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

2. 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.

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

4. 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

5. 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”

6. 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.

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

8. 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”

9. 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

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

11. 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

12. Questions

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

14. 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

15. 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

16. 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

17. 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.

18. 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.

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

20. 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

21. Questions