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Research methods and reporting
Good or best practice statements: proposal for the operationalisation and implementation of GRADE guidance
  1. Omar Dewidar1,2,
  2. Tamara Lotfi3,4,5,
  3. Miranda W Langendam6,
  4. Elena Parmelli7,
  5. Zuleika Saz Parkinson8,
  6. Karla Solo3,4,
  7. Derek K Chu3,9,
  8. Joseph L Mathew10,
  9. Elie A Akl3,11,
  10. Romina Brignardello-Petersen3,4,
  11. Reem A Mustafa12,
  12. Lorenzo Moja13,
  13. Alfonso Iorio3,
  14. Yuan Chi14,15,
  15. Carlos Canelo-Aybar16,
  16. Tamara Kredo17,18,
  17. Justine Karpusheff19,
  18. Alexis F Turgeon20,21,
  19. Pablo Alonso-Coello16,
  20. Wojtek Wiercioch3,4,5,
  21. Annette Gerritsen17,
  22. Miloslav Klugar22,
  23. María Ximena Rojas23,
  24. Peter Tugwell24,25,
  25. Vivian Andrea Welch1,2,
  26. Kevin Pottie26,
  27. Zachary Munn27,
  28. Robby Nieuwlaat3,4,5,
  29. Nathan Ford28,
  30. Adrienne Stevens3,4,
  31. Joanne Khabsa29,
  32. Zil Nasir3,4,5,
  33. Grigorios Leontiadis4,9,
  34. Joerg Meerpohl30,31,
  35. Thomas Piggott3,4,5,
  36. Amir Qaseem32,
  37. Micayla Matthews3,4,5,
  38. Holger J Schünemann3,4,5,9,33,34
  39. the eCOVID-19 recommendations map collaborators
  1. 1 Methods Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
  2. 2 School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
  3. 3 Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
  4. 4 Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada
  5. 5 WHO Collaborating Center for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Ontario, Canada
  6. 6 Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
  7. 7 Joint Research Centre, European Commission, Ispra, Lombardia, Italy
  8. 8 Instituto de Salud Carlos III, Agencia de Evaluación de Tecnologías Sanitarias, Madrid, Spain
  9. 9 Department of Medicine, McMaster University, Hamilton, Ontario, Canada
  10. 10 Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
  11. 11 Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
  12. 12 Internal Medicine, Division of Nephrology and Hypertension, University of Kansas School of Medicine, Kansas City, Kansas, USA
  13. 13 Department of Health Product Policy and Standards, World Health Organization, Geneva, Switzerland
  14. 14 Yealth Network, Beijing Yealth Technology Co., Ltd, Beijing, China
  15. 15 Cochrane Campbell Global Ageing Partnership, London, UK
  16. 16 Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
  17. 17 Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
  18. 18 Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
  19. 19 National Institute for Health and Care Excellence, London, UK
  20. 20 Centre de Recherche du Centre Hospitalier Affilié Universitaire de Québec (CHA), CHA-Hôpital de l'Enfant-Jésus, Université Laval, Québec City, Québec, Canada
  21. 21 Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
  22. 22 Czech National Centre for Evidence-Based Healthcare and Knowledge Translation, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic
  23. 23 Department of Clinical Epidemiology and Public Health, Institut d’Investigació Biomèdica Sant Pau IIB Sant Pau, Barcelona, Spain
  24. 24 Department of Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
  25. 25 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  26. 26 Deparatment of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
  27. 27 Joanna Briggs Institute, University of Adelaide, Adelaide, South Australia, Australia
  28. 28 Department of HIV, Hepatitis and Sexually Transmitted Infections, World Health Organization, Geneva, Switzerland
  29. 29 Clinical Research Institute, American University of Beirut, Beirut, Lebanon
  30. 30 Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
  31. 31 Medical Center - University of Freiburg, Institute for Evidence in Medicine, Freiburg, Germany
  32. 32 American College of Physicians, Philadelphia, Pennsylvania, USA
  33. 33 Department of Biomedical Sciences Humanitas University, Humanitas University, Milan, Italy
  34. 34 Cochrane Canada, Hamilton, Ontario, Canada
  1. Correspondence to Dr Holger J Schünemann, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; schuneh{at}mcmaster.ca

