1. Developing evidence-based guidelines at WHO

2. Evidence-based guidelines at WHO | January 17, 2016 2 |2 |

3. 3 |3 | The Problem WHO guidelines: not transparent, not evidence-based ↓ Systematic reviews ↓ Transparency about judgements ↑ Expert opinion ↓ Adaptation of global guidelines to end users' needs ↔ Tension between time taken and when advice needed ↓ Resources Oxman et al, Lancet 2007;369:1883-9

4. Evidence-based guidelines at WHO | January 17, 2016 4 |4 | WHO's response Guideline review committee Standards for: –Reporting –Processes –Use of evidence WHO handbook for guidelines Different types of documents for different purposes

5. Evidence-based guidelines at WHO | January 17, 2016 5 |5 | Guideline types Emergency –Response to acute need, evidence informed, limited consultation, short use-by date Standard /focused –Limited topic area, 10-20 'questions', evidence-based, 1 guideline group meeting Comprehensive –Disease/policy area, evidence-based, 3-4 meetings Textbooks Joint guidelines

6. Evidence-based guidelines at WHO | January 17, 2016 6 |6 | What is a WHO guideline? "Guidelines are recommendations intended to assist providers and recipients of health care and other stakeholders to make informed decisions. Recommendations may relate to clinical interventions, public health activities, or government policies." WHO 2003, 2007

7. Evidence-based guidelines at WHO | January 17, 2016 7 |7 | But what is it, really? YES: Clinical and public health interventions, policy recommendations NO: Standards (eg pharmacopoeia, food), standard operating procedures, evidence synthesis without recommendations, 'how to' manuals UNCLEAR: compilations of clinical information without clear recommendations IN ANY CASE: The name is irrelevant

8. Evidence-based guidelines at WHO | January 17, 2016 8 |8 | Example: A policy question How to maintain health workforce staffing levels in rural areas? Population: Nurses in rural areas Intervention: hire more males Comparison: no changes in hiring practices Outcomes: increase retention

9. Evidence-based guidelines at WHO | January 17, 2016 9 |9 | 8 easy steps 1.Scope the document: describe problems with existing evidence and recommendations, variations, and gaps 2.Determine composition of expert group and the consultation process 3.Solicit declaration of interest 4.Formulate questions and choices of relevant outcomes 5.Retrieve, evaluate and synthesize evidence 6.Establish benefit/risk profile (integrate evidence with values and preferences, equity and costs) 7.Formulate recommendations 8.Plan for the implementation and evaluation of impact

10. Evidence-based guidelines at WHO | January 17, 2016 10 | 5. Retrieve, evaluate and synthesize evidence –Synthesis of all available evidence –Formal assessment of quality of evidence –Evidence summaries for group meetings using standard template

11. Evidence-based guidelines at WHO | January 17, 2016 11 | Why bother about grading? People draw conclusions about the –quality of evidence –strength of recommendations Systematic and explicit approaches can help –protect against errors –resolve disagreements –facilitate critical appraisal –communicate information

12. Evidence-based guidelines at WHO | January 17, 2016 12 | Quality of evidence

13. Evidence-based guidelines at WHO | January 17, 2016 13 | Recommendations are judgements, reflecting: –Quality of evidence –Trade off between benefits and harms –Costs –Values and preferences –Local circumstances Making good recommendations involves –Asking the right questions in the first place explicit question formulation Differences between evidence and recommendations

14. Evidence-based guidelines at WHO | January 17, 2016 14 | Although the degree of confidence is a continuum, two categories are used: strong and weak. Strong: one for which the panel is confident that the desirable effects of adherence to a recommendation outweigh the undesirable effects. Weak: one for which the panel concludes that the desirable effects of adherence to a recommendation probably outweigh the undesirable effects, but the panel is not confident about these trade-offs. Reasons for not being confident can include: –absence of high quality evidence; –presence of imprecise estimates of benefits or harms; –uncertainty or variation in how different individuals value the outcomes; –small benefits; –the benefits may not be worth the costs. Strength of a recommendation

15. Evidence-based guidelines at WHO | January 17, 2016 15 | Implications of strong and weak recommendations Strong: –For patients: most people in your situation would want the recommended course of action and only a small proportion would not. –For clinicians: most patients should receive the recommended course of action. Adherence to this recommendation is a reasonable measure of good quality care. –For policy-makers: the recommendation can be adapted as a policy in most situations. Quality initiatives could use this recommendation to measure variations in quality. Weak: –For patients: the majority of people in your situation would want the recommended course of action but many would not. –For clinicians: be prepared to help patients to make a decision that is consistent with their own values. –For policy-makers: There is a need for substantial debate and involvement of stakeholders.

16. Evidence-based guidelines at WHO | January 17, 2016 16 | Making a recommendation What clinical/policy decision are you addressing? What are all of the possible courses of action? What are all of the possible outcomes, both beneficial and adverse? What does your evidence show about the link between the options and outcomes? Define values and judgments you will use to decide on the optimal course of action. Consider local circumstances, resources, and barriers. Adjust optimal course of action accordingly.

17. Evidence-based guidelines at WHO | January 17, 2016 17 | Discussion: Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. 2007. Lancet 369:1883-1889. –Correspondence: Quigley,Simon, Peterson, Kelly, Elliot et al. Duke T, Cambell H, Ayieko P et al. Accessing and understanding the evidence. 2006. Bulletin of the World Health Organization. 84:922. Gwatkin DR. IMCI: what can we learn from an innovation that didn't reach the poor? 2006. Bulletin of the World Health Organization. 84:768. Walters ND, Lyimo T, Skarbinski J. Why first level health workers fail to follow guidelines for the managing severe disease in children in the Coast region, United Republic of Tanzania. 2009. Bulletin of the World Health Organization. 84:922.