indicated by lower values) 8randomised trials no serious limitations serious 8 no serious indirectness no serious imprecision none MD 0.02 higher (1 lower to 1 higher)  MODERATE IMPORTANT 1 Self-management is a term applied to any formalized patient education programme aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. Of the 14 studies, there were four in which the education delivery mode consisted of group education; nine which were individual education and one study which was written education material only. In six studies the use of an action plan for self-treatment of exacerbations was assessed. 2 Seven other studies were not pooled and some showed non-significant effects. 3 No allocation concealment in 1 study. Incomplete follow-up. 4 Sparse data. 5 Different definitions of exacerbations used and studies could not be pooled. 6 Two studies with very severe COPD patients weighted heavily in meta-analysis. Therefore, there is some uncertainty with the applicability of effect to all risk groups. 7 The low and high risk values are the two extreme numbers of admissions in the control groups from two studies (8% was rounded to 10% and 51% to 50%). 8 Unexplained heterogeneity.

Question: Should self management vs usual care be used for chronic obstructive pulmonary disease? 1 Settings: primary care, community, outpatient Bibliography: Effing TTW, Monninkhof EEM, van der Valk PP.D.L.P.M., van der Palen JJ, van Herwaarden CLA, Partidge MR, Walters HEH, Walters EH, Zielhuis GG.A.. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, Issue 4. Quality assessmentNo of patientsEffect QualityImportance No of studies DesignLimitationsInconsistencyIndirectnessImprecisionOtherSelf managementUsual care Relative (95% CI) Absolute Quality of Life (follow-up 3 to 12 months; measured with: St George's Respiratory Questionnaire; range of scores: (worse); Better indicated by lower values) 7randomised trials no serious limitations no serious inconsistency no serious indirectness no serious imprecision reporting bias MD 2.58 lower (5.14 to 0.02 lower)  MODERATE CRITICAL Dyspnoea (follow-up 3 to 6 months; measured with: Borg Scale; range of scores: 0-10 (worse); Better indicated by lower values) 2randomised trials serious 3 no serious inconsistency no serious indirectness serious 4 none MD 0.53 lower (0.96 to 0.1 lower)  LOW CRITICAL Number and severity of exacerbations 5 (Better indicated by lower values) 3randomised trials no serious limitations no serious inconsistency no serious indirectness very serious imprecision 5 none not pooled 5  LOW CRITICAL Respiratory-related hospital admissions (follow-up 3 to 12 months) 8randomised trials no serious limitations no serious inconsistency serious 6 no serious imprecision none 95/528 (18%) 10% 7 OR 0.64 (0.47 to 0.89) 3 fewer per 100 (from 1 fewer to 5 fewer)  MODERATE CRITICAL 50% 7 11 fewer per 100 (from 3 fewer to 18 fewer) Emergency department visits for lung diseases (follow-up 6 to 12 months; Better indicated by lower values) 4randomised trials no serious limitations no serious inconsistency no serious indirectness serious 4 none MD 0.1 higher (0.2 lower to 0.3 higher)  MODERATE IMPORTANT Doctor and nurse visits (follow-up 6 to 12 months; Better indicated by lower values) 8randomised trials no serious limitations serious 8 no serious indirectness no serious imprecision none MD 0.02 higher (1 lower to 1 higher)  MODERATE IMPORTANT 1 Self-management is a term applied to any formalized patient education programme aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. Of the 14 studies, there were four in which the education delivery mode consisted of group education; nine which were individual education and one study which was written education material only. In six studies the use of an action plan for self-treatment of exacerbations was assessed. 2 Seven other studies were not pooled and some showed non-significant effects. 3 No allocation concealment in 1 study. Incomplete follow-up. 4 Sparse data. 5 Different definitions of exacerbations used and studies could not be pooled. 6 Two studies with very severe COPD patients weighted heavily in meta-analysis. Therefore, there is some uncertainty with the applicability of effect to all risk groups. 7 The low and high risk values are the two extreme numbers of admissions in the control groups from two studies (8% was rounded to 10% and 51% to 50%). 8 Unexplained heterogeneity.

Question: Should self management vs usual care be used for chronic obstructive pulmonary disease? 1 Settings: primary care, community, outpatient Bibliography: Effing TTW, Monninkhof EEM, van der Valk PP.D.L.P.M., van der Palen JJ, van Herwaarden CLA, Partidge MR, Walters HEH, Walters EH, Zielhuis GG.A.. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, Issue 4. Quality assessmentNo of patientsEffect QualityImportance No of studies DesignLimitationsInconsistencyIndirectnessImprecisionOtherSelf managementUsual care Relative (95% CI) Absolute Quality of Life (follow-up 3 to 12 months; measured with: St George's Respiratory Questionnaire; range of scores: (worse); Better indicated by lower values) 7randomised trials no serious limitations no serious inconsistency no serious indirectness no serious imprecision reporting bias MD 2.58 lower (5.14 to 0.02 lower)  MODERATE CRITICAL Dyspnoea (follow-up 3 to 6 months; measured with: Borg Scale; range of scores: 0-10 (worse); Better indicated by lower values) 2randomised trials serious 3 no serious inconsistency no serious indirectness serious 4 none MD 0.53 lower (0.96 to 0.1 lower)  LOW CRITICAL Number and severity of exacerbations 5 (Better indicated by lower values) 3randomised trials no serious limitations no serious inconsistency no serious indirectness very serious imprecision 5 none not pooled 5  LOW CRITICAL Respiratory-related hospital admissions (follow-up 3 to 12 months) 8randomised trials no serious limitations no serious inconsistency serious 6 no serious imprecision none 95/528 (18%) 10% 7 OR 0.64 (0.47 to 0.89) 3 fewer per 100 (from 1 fewer to 5 fewer)  MODERATE CRITICAL 50% 7 11 fewer per 100 (from 3 fewer to 18 fewer) Emergency department visits for lung diseases (follow-up 6 to 12 months; Better indicated by lower values) 4randomised trials no serious limitations no serious inconsistency no serious indirectness serious 4 none MD 0.1 higher (0.2 lower to 0.3 higher)  MODERATE IMPORTANT Doctor and nurse visits (follow-up 6 to 12 months; Better indicated by lower values) 8randomised trials no serious limitations serious 8 no serious indirectness no serious imprecision none MD 0.02 higher (1 lower to 1 higher)  MODERATE IMPORTANT 1 Self-management is a term applied to any formalized patient education programme aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. Of the 14 studies, there were four in which the education delivery mode consisted of group education; nine which were individual education and one study which was written education material only. In six studies the use of an action plan for self-treatment of exacerbations was assessed. 2 Seven other studies were not pooled and some showed non-significant effects. 3 No allocation concealment in 1 study. Incomplete follow-up. 4 Sparse data. 5 Different definitions of exacerbations used and studies could not be pooled. 6 Two studies with very severe COPD patients weighted heavily in meta-analysis. Therefore, there is some uncertainty with the applicability of effect to all risk groups. 7 The low and high risk values are the two extreme numbers of admissions in the control groups from two studies (8% was rounded to 10% and 51% to 50%). 8 Unexplained heterogeneity.

Before you start... Systematic review is done (analyses done) Decide on the clinical question to present – One population – One intervention – One comparison Choose critical and important outcomes