Abstract

An evidence-based approach is considered the gold standard for health decision-making. Sometimes, a guideline panel might judge the certainty that the desirable effects of an intervention clearly outweigh its undesirable effects as high, but the body of supportive evidence is indirect. In such cases, the application of the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach for grading the strength of recommendations is inappropriate. Instead, the GRADE Working Group has recommended developing ungraded best or good practice statement (GPS) and developed guidance under which circumsances they would be appropriate.

Through an evaluation of COVID-1- related recommendations on the eCOVID Recommendation Map (COVID-19.recmap.org), we found that recommendations qualifying a GPS were widespread. However, guideline developers failed to label them as GPS or transparently report justifications for their development. We identified ways to improve and facilitate the operationalisation and implementation of the GRADE guidance for GPS.

Herein, we propose a structured process for the development of GPSs that includes applying a sequential order for the GRADE guidance for developing GPS. This operationalisation considers relevant evidence-to-decision criteria when assessing the net consequences of implementing the statement, and reporting information supporting judgments for each criterion. We also propose a standardised table to facilitate the identification of GPS and reporting of their development. This operationalised guidance, if endorsed by guideline developers, may palliate some of the shortcomings identified. Our proposal may also inform future updates of the GRADE guidance for GPS.

  • COVID-19
  • Evidence-Based Practice

Data availability statement

No data are available.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjebm-2022-111962

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    Data availability statement

    No data are available.

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    Footnotes

    • Twitter @okdewidar

    • Correction notice This article has been corrected since it first published. ORCID has been added for Miloslav Klugar.

    • Contributors OD, TL, MWL, ZSP, EP and HJS conceived of this paper and designed the first draft of the guidance. OD and HJS presented proposals at the development meetings. OD prepared all the material for the meetings. The coauthors were involved in the meetings and provided feedback on the conceptual approach used in this study. OD and TL collated the feedback and OD prepared the first draft of the manuscript. All authors provided critical review, interpretation and approval of the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. HJS acts as guarantor accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding CIHR (FRN VR4-172741 & GA3-177732) for COVID-19 recommendation mapping. AFT is the Chairholder of the Canada Research Chair in Critical Care Neurology and Trauma.

    • Competing interests This work was supported by grants from Canadian Institutes of Health (FRN VR4-172741 and GA3-177732) and WHO during the conduct of the study. EA, HJS and PA-C report contribution to the development of the original five criteria for assessing the appropriateness of issuing good practice statements. The remaining authors have nothing else to declare.

    • Provenance and peer review Commissioned; internally peer reviewed.

    Linked Articles

    • Original research
      Which actionable statements qualify as good practice statements In Covid-19 guidelines? A systematic appraisal
      Omar Dewidar Tamara Lotfi Miranda Langendam Elena Parmelli Zuleika Saz Parkinson Karla Solo Derek K Chu Joseph L Mathew Elie A Akl Romina Brignardello-Petersen Reem A Mustafa Lorenzo Moja Alfonso Iorio Yuan Chi Carlos Canelo-Aybar Tamara Kredo Justine Karpusheff Alexis F Turgeon Pablo Alonso-Coello Wojtek Wiercioch Annette Gerritsen Miloslav Klugar María Ximena Rojas Peter Tugwell Vivian Andrea Welch Kevin Pottie Zachary Munn Robby Nieuwlaat Nathan Ford Adrienne Stevens Joanne Khabsa Zil Nasir Grigorios I Leontiadis Joerg J Meerpohl Thomas Piggott Amir Qaseem Micayla Matthews Holger J Schünemann
      BMJ Evidence-Based Medicine 2022; 27 361-369 Published Online First: 15 Apr 2022. doi: 10.1136/bmjebm-2021-111866