Grading the quality of evidence and the strength of recommendations Equity

For disadvantaged groups are there different 1.Effects? 2.Values? 3.Thresholds for costs? 4.Distributions of disease? 5.Settings? 6.Baseline risks?

Different effects Quality across studies for specific outcomes 1.Are there different effects? Overall quality of evidence across outcomes Balance of benefits and harms Balance of net benefits and costs Recommendations

1. Are there different effects for disadvantaged groups? If there are inconsistent results that can be explained by social inequalities  Different balance sheets for different groups –Tobacco taxation If there is uncertainty about the directness of evidence for disadvantaged groups  Lower quality of evidence –Pneumococcal vaccine

Different values Quality across studies for specific outcomes Overall quality of evidence across outcomes 2.Are there different values? Balance of benefits and harms 2.Are there different values? Balance of net benefits and costs Recommendations

2. Are there differences in the relative importance of the health outcomes for disadvantaged groups? If an outcome is critical for a disadvantaged group and not for others  This may change the overall quality of evidence –If evidence regarding return to work is critical for disadvantaged groups and there is lower quality evidence for this outcome, the overall quality of evidence might be lowered If there are differences in the relative importance of health outcomes  This may change the balance of benefits and harms –Giving more weight to returning more quickly to work may shift the balance in favour of ARVs for HIV

Different thresholds for costs or distributions of disease Quality across studies for specific outcomes Overall quality of evidence across outcomes Balance of benefits and harms Balance of net benefits and costs 3.Are there different thresholds for costs? 4.Are there differences in the distribution of disease? Recommendations

3. Is the cost of an intervention high for disadvantaged groups? If the cost of an intervention is high for disadvantaged groups  This may change the balance of net benefits and costs –Cholesterol screening

4. Are there differences in the distribution of the burden of illness that might affect judgements about whether the intervention is worth the costs? Differences in the distribution of the burden of illness  May change the balance of net benefits and costs –It may be more important to use resources for HIV than for screening for colorectal cancer

Differences in settings or baseline risks Quality across studies for specific outcomes Overall quality of evidence across outcomes Balance of benefits and harms Balance of net benefits and costs Recommendations 5.Are there differences in settings? 6.Are there different baseline risks?

5. Are there factors that would affect the translation of the evidence into practice in disadvantaged settings? If there are important factors that could be expected to modify the size of the expected effects, such as proximity to a hospital or available expertise  This may change a recommendation –Magnesium sulphate

6. Are there differences in baseline risk for disadvantaged groups? If disadvantaged groups are at higher risk  This will increase the benefits –Penicillin for strept throat to prevent Rheumatic fever If there is uncertainty about the baseline risk for disadvantaged groups  This may change a recommendation –BCG for tuberculosis

How do judgements about equity affect recommendations? For disadvantaged groups different 1.Effects –Inconsistant results (tobacco taxation) – explicit value judgment –Uncertainty about directness (pneumococcal vaccine) – recommend evaluation 2.Values –Different values (ARV) – different recommendation 3.Thresholds for costs –Different thresholds (cholesterol screening) – different recommendation 4.Distributions of disease –Different distribution (colorectal cancer screening) – different priorities 5.Settings –Different settings (magnesium sulphate) – different recommendations 6.Baseline risks –Different baseline risks (BCG) – different recommendations 7.People may choose to recommend interventions that are less cost- effective because of equity

Equity should also be considered in formulating questions, implementing recommendations and evaluating the implementation of recommendations Formulating and prioratising questions Quality of studies for specific outcomes Quality across studies for specific outcomes Overall quality of evidence across outcomes Balance of benefits and harms Balance of net benefits and costs Recommendations Implementing recommendations Evaluation